Objective: The medical literature has demonstrated disparities and variability in physician salaries and, specifically, emergency physician (EP) salaries. We sought to investigate individual physician characteristics, including sex and educational background, together with individual preferences of graduating EPs, and their association with the salary of their first job. Methods: The American College of Emergency Physicians and the George Washington University Mullan Institute surveyed 2019 graduating EPs. The survey included respondents’ demographic and educational background, post-training job characteristics and location, hospital characteristics, importance of different personal priorities, and starting salaries. We performed a multivariable regression analysis to determine how salaries were associated with job types and individuals’ characteristics. Results: We sent surveys to 2,192 graduating residents in 2019. Of these, 487 (22.2%) responded, and 270 (55.4%) accepted first-time clinical jobs and included salary data (12.3% of all surveys sent). Male sex, osteopathic training, and full-time work were significantly associated with higher salary. Men and women prioritized different factors in their job search. Women were more likely to consider such factors as parental leave policy, proximity to family, desired practice setting, type of hospital, and desired location as important. Salary/compensation was considered very important by 51.8% of men and 29.6%of women. Men’s median salary was $30,000 more than women’s (p= 0.01, 95% CI +$6,929 ± $53,071), a significant pay differential. Conclusion: Salaries of graduating emergency medicine residents are associated with the resident’s sex and degree type: doctor of osteopathic medicine or doctor of allopathic medicine. Multiple factors may contribute to men having higher salaries than women, and some of this difference reflects different priorities in their job search. Women were more likely to consider job conditions and setting to be more important, while men considered salary and compensation more important.

Objective:Income fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income. Methods:We distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income. Results:From 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference -$43,565, 95% CI, -$52,217 to -$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference -$30,048; 95% CI, -$48,183 to -$11,912, non-ACGME-program difference -$27,640, 95% CI, -$40,970 to -$14,257. Working at a for-profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767. Conclusions:This study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification.

Background Previous studies of patients with nontraumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume‐outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke center certification. Methods and Results Data from 8512 discharges in the National Inpatient Sample (NIS) from 2010 to 2011 were analyzed using logistic regression models to evaluate the association between clinical outcomes (in‐hospital mortality and the NIS‐SAH Outcome Measure [NIS‐SOM]) and measures of hospital annual case volume (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable outcomes with different volume thresholds were performed. During 8512 SAH hospitalizations, 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2% for in‐hospital mortality and 38.6% for poor outcome on the NIS‐SOM. The mean (range) of SAH, coiling, and clipping annual case volumes were 30.9 (1–195), 8.7 (0–94), and 6.1 (0–69), respectively. Logistic regression demonstrated improved outcomes with increasing annual case volumes of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/year. Analysis of sensitivity and specificity using different volume thresholds confirmed these results. Analysis of previously proposed volume thresholds, including those utilized as minimum standards for comprehensive stroke center certification, showed that hospitals with more than 35 SAH cases annually had consistently superior outcomes compared with hospitals with fewer cases, although some hospitals below this threshold had similar outcomes. The adjusted odds ratio demonstrating lower risk of poor outcomes with SAH annual case volume ≥35 compared with 20 to 34 was 0.82 for the NIS‐SOM (95% CI, 0.71–094; P=0.0054) and 0.80 (95% CI, 0.68–0.93; P=0.0055) for in‐hospital mortality. Conclusions Outcomes for patients with SAH improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

Study objective The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. Methods To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. Results The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. Conclusion The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

