System Change to Deliver Timely Reperfusion for Myocardial Infarction in Regional New Zealand: The NMDHB STEMI Pathway Experience

Background: Delivery of timely reperfusion for ST elevation myocardial infarction (STEMI) remains a key target for healthcare delivery but lack of coordinated approach in regional NewZealand leads to low levels of revascularisation and poorer outcomes compared to metropolitan centres. Methods:NMDHB and St John have implemented a pathway for STEMI care including pre-hospital transmission of ECGs to a STEMI coordinator (Senior Emergency Department Doctor) responsible for coordinating reperfusion therapy and transport to Percutaneous Coronary Intervention (PCI) centre. Median(inter-quartile range) are reported. Results: In the ten months from 1 April 2015 to 31 January 2016, 78 patients presented with STEMI, the initial reperfusion strategy was 32(41%) for thrombolysis, 29(37%) PPCI and 17(22%) medical. First medical contact (FMC)-to-needle time was 71(65-102)minutes for the 34(45%) patients transported to hospital via ambulance compared to 25(17-38) minutes for those presenting directly to hospital. FMC to device time was 83(55-125)minutes for patients undergoing primary PCI. Of patients presenting to non-PCI centre (22%) who received thrombolysis as the primary treatment, FMC to helicopter activation was 46(29-70)minutes, door-in-door out (DIDO) time was 95(69-129)minutes and FMC to PCI centre was 147(130-198)minutes. Conclusion: Despite provision of a coordinated multidisciplinary pathway, timely reperfusion did not occur due to long transfer times and delayed activation of retrieval services. STEMI coordination requires expert input (ideally cardiologist) from FMC with provision for pre-hospital thrombolysis by paramedics where transport to a PCI capable centre is delayed beyond 60 minutes. Presently for regional patients, transfer times extend beyond where primary PCI could be reliably delivered.