Time is muscle and the earlier you get to PCI the more muscle you can save. So, we should just drive by all the critical access hospitals and go straight to PCI-capable centers? The Dutch, in this retrospective study, think we should. Everything in their protocol hinges on EMS reading a computer interpretation of the EKG, and, if it says STEMI, they go to the PCI center. At the end of the day, everyone who went to the PCI capable center first rather than the spoke hospital first had a mortality benefit between 2% and 2.6% at one year.
What they really don’t discuss much are the outcomes of the 5.7% of their intention-to-treat analysis that had false positives. False positives, at least, are typically not harmful to the patient – the alternative diagnoses for chest pain that would benefit from immediate treatment at one of their non-PCI “spoke” hospitals are probably not that frequent – aortic dissections and submassive PEs tend to be the sorts of things that would benefit. But, even if they did a true intention-to-treat analysis, they’d probably still have a mortality benefit. The other problem with false positives is the financial costs associated with unneeded cath lab activation and the costs to the system associated with taking EMS out of service. It’s obvious that treating patients for their disease in the most timely fashion for certain diseases improves outcomes – but we must always beware of the unintended consequences.
http://www.ncbi.nlm.nih.gov/pubmed/21315209
This is actually a big deal sort of topic in EM right now as it relates to the regionalization of care, which is something that the Academic Emergency Medicine consensus conference is dealing with right now. Attempting to mirror what’s happened with trauma networks, they’re trying to extend the benefits to other acute conditions that otherwise benefit from transfer to higher levels of care. Clearly, a myriad of life-threatening conditions benefit from the resources of tertiary referral centers – but the logistics and political issues associated with centralizing care for different conditions remains a significant barrier.
http://www.ncbi.nlm.nih.gov/pubmed/21122020