Emergency hospital transfer of STEMI patients might be expedited with a hospital-level 'Call 911 protocol'

Despite the American Heart Association (AHA) Mission: Lifeline Program being implemented to reduce transfer times of ST‐segment–elevation myocardial infarction (STEMI) patients in a timely manner to hospitals with primary percutaneous coronary intervention (PCI) capability, response times still often lag, according to a new study published in the Journal of the American Heart Association.[1] The researchers suggest adding a simple 3‐step process of an interhospital “Call 911” protocol might expedite this process.

The AHA implemented the Mission: Lifeline Program in 2007 as a national, community‐based initiative to improve the quality of care and outcomes for STEMI by reducing response times. Every minute of delay in treatment of patients with STEMI affects 1‐year mortality, not only in thrombolytic therapy, but also in primary angioplasty. Current data measured in the AHA Get With The Guidelines Registry suggests that just over half of EMS patients receive PCI within the recommended 90 minute treatment window.

As vascular emergency care rapidly expands to now include stroke and pulmonary embolism (PE) thrombectomy, the Mission: Lifeline program is seeing additional demands for emergency transfers.  

A research team from Harbor–UCLA Medical Center found in this study there is still a large amount of variability in system parameters, resources, geography, regulation and response times in the United States affecting prehospital care systems. Patients with time‐sensitive conditions like STEMI or stroke need specialized resources and rapid transport, but in a safe, well‐organized, comprehensive transfer process with oversight. Minimizing the amount of time needed to facilitate STAT TRANSFER is an important goal. 

They suggest in the article a more consistent strategy to reduce variability in interhospital transfer times. They propose the term “STAT TRANSFER” to describe emergency transport between hospitals to promote predictability in the transfer process that decrease system delays and reduce EMS variability. In addition, a "Call 911" interhospital transfer process is suggested to expedite care of patients with STEMI or stroke involved in STAT TRANSFER. 

The STAT TRANSFER process uses a systems approach that considers new ways for how patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming STEMI patient. But, the authors wrote any processes of care, such as STAT TRANSFER or Call 911, must be tailored to meet the unique needs of the local community to make the system of care predictably efficient in all urban and rural areas.


The authors outlined the following components for a regional STAT TRANSFER program:

   • Policies favoring standardization of transport from the scene among EMS agencies directly to a 24/7 PCI‐capable receiving center. Exemptions include timing issues needing initiation of fibrinolytic therapy, hemodynamic instability, and airway management that the ambulance crew is unable to resolve.

   • Criteria to identify patients for transfer.

   • Policies seeking agreement from patient or family for transport to a higher level of care facility.

   • Processes to minimize delays in ambulance arrival to a referring hospital to ≤15 minutes, after a request for STAT TRANSFER.

   • Processes to minimize delays for initiating transfer from referring hospitals after ambulance arrival.

   • Policies to minimize disruptions in emergency ambulance coverage of communities served by ambulances used for STAT TRANSFER.

   • Procedures at referring hospitals to meet the stroke door-in-door-out time (DIDO) time goal of ≤30 to 45 minutes.

   • Processes to minimize patient risk during STAT TRANSFER.

   • Processes to minimize delays between patient's arrival at the referring hospital to definitive intervention by emergency department (ED) and specialty service staff at the receiving center:

     1. Activation of hospital resources before ambulance arrival including activation of the cardiac catheterization team before patient arrival at the receiving hospital.

     2. Prehospital registration of the patient and, if possible, ordering labs by receiving center before arrival. For patients transferred out of system, use of generic registration credentials with immediate creation of patient record and initiation of STEMI charting.

     3. Implementation of ED protocols that allow STAT TRANSFER ambulance crew to bring the patient directly to the cardiac catheterization laboratory (CCL) when clinically appropriate.

   • Policies to avoid simultaneous STAT TRANSFERS to the same hospital unless there is confirmation of PCI capacity without significant delay.

   • In regions where ≥2 STEMI receiving center (SRC) are accessible, policies are needed in referring hospitals for rapid selection of which receiving center is used for transfer. Ideally, this policy is often decided by distance or transport times, but may also be influenced by health system affiliations, partnerships, patient preference, continuity of care, and accessibility of prior medical records.

   • Mechanisms for tracking STAT TRANSFER process performance at the network SRC including regularly scheduled quality performance reviews that access the process and accountability for all system‐of‐care participants.


Use of EMS for STAT TRANSFER Call 911 transport activation

The authors wrote STAT TRANSFER provides an alternative interhospital Call 911 process. They said this can use the same EMS provider or ambulance service that responds directly to patient related 911 calls. This option for interhospital transfer should be a formalized process with EMS agencies. The STAT TRANSFER Call 911 process should trigger response from the first available unit, usually an EMS agency, capable of critical transfer within a specified time. The STAT TRANSFER process should also be assessed by EMS agencies and regional/community SRCs for quality and outcomes with improvements made as needed. 

Other sections of the article cover the STAT TRANSFER activation process, and the responsibilities of community healthcare leaders, EMS, communications call centers, initial ambulance response provider, referring hospital, receiving center and of the STAT TRANSFER ambulance provider. The article also outlines policies and procedures for STEMI receiving centers, barriers in rural areas and what should be including in score cards to grade response times.

Read the full article

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