HomeJournal of the American Heart AssociationVol. 9, No. 2Prehospital Activation of Hospital Resources (PreAct) ST‐Segment–Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessResearch ArticlePDF/EPUBPrehospital Activation of Hospital Resources (PreAct) ST‐Segment–Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program Michael C. Kontos, MD, Michael R. Gunderson, EMT‐P, FAEMS, Jessica K. Zegre‐Hemsey, PhD, RN, David C. Lange, MD, William J. French, MD, Timothy D. Henry, MD, James J. McCarthy, MD, Claire Corbett, MMS, MBA, EMT‐P, Alice K. Jacobs, MD, James G. Jollis, MD, Steven V. Manoukian, MD, Robert E. Suter, MD, David T. Travis, MPH and J. Lee Garvey, MD Michael C. KontosMichael C. Kontos *Correspondence to: Michael C. Kontos, MD, Room 285 Gateway Building, 2nd Floor Gateway, PO Box 980051, 1200 E Marshall St, Richmond, VA 23298‐0051. E‐mail: E-mail Address: [email protected] Pauley Heart Center, , Virginia Commonwealth University, , Richmond, , VA Search for more papers by this author , Michael R. GundersonMichael R. Gunderson Center for Systems Improvement, , Tampa, , FL Search for more papers by this author , Jessica K. Zegre‐HemseyJessica K. Zegre‐Hemsey School of Nursing, , University of North Carolina at Chapel Hill, , NC Search for more papers by this author , David C. LangeDavid C. Lange The Permanente Medical Group, , Kaiser Permanente Santa Clara, , Santa Clara, , CA Search for more papers by this author , William J. FrenchWilliam J. French Harbor‐UCLA Medical Center and Los Angeles Biomedical Institute, , Torrance, , CA David Geffen School of Medicine at UCLA, , Los Angeles, , CA Search for more papers by this author , Timothy D. HenryTimothy D. Henry The Lindner Center for Research and Education at The Christ Hospital, , Cincinnati, , OH Search for more papers by this author , James J. McCarthyJames J. McCarthy Department of Emergency Medicine, , McGovern Medical School, , University of Texas Health Science Center at Houston, , TX Search for more papers by this author , Claire CorbettClaire Corbett New Hanover Regional Medical Center, , Wilmington, , NC Search for more papers by this author , Alice K. JacobsAlice K. Jacobs Section of Cardiology, , Department of Medicine, , Boston University Medical Center, , Boston, , MA Search for more papers by this author , James G. JollisJames G. Jollis Duke University, , Durham, , North Carolina Search for more papers by this author , Steven V. ManoukianSteven V. Manoukian HCA Healthcare, , Nashville, , TN Search for more papers by this author , Robert E. SuterRobert E. Suter Department of Emergency Medicine, , UT Southwestern and Augusta University, , Dallas, , Texas Department of Military and Emergency Medicine, , Uniformed Services University, , Dallas, , TX Search for more papers by this author , David T. TravisDavid T. Travis EMS Programs, , Hillsborough Community College, , Tampa, , FL Search for more papers by this author and J. Lee GarveyJ. Lee Garvey Department of Emergency Medicine, Carolinas Medical Center, , Charlotte, , NC Search for more papers by this author Originally published20 Jan 2020https://doi.org/10.1161/JAHA.119.011963Journal of the American Heart Association. 2020;9:e011963ST‐segment–elevation myocardial infarction (STEMI) is a high‐risk condition in which survival and other clinical outcomes are significantly impacted by reducing the time from vessel occlusion to coronary blood flow restoration (total ischemic time).1, 2, 3 Initiatives to reduce specific components of system delays such as the American College of Cardiology's Door to Balloon4 and American Heart Association's (AHA) Mission: Lifeline programs5, 6, 7 have been instrumental in reducing reperfusion times, with a reduction in median door to balloon time to the current level of <60 minutes.8Door to balloon time includes only hospital performance components; in contrast, first medical contact‐to‐device (FMC2D) time also encompasses the prehospital period, and therefore is a more accurate reflection of a systems performance. Consequently, efforts targeting reductions in FMC2D time provide additional opportunities for reductions in the total ischemic time.The AHA's Mission:Lifeline program was introduced in 2007 to develop systems of care for high‐risk time‐sensitive cardiovascular conditions.5 Mission: Lifeline addressed the continuum of care for STEMI, including symptom onset, first medical contact, and Emergency Medical Services (EMS) transport and transfer. Its focus has been on establishing formal STEMI “systems of care” teams to improve the quality of care and outcomes of all STEMI patients by improved communication and process flows between EMS, emergency physicians, cardiologists, and other hospital staff in both referral and receiving hospitals.6, 7 Mission: Lifeline is a national but community‐based initiative, establishing state and regional working groups to implement the national recommendations locally, in consideration of resources, geography, legislation, and regulation.Efforts by Mission:Lifeline to reduce delays have led to a number of important strategies (Table). The strategies have been codified in the 2013 STEMI guidelines that recommended prehospital ECG to diagnose STEMI to activate the Cardiac Catheterization Laboratory (CCL) while the patient is en route to the hospital.9 Pre‐activation CCL is a critical component of reducing reperfusion time, allowing parallel processing in which the patient is brought to the hospital while the CCL staff is arriving. Importantly, this has been associated with decreased mortality.10Table 1. Strategies Recommended by Mission:Lifeline to Reduce Delays in Reperfusion for Primary Percutaneous Coronary Intervention for STEMI PatientsAcquiring PH‐ECGsTransmission of the PH‐ECG to the emergency physician and/or cardiologist for potential activation of the CCL team before hospital arrivalParamedic interpretation of the PH‐ECG and clinical presentation to consider activation of the CCL team from the fieldEstablishing EMS destination policies and protocols that bypass hospitals without percutaneous coronary intervention capabilities in favor of an STEMI Receiving Center when STEMI is suspected in the field on the basis of the PH‐ECG and clinical presentationStrategies for rapid evaluation, guideline recommended therapies and transfer to STEMI receiving hospital for patients initially presenting at referral hospitals (focusing on door‐in‐door‐out time)Direct activation of the CCL by the Emergency DepartmentIf STEMI is strongly suspected, consideration of taking patients directly to the CCL without prior admission to the Emergency Department, when appropriateJohn Wiley & Sons, LtdCCL indicates cardiac catheterization laboratory; EMS, emergency medical services; PH‐ECG, prehospital ECG; STEMI, ST‐segment–elevation myocardial infarction.An important drawback to pre‐hospital activation of CCL has been the frequent cancellation of the CCL team after EMS field activation.11, 12, 13, 14, 15, 16, 17 While reasons for cancellation are numerous, a variety of patient‐specific (eg, goals of care, medical comorbidities, contraindications to catheterization, etc) and system‐specific factors (eg, ECG misinterpretation, ECG “STEMI‐mimics,” use of ECG computer algorithm versus EMS interpretation, difficulties in ECG transmission, etc) contribute to reasons for cancellation.11, 12, 13, 14, 15, 16, 17Incorrect activation of the CCL has a number of adverse consequences. First, unnecessary CCL activations can cause CCL staff fatigue and lead to “burn out” among physicians and the CCL staff members. There may be a loss of urgency among physicians and the CCL staff members, as they may begin to assume that STEMI protocol activation may well represent a “false alarm”. Inappropriate CCL activations are costly, as staff are often paid overtime to take calls and respond to CCL activations, regardless of whether or not the patient undergoes emergent coronary angiography.18The 2013 STEMI guidelines indicate that consideration should be given to the development of local protocols that allow preregistration and direct transport to the CCL, bypassing the Emergency Department (ED) for patients who do not require emergency stabilization upon arrival.9 Similarly, the European Society of Cardiology STEMI guidelines have recommended a strategy of ED bypass when an STEMI diagnosis is made by the EMS in the pre‐hospital setting.19 Use of Direct to CCL results in reductions in time to reperfusion similar to, if not greater than pre‐hospital notification, despite long transport times.20 If STEMI is strongly suspected, consideration of taking patients directly to the CCL20, 21, 22, 23, 24, 25, 26, 27 without prior admission to the ED, when appropriate, can reduce the time the patient spends in the ED (“dwell time”), which is often the most variable time component, therefore potentially the most modifiable component of FMC2D time.To successfully implement the strategy for shortening the FMC2D interval by taking the patient directly to the CCL, it is critical that the processes for field assessment accurately and reliably identify patients who are most likely having an STEMI and who are appropriate candidates for angiography. This process must be both sensitive and specific for detecting and triaging STEMI patients.To support standardization and implementation of prehospital activation and Direct to CCL strategies, the Mission: Lifeline program established an implementation project team, which led to the development of the Mission: Lifeline Prehospital Activation of Hospital Resources (PreAct) STEMI algorithm (Figure). The PreAct STEMI algorithm outlines a process for patient triage in the field and routing upon hospital arrival. It incorporates best practices