Intervention Programs to Reduce Patient
Delays in Acute Myocardial Infarction
Johan Herlitz, MD, PhDDepartment of Heart and Lung Diseases
Division of Cardiology
Sahlgrenska University Hospital
Göteborg, Sweden
Quick Overview
The delay between the onset of symptoms and the start of treatment has become a critical factor in the attempt to limit cardiac muscle damage and thus improve the prognosis in acute myocardial infarction (AMI). The rationale for this is that the new treatment regimens for AMI developed during the last decade, such as thrombolysis, (1-4) beta blockers, (5-7) and the opportunity to perform percutaneous transluminal coronary angioplasty (PTCA), (8-10) can limit infarct size and improve the prognosis. It is now clearly shown that the interval between the onset of symptoms and the start of intervention, particularly with thrombolysis, is directly correlated with outcome. The earlier such intervention is started, the better is the prognosis. (1) The dominant part of the total delay time until delivery of treatment is the time from symptom onset to the time the patient seeks medical assistance. During the last two decades, various efforts have been made in order to reduce this decision time in terms of educational campaigns, mostly delivered to the general public.
Impact of Educational Campaigns on Patient Delay
Following the study conducted by Rowley et al, (11) there have been at least eight documented media campaigns designed to educate the public about the dangers of acute chest pain and the possibility of improving outcomes in the case of AMI if treatment is started early.
The first of these campaigns, called Signals and Action, was conducted in Halifax, Canada. It was a short-term campaign with a pretest period of 4 weeks, an intervention period of 8 weeks, and a 1-week post-test period, 3 months after the end of the campaign. During the pretest period 16% of patients with acute chest pain were admitted to the hospital within 2 hours after onset of chest pain as compared with 32% during the campaign (P<0.05). In the post-test period, 29% presented within 2 hours. (12)
In the "Göteborg Heart Pain 90,000" campaign, a 1-year media campaign was preceded by a 21-month control period. The median delay time between onset of pain and arrival in the hospital among AMI patients fell from 3 hours during the control period to 2 hours 20 minutes during the year of the campaign (P<0.001). (13)
In Seattle, a 2-month educational campaign was evaluated by comparing a pretest period of 4.5 months and a post-test period of the same duration. The campaign did not significantly shorten patient delay in seeking care (premessage median delay of 2.6 hours; postmessage median delay of 2.3 hours). (14)
A media campaign in the city of Ludwigshafen in West Germany was more successful. (15) During a pretest period of 4 months, 42% of patients with acute chest pain arrived at the hospital within 2 hours of the onset of pain as compared with 82% during the campaign (P<0.05). The median delay decreased from 4.0 hours prior to the campaign to 3.2 hours during the intervention.
A 2-year media campaign in Jacksonville, Illinois, was evaluated before and after the program. The postcampaign delay time did not differ significantly from that prior to the campaign. (16)
National Heart Week in Australia took place in 1989. Three surveys of coronary care units in various parts of the country were performed, 6 months prior to the campaign, 1 month prior to it, and 6 months after it. The mean delay between the onset of symptoms and arrival at hospital remained similar during these three periods: 8.9, 8.6, and 8.3 hours, respectively. (17)
Under the slogan "Heart attack? Every minute counts! Call 144," a 1-year media campaign was performed in Geneva, Switzerland. In chest pain patients, the median delay was reduced from 3 hours 0 minutes prior to the campaign to 2 hours 40 minutes during its performance. (18)
There is no evidence of increased ambulance use with media campaigns. (13,19) The use of ambulances in AMI appears to have remained stable over the last two decades. (20)
What Happens in the Emergency Department?
When media campaigns that aim to reduce delays for patients with acute chest pain are conducted, there is a marked increase in the number of these patients in emergency departments (EDs). (18,21,22) This increase consists mainly of patients with chest pain of noncardiac origin, (22) but also of those with unstable angina pectoris and AMI. (180 The increase appears early in the campaign but then diminishes rapidly despite the continuation of the campaign. (18,22) During the 1-year media campaign in Göteborg, the number of patients who came to the ED with acute chest pain increased by 9% as compared with the year before. (22)
Conclusion
Many efforts in the form of educational campaigns have been made to shorten patient decision time. Some have been successful, some have not. It might be that a temporary increase in the number of patients admitted to the ED with noncardiac chest pain can be expected at the initiation of educational campaigns.
