Background: Regional variations in reperfusion times and mortality in patients with ST-segment–elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.

Methods: Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention–capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.

Results: During the study period, 10 730 patients were transported to percutaneous coronary intervention–capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%–74%; P<0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%–56%; P<0.0001), and emergency department dwell time of ≤20 minutes (33%–43%; P<0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%–2.3%; P=0.001) that was not apparent in hospitals not participating in the project during the same time period.

Conclusions: Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment–elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment–elevation myocardial infarction.

背景： ST段抬高型心肌梗死患者再灌注时间和死亡率的区域差异受急诊医疗服务（EMS）与医院之间协调医疗服务差异的影响。我们以Accelerator-1项目为基础，假设通过加大区域努力，可以进一步减少再灌注时间。

方法： 2015年4月至2017年3月，我们与美国12个大城市地区的132家具有经皮冠状动脉介入治疗能力的医院和946家EMS机构合作。在ACTION（急性冠脉治疗和干预预后结局网络）-随指南注册处获取数据，以获取季度任务：生命线报告。主要终点是从基线到最后一个季度，初次就医的EMS转运患者中设备时间≤90分钟的比例的变化。我们还比较了在相应时间段内未参加该项目的医院中接受治疗的患者的治疗时间和死亡率。

结果：在研究期间，有10 730例患者被转移到有经皮冠状动脉介入治疗能力的医院，其中基线季度为974例，最后季度为972例，符合纳入标准。中位年龄为61岁。女性占27％，心脏骤停占6％，入院时出现休克的占6％；黑人占10％，拉丁裔占12％，未投保10％。到干预结束时，所有反映EMS与医院之间协调的过程措施都得到了改善，包括初次就诊与设备时间≤90分钟的患者比例（67％–74％；P <0.002），与设备的医疗接触到导管插入实验室激活的时间≤20分钟（38％–56％；P <0.0001），急诊室的驻留时间≤20分钟（33％–43％）；P <0.0001）。在这12个地区中，有9个地区减少了首次医疗接触设备的时间，并且有8个地区达到或超过了全国目标，即≤90分钟内接受治疗的患者达到75％。治疗时间的缩短与死亡率的显着降低（院内死亡，4.4％–2.3％；P = 0.001）相对应，这在同期未参与该项目的医院中并不明显。

结论：在12个地区的EMS和医院之间组织护理与ST段抬高型心肌梗死患者的再灌注时间显着减少以及院内死亡率相关。这些发现为ST段抬高型心肌梗死的患者提供了一种更深入的区域急救方法。