from STEMI systems of care from across the country. The PreAct STEMI algorithm is intended to: Increase rates and timeliness of appropriate prehospital CCL activation and triage of patients who have ECG findings of STEMI.Reduce rates of prehospital CCL activation for patients who do not have STEMI.Guide decision‐making for which potential STEMI patients are appropriate for: prehospital activation of the CCL; Direct to CCL routing; expedited ED exam before CCL activation; and full ED evaluation before a CCL activation decision.Provide performance measures that can guide quality assurance/quality improvement efforts.Download figureDownload PowerPointFigure 1. The Prehospital Activation of Hospital Resources algorithm. ACS indicates acute coronary syndrome; ASAP, as soon as possible; BP, blood pressure; CCL, cardiac catheterization laboratory; DNR, do not resuscitate; ED, emergency department; EMS, emergency medical services; HR, heart rate; RBBB, right bundle branch block; STEMI, ST‐segment–elevation myocardial infarction.PreAct AlgorithmThe PreAct STEMI algorithm is intended to be applied to patients with ischemic symptoms and/or EMS suspicion of acute coronary syndrome/STEMI. For these patients, EMS should obtain a “clean” PH‐ECG (ie, interpretable and free of artifact) (marker 1) which reduces diagnostic errors by both clinicians and software tools.28, 29, 30 Standard EMS processes should apply to patients where the clinical presentation and/or ECG are not consistent with acute coronary syndrome/STEMI (markers 13, 15).The algorithm branches depending on transmission capabilities (marker 2) and whether the ECG is consistent with STEMI. If transmission is not available and the ECG is consistent with STEMI (by EMS or machine interpretation, marker 3) or if transmission is available and the ECG is consistent with STEMI (by the interpreting emergency physician or cardiologist, marker 4), EMS and the emergency physician should then confer (markers 5, 6). The discussion should focus on determining if the patient fulfills the Direct to CCL criteria (marker 7) and therefore appropriate for immediate CCL activation and direct CCL transport (marker 10). Patients who do not fulfill the Direct to CCL criteria should be transported to the ED to undergo an expedited exam (marker 9), with the goal of rapidly determining if the patient should continue to the CCL.The emergency physician may consider cardiology and/or CCL team notification (without full activation) or full activation of the CCL (marker 8) while the patient is still in the field, depending on ECG and clinical data available.For all approaches, once indications for CCL has been determined, CCL readiness is assessed (marker 11). If the CCL is adequately staffed, the patient should be transported directly to the CCL (on the ambulance stretcher and by EMS when possible). If the CCL is not adequately staffed, the patient should wait in a designated area with appropriate monitoring and supervision (usually the ED), until the CCL is ready to receive the patient (marker 12).In systems where 12 lead ECG transmission is not utilized or when transmission is not possible, the paramedic applies the following criteria (marker 3): (1) an isoelectric baseline reasonably free of artifact and (2) at least 1 mm of ST elevation in ≥2 contiguous leads with a paramedic or machine interpretation of STEMI. If met, the receiving ED is notified as soon as possible (marker 5). The paramedic and emergency physician discuss the patient (marker 6), including Direct to CCL criteria (marker 7), with further care as outlined in the algorithm.Direct to CCL CriteriaDespite pre‐hospital notification of STEMI patient, ED length of stay is frequently prolonged.22 The purpose of the PreAct criteria (marker 7) is to identify a subset of patients who clearly have an STEMI for whom direct transfer to the CCL is appropriate, as this substantially reduces reperfusion times.20, 21, 22, 23, 24, 25, 26, 27 We use the phrase “Direct to CCL” rather than “ED Bypass” for the following reasons. First, Direct to CCL more accurately describes the intent of the efforts. Most hospital ambulance entrances flow into the ED making the path to the CCL through the ED area unavoidable. Second, in most hospitals, the process of accomplishing Direct to CCL requires participation by ED staff to coordinate CCL team communications and patient registration. At times this may require a brief “pause” or “pit stop” in the ED. Finally, Direct to CCL best describes the receiving hospitals intent with regard to its Emergency Medical Treatment and Labor Act31 obligations to provide an appropriate Medical Screening Exam, since some patients who are transported directly to the CCL may be ultimately determined to have non‐cardiac conditions requiring other specialists.Despite significantly reducing time to reperfusion, the Direct to CCL concept remains controversial. Concerns include CCL activations without a true STEMI, the difficulty in reaching consensus on Direct to CCL criteria for a standardized EMS protocol, and safety of transporting a patient to the CCL without adequate staff being present. Specific criteria were developed (marker 7) for standardized decision making for EMS and emergency physicians on appropriateness for going directly to the CCL.However, for Direct to CCL to be successful, appropriate planning is critical.22, 23, 24, 25, 26, 27, 28 Centers that have successfully implemented Direct to CCL have included additional designated in‐hospital CCL activation team members who are notified by the STEMI group page to assist with patient transfer to the CCL and subsequent monitoring until the CCL team arrives.22, 23, 24, 25, 26, 27, 28 Team members can vary depending on the hospital, and have included intensive care unit and/or ED nursing, in‐house CICU residents, and/or dedicated transportation staff. In some centers, the team can place the patient on the procedure table, connect monitoring equipment, and confirm that all appropriate equipment is available. The success of this process is dependent on the CCL staff arriving within the recommended 30 minutes of paging.Education of all team members is critical for patient's safety. The transportation team members should be familiar with the location of the resuscitation equipment in the CCL and have the capability of providing immediate resuscitative treatment if required, which includes starting intravenous drips, performing defibrillation, and requesting intubation by respiratory therapy.22, 23, 24, 25, 26, 27, 28Direct to the CCL may not be possible for all patients or all hospitals. An alternative for hospitals that do not have the resources for off hours Direct to CCL, or in situations when pre‐hospital notification is short, is the establishment of a process for a short “pit stop” or “brief pause” in the ED for STEMI patients who only need to be monitored for a brief period.26 If possible, patients should be kept on the EMS gurney with continued supervision by EMS and ED nursing. If time permits, admission laboratory testing can be obtained. As soon as the CCL is available, the patient should be directly transported to the CCL. The protocol should be explicit that transportation should occur promptly when the CCL is ready and should not be delayed for routine testing (eg, chest x‐ray, ECG when the EMS ECG is diagnostic).Patients who are seen at a non‐percutaneous coronary intervention (PCI) hospital ED initially have the benefit of 12 lead ECGs, physician evaluation, and possibly cardiology consultation before transfer to the PCI hospital. Therefore, taking patients directly to the CCL should be standard practice for inter‐facility STEMI transfers.32PreAct Inclusion/Exclusion CriteriaOf the Direct to CCL criteria specified, 4 are considered essential—(1) Paramedic confident in the STEMI diagnosis; (2) emergency physician and/or cardiologist confident in the STEMI diagnosis; (3) ability to provide informed consent; and (4) no “do not resuscitate” (DNR): Paramedic confident in STEMI diagnosis—When EMS is uncertain about whether STEMI ECG criteria are met (in the absence of transmission) or whether the patient is having an STEMI based on the clinical presentation, initial evaluation in the ED is indicated.Emergency physician and/or cardiologist confident in STEMI diagnosis—Based on the prehospital report and prehospital ECG, if the emergency physician and/or cardiologist is in doubt of the diagnosis or otherwise believes the patient needs initial ED evaluation, the patient should be evaluated in the ED initially.Ability to provide consent—The patient's mental status should be considered for ability to give informed consent. If there is doubt, direct CCL transfer is not appropriate.No do not resuscitate—Patients who have a known do not resuscitate still should be transported to an STEMI receiving center for further evaluation. Patient preference, shared‐decision making, and informed consent are important and legally mandated components of the STEMI process,33, 34 in whom after an informed discussion emergent coronary angiography may still be performed.ST Elevation ≥2 mm in ≥2 Contiguous LeadsUsing ≥2 mm as a direct criterion decreases diagnostic uncertainty and improves specificity.35 This criterion is more stringent than typical criteria for STEMI diagnosis to account for technical and interpretation challenges inherent to the prehospital environment that can lead to a higher rate of over activations.35 Larger extent of ST elevation also identifies patients who have greater areas at risk36 and therefore more likely to benefit from accelerated reperfusion.Aged 30 to 90 YearsYounger patients (aged <30 years) are less likely to have myocardial infarction and significantly