P2742Misdiagnosis of ST-elevation myocardial infarction and treatment delays: impact of case-based training with structured feedback on system quality in a high volume PCI center

Abstract

Background: Mortality of ST-Elevation myocardial infarction (STEMI) has declined substantially due to timely reperfusion therapy using primary PCI (PPCI). Initiation of therapy relies in accurate and fast diagnosis at first-medial contact (FMC) and fast transfer. Aim(s): (1) To prospectively investigate pre- and intrahospital time delays in a highvolume PCI center. (2) To reduce treatment delays by implementing a prospective STEMI registry, and frequent training of emergency physician using structured and case-based feedback. Method(s): Treatment parameters (e.g. D2B, door-to-ballon; C2B, contact-ballon; C2P, cath-to-puncture) were prospectively determined for each case. Patients were followed until hospital discharge and after 30 days. Suboptimal cases were anonymized and used for case-based learning after 4 and 8 months. Result(s): So far, 169 consecutive patients with STEMI were prospectively included. For initial diagnosis and therapy initiation emergency physicians are key players in most patients (72.7%). Up to 15% of patients are self-presenters, which remains a challenge for timely diagnosis at the Emergency Department (ED). At baseline only 62.5% of the patients met the goals for D2B <0.05). Cath lab personnel did not receive specific training. However, cath lab work flow (C2P) also accelerated due to increased awareness (Fig. 1b, p=0.03). PPCI quality with a mean puncture-to-balloon time of 20.8+/-13.9 min (median 18.0 min) was high and stable resulting also in stable D2B times, if the patient was directly transferred (D2B at the 3 time intervals: 36.4+/-8.2 vs. 36.8+/-13.6 vs. 38.3+/-12.8 min). Conclusion(s): Structured feedback seminars improve diagnostic accuracy and treatment times of STEMI patients. Cardiologists are less likely to influence timely therapy since delays mainly occur before arrival at the cath lab. Direct transfer of STEMI patients to the cath lab, and ensurance of correct ECG interpretation are essential to meet guideline time goals for reperfusion therapy.