A Pilot Rapid Triage Process for Prehospital ST-Segment Myocardial Infarction Patients Direct to the Catheterization Lab

Abstract

BackgroundRapid treatment of ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) significantly reduces morbidity and mortality rates. Recent studies emphasize the importance of reducing total ischemic time, making first-medical-contact-to-balloon (FMCTB) time a key performance indicator. To improve FMCTB times in patients brought to the Emergency Department (ED) by Emergency Medical Services (EMS), we implemented a "Direct to Lab" (DTL) workflow during the following conditions: weekday daytime hours, when the lab is fully staffed, and for hemodynamically stable STEMI patients presenting via EMS.MethodsWe performed a pre/post analysis following the implementation of a pilot workflow for EMS STEMI patients to be rapidly triaged to the cardiac catheterization lab as compared to those patients who underwent the standard workflow before program implementation at a 225-bed community hospital in a suburban setting in Maryland, USA. The hospital’s STEMI database was queried from 2/1/2021 through 3/1/2024, including all EMS STEMI alert activations during the study period. Cases were excluded if the patient arrived after program operating hours, declined PCI, or if clinical circumstances (such as cardiac arrest or the need for other resuscitative or diagnostic interventions) necessitated additional ED stabilization before PCI.ResultsA total of 30 patients met the inclusion criteria. The analysis revealed significantly reduced ED, door-to-balloon (DTB), and FMCTB times for patients under the "Direct to Lab" workflow, including a total ED time of 8.4 minutes faster, an average DTB time of 19.6 minutes faster, and an average FMCTB time of 24.3 minutes faster than those triaged via the standard workflow. Complication rates were similar among both groups. The most common reason that stable patients were not taken directly to the lab was the need for further clinical evaluation before cardiac catheterization or the lab not being immediately available.ConclusionIn this pilot single-center analysis, STEMI patients who were expeditiously triaged "Direct to Lab" experienced significantly lower total ED, DTB, and FMCTB times with no difference in procedural complications. This study highlights the patient-centered benefits of a robust collaboration between EMS, ED, and Interventional Cardiology teams.