References
1. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet. 1986;1:397-402.
2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet. 1988;2:349-360.
3. White HD, Norris RM, Brown MA, et al. Effect of intravenous streptokinase on left ventricular function and early survival after acute myocardial infarction. N Engl J Med. 1987;317:850-855.
4. Weaver WD, Cerqueira M, Hallstrom AP, et al. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention trial. JAMA. 1993;270:1211-1216.
5. Hjalmarson A, Elmfeldt D, Herlitz J, et al. Effect on mortality of metoprolol in acute myocardial infarction. A double-blind randomised trial. Lancet. 1981;2:823-827.
6. Metoprolol in Acute Myocardial Infarction (MIAMI). A randomized placebo-controlled international trial. The MIAMI Trial Research Group.
Eur Heart J. 1985;6:199-226.
7. ISIS-I Collaborative Group: A randomized trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction. Lancet. 1986;2:57-66.
8. Grines CL, Browne KF, Marco J, et al, for the Primary Angioplasty in Myocardial Infarction Study Group. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med. 1993;328:673-679.
9. Zijlstra F, de Boer J, Hoorntje JCA, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med. 1993;328:680-684.
10. Gibbons RJ, Holmes DR, Reeder GS, et al, for the Mayo Coronary Care Unit and Catheterization Laboratory Groups. Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med. 1993;328:685-691.
11. Rowley JM, Hill JD, Mitchell JRA. Early reporting of myocardial infarction: impact of an experiment in patient education. Br Med J. 1982;284:1741-1746.
12. Mitic WR, Perkins J. The effect of a media campaign on heart attack delay and decision times. Can J Public Health. 1984;75:414-418.
13. Herlitz J, Blohm M, Hartford M, et al. Follow-up of a 1-year media campaign on delay times and ambulance use in suspected acute myocardial infarction. Eur Heart J. 1992;13:171-177.
14. Ho MT, Eisenberg MS, Litwin PE, et al. Delay between onset of chest pain and seeking medical care: the effect of public education. Ann Emerg Med. 1989;18:727-731.
15. Rustige JM, Burczk U, Schiele R, et al. Media campaign on delay times in suspected myocardial infarction. The Ludwigshafen community project. Eur Heart J. 1990;11(suppl):171. Abstract.
16. Moses HW, Engelking N, Taylor GJ, et al. Effect of a two-year public education campaign on reducing response time of patients with symptoms of acute myocardial infarction. Am J Cardiol. 1991;68:249-251.
17. Bett N, Aroney G, Thompson P. Impact of a national educational campaign to reduce patient delay in possible heart attack. Aust NZ J Med. 1993;23:157-161.
18. Gaspoz J-M, Unger P-F, Urban P, et al. Impact of a public campaign on pre-hospital time delays in suspected acute myocardial infarction. Circulation. 1993;88(4 suppl 2):I-13. Abstract.
19. Herlitz J, Hartford M, Blohm M, et al. Effect of a media campaign on delay times and ambulance use in suspected acute myocardial infarction. Am J Cardiol. 1989;64:90-93.
20. Wennerblom B, Holmberg S, Wedel H. The effect of a mobile coronary care unit on mortality in patients with acute myocardial infarction or cardiac arrest outside hospital. Eur Heart J. 1982;3:504-515
.
21. Eppler E, Eisenberg MS, Schaeffer S, et al. 9-1-1 and emergency department utilization for chest pain: results of a media campaign. Ann Emerg Med. 1994;24:202-208.
22. Herlitz J, Hartford M, Karlson BW, et al. Effects of a media campaign to reduce delay times for acute myocardial infarction on the burden of chest pain patients in the emergency department. Cardiology. 1991;79:127-134.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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