more likely to have ECG abnormalities that mimic STEMI. Extremely elderly patients (aged >90 years) are more likely to have significant medical comorbidities or goals of care that may preclude cardiac catheterization, such that discussions of goals of care with the patient and/or their family before angiography is appropriate.Pain <24 HoursSymptom duration is an important predictor of clinical outcomes in patients presenting with STEMI.9 Symptoms lasting >24 hours may suggest that transmural damage had occurred—a relative contraindication to emergency catheterization.9 However, prolonged symptoms should not be considered an absolute contraindication to coronary angiography, as symptom duration may be an inaccurate measure of infarct onset, such as in patients with stuttering ischemia or limited recall.QRS <0.12 (Unless Right Bundle Branch Block is Present)Prolonged QRS duration is usually secondary to left bundle branch block or paced rhythm, both of which frequently obscure evidence of ischemia.37, 38 The presence of a right bundle branch block is an exception to this criterion.No Paced RhythmMany patients with paced rhythms have a left bundle branch block pattern, which may obscure ECG evidence of ischemia.38Systolic Blood Pressure >80 mm HgPatients with severe hypotension (eg, systolic blood pressure <70–80 mm Hg despite vasopressors) usually require stabilization before emergency coronary angiography. However, extensive delays when hypotension is due to cardiogenic shock should be avoided, as definitive treatment with PCI and/or percutaneous left ventricular support is likely to be beneficial.39No Significant ArrhythmiasPatients who have significant arrhythmias that require stabilization should undergo ED evaluation before being transported to the CCL. However, in situations when the arrhythmia is ischemia related, such as recurrent ventricular tachycardia or fibrillation, or heart block, proceeding rapidly to the CCL for PCI may be the most appropriate course.Heart Rate >130 bpmExcessive tachycardia can indicate impending shock, hypoxia, pulmonary edema, tachyarrhythmia, or other serious conditions that would increase the risk of Direct to CCL routing, as well as obscure the interpretation of the 12‐lead ECG and warrants further evaluation and stabilization in the ED before coronary angiography.Significant Hypoxia Despite Supplemental OxygenSignificant hypoxia despite supplemental oxygen (eg, 100% non‐rebreather) may be secondary to severe pulmonary edema or non‐cardiac etiologies. Stabilization, including possible intubation before emergent angiography may be required. This is best addressed in the ED rather than in the CCL.Additional ConsiderationsThe Mission: Lifeline program advocates for a consistent and standardized process for paramedics to discuss the patient with emergency physicians and/or cardiologists to determine if they meet the Direct to CCL criteria. Ideally, this should be a recorded or documented conversation for medicolegal purposes. In addition, having the Direct to CCL criteria formatted as a checklist is recommended. Patients who meet all criteria can be designated as eligible for the Direct to the CCL pathway by protocol. Monitoring with prompt feedback should be performed by the hospital STEMI quality assurance/quality improvement program to facilitate refinement of the Direct to CCL pathway based on outcomes. Open lines of communication and respectful dialogue among team members are paramount for a successful Direct to CCL program.The PreAct STEMI algorithm provides a template that can be modified by EMS medical directors, emergency physicians, and cardiologists at a systems level based on local experience, circumstances, and resources (ie, ECG transmission, destination protocols). Similarly, systems without reliable capabilities for ED bypass may use other components of the PreAct STEMI algorithm. Mission: Lifeline encourages systems that modify criteria to measure algorithm compliance, algorithm performance, and report the results so that the Direct to CCL criteria can be refined.Written protocols should be in place for when a patient presents for care at the hospital but not necessarily in the ED.31 If patients are determined to be inappropriate for emergency angiography, the patient can be routed back to the ED, as movement of patients between 2 areas of a hospital or facility that share the same Medicare provider number is acceptable under the Emergency Medical Treatment and Active Labor Act regulations and is not considered a transfer.31 It is critical to have written policies that guide processes for the Emergency Medical Treatment and Active Labor Act screening exams in the CCL and how patients are handled if they are not found to be appropriate for emergency angiography and PCI.Quality MetricsDefinitions for false positive (overactivation) and false negative (under‐activation) activations from EMS have varied.11, 12, 13, 14, 15, 16, 17 Without standardized definitions that are widely used, comparison between agencies and systems is difficult. Because the terminology of “false positive” and “false negative” are often perceived pejoratively, particularly by EMS, the terms “overcall,” “undercall,” and “correct call” are recommended.For EMS, an overcall is defined when EMS declares a “STEMI Alert” (eg, EMS notifies the hospital of their field impression of STEMI) but the patient does not undergo emergency angiography and is not diagnosed with myocardial infarction. Emergency angiography was specifically selected as the discriminating factor. If the interventional cardiologist thought emergency angiography was indicated, it should be sufficient to support the decision leading to an EMS STEMI Alert. Exclusions can be made for cases where symptoms and/or ECG changes resolved after the STEMI Alert was declared.An EMS undercall is defined as cases where the patient diagnosed with STEMI who arrived by ambulance and underwent emergency angiography who met PreAct criteria, but EMS did not declare a STEMI Alert before arrival at the ED.An EMS correct call is defined as cases where there is an STEMI Alert with subsequent emergency angiography or emergency thrombolytic administration (true positive); or, where there is not an STEMI Alert and neither emergency angiography nor emergency thrombolytic administration is performed (true negative).Similar definitions for over‐, under‐ and correct calls should be applied to the ED CCL activations.Feedback on all STEMI activations should be provided in a timely manner, typically within 24 to 48 hours after CCL activation. Summary statistics on over‐, under‐, and correct calls should be provided to each EMS agency on a regular basis (eg, monthly, quarterly). More granular determination of reasons for overactivation can be useful to identify common reasons with the potential for protocol modification.DiscussionCurrent guidelines recommend an FMC2D time of ≤90 minutes.26 Use of prehospital ECGs decreases time‐to‐revascularization, with or without transmission to the STEMI receiving center.40, 41 These time savings translate into improved patient outcomes.6, 7, 42 The premise of the PreAct STEMI program is that a consistently applied process including routine, timely prehospital ECGs with prehospital notification will improve the accuracy and decision‐making of activation of the CCL for STEMI patients, leading to expedited patient evaluation and routing upon hospital arrival, including taking patients direct to the CCL. Application of a consistent process should increase the appropriateness of patients undergoing cardiac catheterization, reducing delays, and improving outcomes.Prehospital Barriers to EMS Prehospital Acquisition, Interpretation, and TransmissionPrehospital identification of STEMI has been successfully implemented in many regions by training EMS personnel to make STEMI‐focused interpretations of 12‐lead ECGs. However, universal adoption of prehospital ECG acquisition with CCL activation remains limited. Barriers include funding for ECG transmission equipment and interpretation training, and issues with hospital acceptance of a broader EMS role in STEMI care.One barrier to widespread use of prehospital ECGs is funding to train and equip EMS personnel to acquire, interpret, and transmit the prehospital ECG. At present, there are no standards defining the education required to achieve and maintain competence in STEMI‐focused prehospital 12‐lead ECG interpretation.The AHA recommends 3 modes of prehospital ECG interpretation: paramedic interpretation, computerized algorithm diagnosis, and ECG transmission for remote interpretation.35 Paramedics can be trained to acquire and interpret prehospital ECGs accurately in the absence of confounding ECG factors, with high sensitivity and specificity.6, 35, 42, 43, 44, 45, 46 An alternative to reliance on paramedic ECG interpretation is to use the computerized interpretation technology. This process is rapid, easy, requires minimal training, is readily available and accessible regardless of geographic location, and is not dependent on a wireless network.35 However, compared with physician interpretation, computer‐based ECG interpretation results in more false‐positive and false‐negative ECGs.35The results of EMS programs for STEMI recognition have been mixed. In some communities, EMS can recognize STEMI with good sensitivity and specificity.6, 47, 48, 49 In others, there have been high percentages of EMS‐initiated CCL activations for patients who did not ultimately have STEMI.11, 12, 13, 14, 15, 16, 17 The expense and inconvenience of these cases, particularly in off‐hours, can be considerable, and has contributed to under‐use and decreased adoption of prehospital CCL activation.The third met

