Читать книгу Emergency Medical Services - Группа авторов - Страница 238

Almost 80% of the adult population of the United States lives within 60 driving minutes of a PCI‐capable center [63]. Of those patients whose closest hospital is not capable of PCI, 74% require additional transport time of less than 30 minutes to reach a PCI‐capable institution. Many states and communities have developed protocols to facilitate EMS transport of STEMI patients directly to hospitals with 24/7 capability to perform PCI. In a study of 19,287 patients, comparing states that allowed EMS to bypass closer non–PCI‐capable institutions and transport directly to a PCI‐capable institution, it was found that in bypass‐approved states, 57% of people exhibiting myocardial infarction received PCI in <90 minutes and 82% underwent PCI within 120 minutes of EMS contact. In states with no bypass policies, only 45% of people received PCI within 90 minutes and 77% within 120 minutes [64]. In Ottawa, a STEMI bypass protocol for EMS was implemented in May 2005 [65]. Paramedics performed a 12‐lead ECG, and if STEMI was identified in a hemodynamically stable patient, the patient was transported directly to the region’s single cardiac center catheterization laboratory with prehospital notification of the impending arrival of the STEMI patient. To do so, EMS often bypassed one of the four other EDs in the city. The median first door‐to‐balloon time was 69 minutes for patients brought to the catheterization laboratory directly by EMS, compared with 123 minutes for those needing interhospital transfer. In the Netherlands, prehospital identification of patients with STEMI and transport to a PCI‐capable center, bypassing other EDs, was associated with improved left ventricular function [66].

Some systems are directing EMS to take STEMI patients directly to the heart catheterization lab, bypassing the ED. The strategy reduces door‐to‐balloon time up to 60 minutes [67]. In rural settings without available PCI centers, coordinated programs with regional STEMI receiving centers can achieve remarkable door‐to‐balloon times, even when measuring from the first door (i.e., the door of the rural ED). Two reports from Minnesota show that excellent treatment times can be achieved. In the Minneapolis area, the median first door‐to‐balloon time was 95 minutes if the referring hospital was less than 60 miles from the PCI center and 120 minutes if the referring hospital was farther away [68]. In the Mayo Clinic STEMI system, patients were transferred from 28 regional hospitals up to 150 miles away from the PCI center. The median first door‐to‐balloon time for the transferred patients was 116 minutes [69].