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Table 1.  
Demographics, Treatment Times, and Survival of Control and Intervention Patients
Demographics, Treatment Times, and Survival of Control and Intervention Patients
Table 2.  
Outcomes of Inpatient STEMIs by Year
Outcomes of Inpatient STEMIs by Year
1.
Dai  X, Bumgarner  J, Spangler  A, Meredith  D, Smith  SC, Stouffer  GA.  Acute ST-elevation myocardial infarction in patients hospitalized for noncardiac conditions.  J Am Heart Assoc. 2013;2(2):e000004.PubMedGoogle ScholarCrossref
2.
Dai  X, Kaul  P, Smith  SC  Jr, Stouffer  GA.  Predictors, treatment, and outcomes of STEMI occurring in hospitalized patients.  Nat Rev Cardiol. 2016;13(3):148-154.PubMedGoogle ScholarCrossref
3.
Kaul  P, Federspiel  JJ, Dai  X,  et al.  Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes.  JAMA. 2014;312(19):1999-2007.PubMedGoogle ScholarCrossref
4.
Garberich  RF, Traverse  JH, Claussen  MT,  et al.  ST-elevation myocardial infarction diagnosed after hospital admission.  Circulation. 2014;129(11):1225-1232.PubMedGoogle ScholarCrossref
5.
Richmond  T, Holoshitz  N, Haryani  A, Purim-Shem-Tov  Y, Sharma  G, Schaer  GL.  Adverse outcomes in hospitalized patients who develop ST-elevation myocardial infarction.  Crit Pathw Cardiol. 2014;13(2):62-65.PubMedGoogle ScholarCrossref
6.
Jaski  BE, Grigoriadis  CE, Dai  X,  et al.  Factors associated with ineligibility for PCI differ between inpatient and outpatient ST-elevation myocardial infarction.  J Interv Cardiol. 2016;29(4):363-369.PubMedGoogle ScholarCrossref
Research Letter
December 2016

A Quality Improvement Program for Recognition and Treatment of Inpatient ST-Segment Elevation Myocardial Infarctions

Author Affiliations
  • 1Division of Cardiology, University of North Carolina, Chapel Hill
  • 2McAllister Heart Institute, University of North Carolina, Chapel Hill
JAMA Cardiol. 2016;1(9):1077-1079. doi:10.1001/jamacardio.2016.3031

Rapid reperfusion with percutaneous coronary intervention or thrombolytic therapy is the standard of care for ST-segment elevation myocardial infarction (STEMI). STEMIs that occur in hospitalized patients have delayed symptom recognition, longer times from electrocardiography (ECG) to first-device activation (FDA), lower rates of percutaneous coronary intervention, and higher mortality rates compared with outpatient STEMIs.1-6

We identified the barriers contributing to these delays and implemented a quality improvement program (QIP) to enhance the response to inpatient STEMIs. Our QIP included the following 4 specific interventions: (1) a hospital-wide education campaign aimed at nurses, medical teams, and allied health care professionals on the recognition of inpatient STEMI and the importance of the timely reperfusion; (2) a requirement that ECG technicians and nurses immediately notify the cardiologist if the automated interpretation of an ECG included ***acute MI***; (3) establishment of an inpatient STEMI protocol and a cardiac response team, modeled on the rapid response team; and (4) monthly review of each inpatient STEMI.

Methods

This single-center prospective study was performed at a tertiary health care facility at the University of North Carolina, Chapel Hill. A previous study1 identified 48 patients on noncardiac services who developed an inpatient STEMI from January 1, 2007, to July 31, 2011 (control group). This study was approved by the institutional review board of the University of North Carolina, who waived the need for informed consent. The QIP began on January 1, 2012, and inpatients who developed STEMIs from January 1, 2012, to April 15, 2016, constituted the intervention group. We analyzed symptom-to-ECG, symptom-to-angiography, and symptom-to-FDA times with a 1-tailed t test. All other continuous variables were analyzed with a 2-tailed t test. Categorical variables were compared using the χ2 test.

Results

Of the 93 patients who had a STEMI while hospitalized in a noncardiac service (59 men [63%]; 34 women [37%]; mean [SD] age, 66 [13] years), 43 (46%) were in a postoperative unit and 24 (26%) were in an intensive care unit at the time of STEMI onset. The index ECG was triggered by patient-reported symptoms (50 patients [54%]), changes in vital signs (18 patients [19%]), changes on telemetry (7 patients [8%]), altered mental status (6 patients [6%]), cardiac arrest (6 patients [6%]), or elevated cardiac biomarker levels (6 patients [6%]).