BACKGROUND:Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI.METHODS:STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals.RESULTS:Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles.CONCLUSIONS:Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.

The author examines the basic features of the final bill on CTR III approved by the Swiss parliament on 17 June 2016, which will be subject to a public vote on 12 February 2017. The article further outlines plans of the cantons of Basel-Stadt, Geneva, Zug and Zurich for implementing the reform at the cantonal level. In addition, the tax implications for beneficial owners of corporate structures are shown, including an outlook on what will happen in the event the final bill is not approved.

Background— The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-needle (DTN) times, was associated with an average 15-minute reduction in DTN times. Target: Stroke phase II was launched in April 2014 with a goal of promoting further reduction in treatment times for tissue-type plasminogen activator (tPA) administration. Methods and Results— We conducted a second survey of Get With The Guidelines-Stroke hospitals regarding strategies used to reduce delays after Target: Stroke and quantify their association with DTN times. A total of 16 901 ischemic stroke patients were treated with intravenous tPA within 4.5 hours of symptom onset from 888 surveyed hospitals between June 2014 and April 2015. The patient-level median DTN time was 56 minutes (interquartile range, 42–75), with 59.3% of patients receiving intravenous tPA within 60 minutes and 30.4% within 45 minutes after hospital arrival. Most hospitals reported routinely using a majority of Target: Stroke key practice strategies, although direct transport of patients to computed tomographic/magenetic resonance imaging scanner, premix of tPA ahead of time, initiation of tPA in brain imaging suite, and prompt data feedback to emergency medical services providers were used less frequently. Overall, we identified 16 strategies associated with significant reductions in DTN times. Combined, a total of 20 minutes (95% confidence intervals 15–25 minutes) could be saved if all strategies were implemented. Conclusions— Get With The Guidelines-Stroke hospitals have initiated a majority of Target: Stroke–recommended strategies to reduce DTN times in acute ischemic stroke. Nevertheless, certain strategies were infrequently practiced and represent a potential immediate target for further improvements.

