The hub-and-spoke model has emerged as a useful strategy to improve the care quality and cost efficiency of treating high-acuity CV patients, like those with ST-elevation myocardial infarction (STEMI). By streamlining the transfer of complex patient to advanced care facilities, care networks can address many of the challenges associated with treating these patients at spoke hospitals, such as limited provider and staff experience, slow response times, and high infrastructure costs.
Learn how to build a regional network for treating complex patients
One of the drawbacks of this model is that transferring STEMI patients to a hub facility for care takes time, and timely care is a key factor in survival for this patient population. It is widely accepted that shorter door-to-treatment times are positively correlated with higher-quality STEMI outcomes, and as a result CV programs are constantly looking for ways to reduce the time it takes to get STEMI patients into a cath lab. Recent studies and current clinical guidelines for STEMI suggest that pre-hospital activation of cath lab teams by referring providers and paramedics in the field is best practice.
The unrealized potential of cath lab pre-activation
A study by Shavadia et al. recently published in the Journal of the American College of Cardiology evaluated the prevalence of cath lab pre-activation and its association with STEMI outcomes. The team evaluated 27,840 STEMI patients transported by EMS to 744 PCI-capable hospitals in the ACTION registry between January 2015 and March 2017, and they found that cath lab pre-activation more than 10 minutes before patient arrival occurred in only 40.9% of cases. When cath labs were pre-activated, however, the patients received significantly faster care and experienced better outcomes compared to those where pre-activation did not occur (see below table).
These findings suggest that cath lab pre-activation presents a significant opportunity to improve STEMI care, and an opportunity that is currently underutilized by health systems. Recognizing the importance of early care team activation, one program implemented a phone alert system to improve pre-activation.
Dedicated STEMI hotlines a great place to start
Vanderbilt University Medical Center has put protocols in place to ensure that cath lab pre-activation is achieved when a referring provider encounters a STEMI patient. They installed yellow phones in the EDs of transferring hospitals to give them a clear visual cue of where to call when they encounter a STEMI patient. When the referring provider initiates a call on this hotline, STEMI protocols are activated at Vanderbilt's hub facility, including a "burst page" (shown below) that sends activation messages to the care team and alerts other staff members of the incoming patient. These notifications ensure rapid care team deployment so that the facility is fully prepared to care for the patient when they arrive at the hospital.
False activations are inevitable
One of hospitals' biggest concerns surrounding cath lab pre-activation is that the prevalence of false activations and cancelled calls will lead to inefficient use of cath lab resources and staff. Data from five studies conducted between January 2011 and August 2013 revealed that only 11% of STEMI diagnoses were found to be false positives, and even the most experienced STEMI programs accept that these are an inevitable challenge that comes with treating complex CV patients.
Learn how to strengthen your STEMI network and leverage it to treat cardiogenic shock
False activation should therefore not deter referring providers from transferring these patients to the advanced care facility, nor should the referring providers be reprimanded for doing so. To minimize false activations, rather, investments should be made to improve training for EMS and referring providers on disease identification, refine transfer protocols, and strengthen coordination across your network.
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