The Impact of Regional ST-Elevation Myocardial Infarction Systems of Care on the Use of Protocols and Quality Improvement Initiatives in Community Hospitals Without Cardiac Catheterization Laboratories Chauncy B. Handran, Kelsey L. Baran, Jason T. Henry, Monique G. Ross, Ross F. Garberich, David M. Larson, Scott W. Sharkey, Timothy D. Henry, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN

Background Primary PCI is the optimal reperfusion strategy for STEMI, however, only 25% of US hospitals have PCI capability AHA Mission Lifeline program and ACC/AHA STEMI guidelines recommend non-PCI hospitals participate in regional STEMI systems in order to improve quality and timely access to PCI 2003 Minnesota survey demonstrated inadequate protocols, standing orders and quality improvement initiatives in non-PCI hospitals (Larson et al., 2003) Multiple regional STEMI systems have been developed in Minnesota since 2003

Objective To assess the impact of the development of regional STEMI systems on the use of protocols, adherence to guidelines, quality assessment methods and decision making regarding treatment and transfer criteria in non-PCI hospitals throughout Minnesota.

Methods Surveys were mailed to emergency department medical directors and nurse managers in 108 Minnesota hospitals that did not have cardiac catheterization labs The survey was identical to the 2003 survey with questions regarding protocols/guidelines, standing orders, quality assurance, decision making and indications for transfer of patients with STEMI A second letter was sent with follow-up phone calls to hospitals not responding to the initial survey

Minnesota hospitals and PCI centers

Guidelines and Protocols 2003 vs. 2009

Decision Making 2003 vs. 2009

Quality Assessment 2003 vs. 2009

Results 94/108 (87%) hospitals surveyed responded 89% (63%,2003) had specific written protocols or guidelines and 88% (57%,2003) had standing orders for treatment of STEMI Less than 10% of responding hospitals did not have protocols/guidelines or standing protocols compared to 33% in 2003 (p<0.001)

Results In 2009 decisions were more likely to be made by the emergency physician and/or protocols and less likely by cardiologists and primary physicians 67% now have triage and transfer criteria compared to only 8% in 2003 In 2009, 56% of hospitals transferred all STEMI patients compared to only 23% in 2003 (p <0.001)

Summary In 2009, > 90% of non-PCI hospitals have guidelines and standing orders to treat STEMI A significant improvement was seen in quality improvement programs Regional STEMI systems have improved the use of guidelines, protocols, standing orders and transfer criteria for Minnesota non-PCI hospitals