Objective: This study aimed to define the ethnographic composition and assess the health-related quality of life (HRQoL) of a large population of undocumented patients with end-stage renal disease (ESRD) seeking emergent dialysis in the emergency department (ED) of a large public hospital in the United States. Design: All ESRD patients presenting to the hospital's main ED were identified during a 4-week consecutive enrollment period. Consenting patients completed two surveys-an ethnographic questionnaire and the validated kidney disease quality of life-36 (KDQOL-36) instrument. Setting: The study was conducted at a large county hospital in Dallas, Texas. In 2013, the hospital recorded >50,000 ED visits and administered approximately 6,000 dialysis treatments to ED patients. Participants: 88 of 101 unfunded patients presenting to the ED during the study period consented to participate, resulting in an 87.1% response rate. 65 of these patients were undocumented immigrants. Main Outcome Measures: Quantitative scores for the 5 subscales of the KDQOL-36 were calculated for the study population. Results: Measures of physical and mental health in our study population were lower than those published for scheduled dialysis patients. 79.5% of our patients lost employment due to their dialysis requirements. At least 71.4% of the study patients were unaware that they required dialysis before immigrating to the United States. Conclusions: Quality of life scores were found to be low among our population of undocumented emergent dialysis patients. Our data also provide some evidence that availability of dialysis at no cost is not a primary driver of illegal immigration of ESRD patients to the United States.