The control group included 48 patients; the intervention group, 45 patients (Table 1). The intervention group had more rapid recognition of symptoms and ECG acquisition and significantly shorter ECG-to-FDA times (Table 1). Symptom-to-FDA times were reduced by 72% in the intervention group (mean [SD], 483 [504] vs 136 [117] minutes; P = .004). The first year of the intervention (2012) saw marked improvement in outcomes that was not as pronounced in 2013 and 2014 (Table 2). After renewed reinforcement of the principles of the QIP, outcomes improved in 2015 through 2016.

Discussion

The QIP resulted in significant improvement in recognition and treatment of inpatient STEMI. One of the hallmarks of the QIP was empowerment of nurses and other health care professionals to recognize inpatient STEMI and activate the response team. Although bypassing the primary medical team is unusual in the inpatient setting, this QIP established a protocol for rapid identification and triage of inpatient STEMIs that closely resembles the paradigm for outpatient STEMIs.

Recent studies found a 2- to 10-fold higher mortality for inpatient STEMI compared with outpatient STEMI.1-6 Although several factors could contribute to this marked difference in mortality, previous studies have documented substantial delays in recognition and treatment of inpatient STEMI.1-6 Extrapolation of data from outpatient STEMI suggests that the benefits of reperfusion are proportional to the rapidity of restoring flow and thus delays in initiating treatment for inpatient STEMI will have negative effects on outcomes.

A limitation of this study was that it used a historical cohort for comparison. The generalizability of the QIP may be limited because it was performed at an academic tertiary care center with 24-hour, on-site cardiology support. Larger studies are needed to determine whether the shorter treatment times resulting from the QIP improve clinical outcomes.

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Article Information

Corresponding Author: George A. Stouffer, MD, Division of Cardiology, University of North Carolina, 99 Manning Dr, Chapel Hill, NC 27599 (rstouff@med.unc.edu).

Published Online: September 21, 2016. doi:10.1001/jamacardio.2016.3031

Author Contributions: Dr Stouffer had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dai, Kaul, Smith, Stouffer.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Dai, Meredith, Sawey, Stouffer.

Critical revision of the manuscript for important intellectual content: Meredith, Kaul, Smith, Stouffer.

Statistical analysis: Meredith, Sawey.

Obtaining funding: Smith, Stouffer.

Administrative, technical, or material support: Meredith, Sawey, Kaul, Stouffer.

Study supervision: Dai, Stouffer.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Dai  X, Bumgarner  J, Spangler  A, Meredith  D, Smith  SC, Stouffer  GA.  Acute ST-elevation myocardial infarction in patients hospitalized for noncardiac conditions.  J Am Heart Assoc. 2013;2(2):e000004.PubMedGoogle ScholarCrossref
2.
Dai  X, Kaul  P, Smith  SC  Jr, Stouffer  GA.  Predictors, treatment, and outcomes of STEMI occurring in hospitalized patients.  Nat Rev Cardiol. 2016;13(3):148-154.PubMedGoogle ScholarCrossref
3.
Kaul  P, Federspiel  JJ, Dai  X,  et al.  Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes.  JAMA. 2014;312(19):1999-2007.PubMedGoogle ScholarCrossref
4.
Garberich  RF, Traverse  JH, Claussen  MT,  et al.  ST-elevation myocardial infarction diagnosed after hospital admission.  Circulation. 2014;129(11):1225-1232.PubMedGoogle ScholarCrossref
5.
Richmond  T, Holoshitz  N, Haryani  A, Purim-Shem-Tov  Y, Sharma  G, Schaer  GL.  Adverse outcomes in hospitalized patients who develop ST-elevation myocardial infarction.  Crit Pathw Cardiol. 2014;13(2):62-65.PubMedGoogle ScholarCrossref
6.
Jaski  BE, Grigoriadis  CE, Dai  X,  et al.  Factors associated with ineligibility for PCI differ between inpatient and outpatient ST-elevation myocardial infarction.  J Interv Cardiol. 2016;29(4):363-369.PubMedGoogle ScholarCrossref
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