Ways to Improve the Care of STEMI that Occurs in the Hospital

ST-elevation myocardial infarctions (STEMI) that occur in hospitalized patients have a mortality rate that is 3 – 10 fold higher than STEMI that occurs as an outpatient. For example, a study of 62021 patients with STEMI treated in California hospitals showed in patients with STEMI had a greater than 3 fold increase in in-hospital mortality (33.6% vs 9.2%; p < 0.001), were less likely to be discharged home (33.7% vs 69.4%; p < 0.001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; p < 0.001) or percutaneous coronary intervention (21.6% vs 65%; p < 0.001) compared to outpatient STEMI. Studies have shown that recognition is often delayed and times to treatment are much longer than outpatient STEMI. A single center quality improvement (QI) protocol was developed to minimize these delays and rapidly identify STEMI patients. The QI program included initiatives to: a) educate hospital personnel on recognition of inpatient STEMI; b) provide a mechanism for rapid ECG interpretation and prompt involvement of a cardiologist; c) streamline the activation of existing STEMI system of care for any hospitalized patient with suspected coronary ischemia and/or change in clinical status; and d) incorporate monthly review of inpatient STEMI cases. Results showed that implementation of the QI program led to significant reductions in symptom-to-ECG time, ECG-to-first device activation time and symptom to FDA times. These results demonstrated that implementation of a QI program led to significant improvements in recognition and treatment of inpatient STEMI.