Aims Post-stroke hypertension is associated with poor short-term outcome, although the results have been conflicting. Our objective was to evaluate the association of blood pressure (BP) and in-hospital outcomes in patients with acute ischaemic stroke. Methods and results Patients in the Get With The Guidelines-Stroke registry with acute ischaemic stroke were included. Admission systolic and diastolic BP was used to compute mean arterial pressure (MAP) and pulse pressure (PP). The outcomes of interest were: in-hospital mortality, not discharged home, inability to ambulate independently at discharge and haemorrhagic complications due to thrombolytic therapy. A total of 309 611 patients with an ischaemic stroke were included. There was a J-shaped/U-shaped relationship between systolic BP and outcomes. Both lower and higher systolic BP values, compared with a central reference value, had higher risk of in-hospital death [e.g. adjusted odds ratio (95% confidence interval) (OR[CI]) = 1.16[1.13-1.20] for 120 vs. 150 mmHg and 1.24[1.19-1.30] for 200 vs. 150 mmHg], not discharged home (OR[CI] = 1.11[1.09-1.13] for 120 vs. 150 mmHg and 1.15[1.12-1.18] for 200 vs. 150 mmHg), inability to ambulate independently at discharge (OR[CI] = 1.16[1.13-1.18] for 120 vs. 150 mmHg and 1.09[1.06-1.11] for 200 vs. 150 mmHg). However, risk of haemorrhagic complications of thrombolytic therapy was lower with lower systolic BP (OR[CI] = 0.89[0.83-0.97] for 120 vs. 150 mmHg), while higher with higher systolic BP (OR[CI] = 1.21[1.11-1.32] for 200 vs. 150 mmHg). The results were largely similar for admission diastolic BP, MAP, and PP. Conclusion In patients hospitalized with ischaemic stroke, J-shaped, or U-shaped relationships were observed between BP variables and short-term outcomes. However, haemorrhagic complications with thrombolytic therapy were lower with lower BP.

Background and Purpose— Antithrombotics are the mainstay of treatment in primary and secondary prevention of stroke, and their use before an acute event may be associated with better outcomes. Methods— Using data from Get With The Guidelines-Stroke with over half a million acute ischemic strokes recorded between October 2011 and March 2014 (n=540 993) from 1661 hospitals across the United States, we examined the unadjusted and adjusted associations between previous antithrombotic use and clinical outcomes. Results— There were 250 104 (46%) stroke patients not receiving any antithrombotic before stroke; of whom approximately one third had a documented previous vascular indication. After controlling for clinical and hospital factors, patients who were receiving antithrombotics before stroke had better outcomes than those who did not, regardless of whether a previous vascular indication was present or not: adjusted odds ratio (95% confidence intervals) were 0.82 (0.80–0.84) for in-hospital mortality, 1.18 (1.16–1.19) for home as the discharge destination, 1.15 (1.13–1.16) for independent ambulatory status at discharge, and 1.15 (1.12–1.17) for discharge modified Rankin Scale score of 0 or 1. Conclusions— Previous antithrombotic therapy was independently associated with improved clinical outcomes after acute ischemic stroke. Ensuring the use of antithrombotics in appropriate patient populations may be associated with benefits beyond stroke prevention.

The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.

BACKGROUND:Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected.METHODS:The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile.RESULTS:Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%).CONCLUSIONS:Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.

Background: The benefits of intravenous tissue plasminogen activator (IV tPA) in acute ischemic stroke are time-dependent. The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-need (DTN) times, was associated with an average 15 minutes reduction in DTN times. To further reduce DTN delays, Target: Stroke Phase II was launched in 2014 and disseminated additional new best practice strategies. Methods: All active Get With The Guidelines-Stroke hospitals (n=1701) were invited to participate in Target: Stroke Phase II and completed an online survey regarding their use of DTN strategies. Hospital respondents reported the use of specific strategies in the 6 months preceding the survey as a binary yes/no or a continuous 0 to 100% of the time scale. Results: A total of 1034 hospitals (61% response rate) completed the survey between Dec 2014 and Apr 2015. The majority of participating hospitals reported routine use of Target: Stroke key practice strategies, although direct transfer to CT scanner, point of care testing, pre-mix of tPA ahead of time, tPA stored in Emergency Department (ED), or initiation of tPA bolus in the imaging suite were used less frequently (Table). Brain imaging located within the ED was reported by 44% of hospitals and 78% had access to an in-house stroke expert 24/7. Among those who did not have stroke expertise at all times, a majority of hospitals used telestroke systems for imaging interpretation (78%) or clinical evaluation (58%). Conclusions: GWTG-Stroke hospitals reported moderate to extensive use of most Target: Stroke key practice strategies to evaluate acute stroke cases for tPA eligibility and reduce DTN times. Nevertheless, use of point of care testing, pre-mixing of tPA, ED storage of tPA, initiation of tPA in the imaging suite, and direct transfer to CT scanner remained low, representing potential targets for additional improvements.

Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014. Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression. Results: There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure). Conclusions: The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.

Introduction: Timely reperfusion is performed less optimally in acute ischemic stroke (AIS) than in acute myocardial infarction (AMI). The degree to which hospital performance is correlated on emergent AMI and AIS care is unknown. Hypothesis: There would be a positive correlation between hospital performance on door-to-balloon time (D2B) for AMI and door-to-needle time (DTN) for AIS; and hospital performance on D2B would predict DTN even after controlling for patient and hospital differences. Methods: Prospective study of all hospitals participating in both Get With The Guidelines (GWTG)-Stroke and -Coronary Artery Disease from 2006-09 and treating ≥10 patients. We compared hospital-level DTN and D2B before and after risk adjustment using Spearman’s rank correlation coefficients and hierarchical linear regression modeling. We also correlated hospitals’ DTN and D2B data from 2013-14 using GWTG (DTN) and Hospital Compare (D2B). Results: There were 43 hospitals contributing data (1976 AIS and 59,823 AMI patients). Hospitals’ DTN times for AIS did not correlate with their D2B times for AMI (median DTN 85 min [IQR 77-99] vs. median D2B 72 min [IQR 62-81]; ρ=-0.09; p=0.55). There was no correlation between hospitals’ proportion of eligible patients treated within target time windows for AIS and AMI (median DTN<60 minutes: 21% [IQR 11-30]; median D2B<90 minutes: 68% [IQR 62-79]; ρ=-0.14; p=0.36). The lack of correlation between hospitals’ DTN and D2B times persisted after risk adjustment. From 2013-14, hospitals’ DTN performance in GWTG was not correlated with D2B performance in Hospital Compare (N=546 hospitals; see figure). Conclusions: We found no correlation between hospitals’ observed or risk-adjusted DTN and D2B times. Opportunities exist to improve hospitals’ performance of time-critical care processes for AIS and AMI in a coordinated rather than condition-specific manner.

Background Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government‐sponsored insurance had worse quality of care or in‐hospital outcomes in acute ischemic stroke. Methods and Results Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in‐hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines‐Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED , or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22‐1.45]; ≥65 years OR 1.54 [95% CI 1.34‐1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6‐0.67]; ≥65 OR 0.56 [95% CI 0.5‐0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [ CI 1.96‐2.2]; OR 2.01 [95% CI 1.91‐2.13]; ≥65 years OR 1.1 [95% CI 1.07‐1.13]; OR 1.41 [95% CI 1.35‐1.46]). Conclusions Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in‐hospital mortality differ by patient insurance status.

BACKGROUND:Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans.METHODS:We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States.RESULTS:Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001).CONCLUSIONS:This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.

Background Non-vitamin K antagonist oral anticoagulants (NOACs, dabigatran, rivaroxaban, apixaban, and edoxaban) have been increasingly used as alternatives to warfarin for stroke prophylaxis in patients with atrial fibrillation. Yet there is substantial lack of information on how patients on NOACs are currently treated when they have an acute ischemic stroke and the best strategies for treating intracerebral hemorrhage for those on chronic anticoagulation with warfarin or a NOAC. These are critical unmet needs for real world clinical decision making in these emergent patients.Methods The ARAMIS Registry is a multicenter cohort study of acute stroke patients who were taking chronic anticoagulation therapy prior to admission and are admitted with either an acute ischemic stroke or intracerebral hemorrhage. Built upon the existing infrastructure of American Heart Association/American Stroke Association Get With the Guidelines Stroke, the ARAMIS Registry will enroll a total of approximately 10,000 patients (5000 with acute ischemic stroke who are taking a NOAC and 5000 with anticoagulation-related intracerebral hemorrhage who are on warfarin or a NOAC). The primary goals of the ARAMIS Registry are to provide a comprehensive picture of current treatment patterns and outcomes of acute ischemic stroke patients on NOACs, as well as anticoagulation-related intracerebral hemorrhage in patients on either warfarin or NOACs. Beyond characterizing the index hospitalization, up to 2500 patients (1250 ischemic stroke and 1250 intracerebral hemorrhage) who survive to discharge will be enrolled in an optional follow-up sub-study and interviewed at 3 and 6 months after discharge to assess longitudinal medication use, downstream care, functional status, and patient-reported outcomes.Conclusion The ARAMIS Registry will document the current state of management of NOAC treated patients with acute ischemic stroke as well as contemporary care and outcome of anticoagulation-related intracerebral hemorrhage. These data will be used to better understand optimal strategies to care for these complex but increasingly common emergent real world clinical challenges.