Emergency Interhospital Transfer of Patients With ST‐Segment–Elevation Myocardial Infarction: Call 9‐1‐1—The American Heart Association Mission: Lifeline Program

Abstract

ABSTRACT: The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction. Every minute of delay in treatment adversely affects 1‐year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3‐step process of an interhospital “Call 9‐1‐1” protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which 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 patient with ST‐segment–elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9‐1‐1 process in a system of care that involves all stakeholders.

Nonstandard Abbreviations and Acronyms

AHA

American Heart Association

CCL

cardiac catheterization laboratory

DANAMI‐2

Danish Multicentre Randomized Trial on Thrombolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction

DIDO

door‐in–door‐out

GWTG

Get With The Guidelines

GWTG‐CAD

Get With The Guidelines–Coronary Artery Disease

QI

quality improvement

SRC

STEMI receiving center

The American Heart Association (AHA) in 2007 introduced Mission: Lifeline, a national, community‐based initiative to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction (STEMI) and to increase the health care system readiness and response to STEMI. Every minute of delay in treatment of patients with STEMI affects 1‐year mortality, not only in thrombolytic therapy but also in primary angioplasty. The risk of 1‐year mortality is increased by 7.5% for each 30‐minute delay ¹ , ² and increased mortality with longer transport times in rural areas. ³ , ⁴ , ⁵ , ⁶ Rapid and safe transfer of patients presenting with STEMI to hospitals with primary percutaneous coronary intervention (PCI) capability is needed to improve outcomes.

When Mission: Lifeline was introduced, a survey performed to assess emergency medical services (EMS) involvement in state and regional STEMI systems of care found significant variability in adoption of STEMI readiness and response in the United States. ¹ Delays in the transfer process may be life threatening when therapies are not delivered in a timely manner. ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ Nallamothu et al ¹² concluded in 2007 that there was “little improvement in door‐to‐balloon times in the recent past,” and they suggested that “matching patients with the most appropriate treatment and location will entail developing a level of coordination and collaboration among hospitals beyond what is currently available in the U.S. health care system.” But treatment times continue to show delays. Current data measured in the AHA GWTG (Get With The Guidelines) registry suggests that just over half of EMS patients receive PCI within 90 minutes.

The DANAMI‐2 (Danish Multicentre Randomized Trial on Thrombolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction) trial showed that emergency transportation for primary PCI had improved cardiovascular outcomes compared with on‐site fibrinolysis in patients with STEMI. ¹³ The 2015 AHA Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care outline recommendations when patients with STEMI present to non–PCI‐capable hospitals and need emergency transfer to a STEMI receiving center. ¹⁴ The 2021 American College of Cardiology/AHA/Society for Cardiovascular Angiography and Interventions Guideline for Coronary Artery Revascularization ¹⁵ update stated:

1. Primary PCI reduces death, myocardial infarction, stroke, and major bleeding as compared with fibrinolysis, especially when treatment delays are minimized. This benefit is seen even among patients transferred from non‐PCI hospitals if transfer times are reasonable and total ischemic time after presentation is <120 minutes.

2. Rescue PCI performed in patients with evidence of failed reperfusion after fibrinolytic therapy has been associated with a reduction in cardiovascular events, when compared with conservative care or repeat fibrinolysis.

Gore et al ¹⁶ in 1983 described a formal system for transfer of critically ill patients with cardiac conditions from community hospitals to a receiving center. Transport of these critically ill patients with cardiac conditions was rapid, with a good short‐term prognosis. Warren et al ¹⁷ in 2004 concluded, “Patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel.” Currently, transfer of patients with time‐sensitive medical (eg stroke, STEMI) and surgical conditions occurs in countries throughout the world. ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ The most remarkable STEMI systems of care are probably represented by programs in Copenhagen and Paris, with their emphasis on prehospital ECG transmission and physician oversight in the field. ²⁴ , ²⁵

In Los Angeles County, California, there are 74 emergency departments (EDs). To reduce delays in treatment, a policy to bypass referring hospitals without PCI capability added only 5 to 10 minutes to transport times with no increase in mortality. Bypass of a referring hospital can occur only if the prehospital ECG is interpreted as a STEMI by either a paramedic, an ED physician at the nearest base station, or an alternative centralized physician model as used in the New York City Fire Department. ²⁶ , ²⁷ , ²⁸

But significant delays in interfacility transport persist in the United States. The Los Angeles County EMS STEMI Database from 2017 to 2020 showed 3447 patients transferred from 40 STEMI referring hospitals to 1 of 35 STEMI receiving centers (SRCs). However, only 14% of patients had a door‐in–door‐out (DIDO) time <30 minutes; ≈30% had a DIDO between 30 and 45 minutes; and 45% had a DIDO >45 minutes. During this period, <61% had a first medical contact at the referring hospital to device time ≤120 minutes. To help reduce DIDO and transport times a “Call 9‐1‐1” strategy between hospitals was developed. ²⁶ , ²⁸

All states license EMS agencies that respond to 9‐1‐1 emergencies and transport patients to a hospital. However, there are an estimated 21 283 local EMS agencies in 50 states with a median number of 249 per state as reported by the Federal Interagency Committee on EMS. The most common organizational structures reported for local EMS agencies are fire department based (40%); governmental, private, nonhospital based (25%); and non–fire department based (21%). One‐third of states reported that most EMS agencies are volunteer agencies. Development of nationwide emergency transfer processes of care could potentially streamline patient transfers and reduce variability and delays (2011 National EMS Assessment, June 2014).

The purpose of this article is to suggest a more consistent strategy to reduce variability in interhospital transfer times. We propose the term “STAT TRANSFER” to describe emergency transport between hospitals to promote predictability in the transfer process that decreases system delays and reduces EMS variability. In addition, a Call 9‐1‐1 interhospital transfer process is suggested to expedite care of patients with STEMI involved in STAT TRANSFER. Together, these initiatives, if adopted within a system of care involving all stakeholders working together, will improve timely and safe transfer of the patient with STEMI. ¹⁰ , ¹¹ , ²⁹ , ³⁰ , ³¹ With specific timing recommendations from the AHA to reduce time to reperfusion, a timely, predictable, and dependable interhospital transfer process is achievable.

The STAT TRANSFER Process

Overall Objectives

The components of a regional STAT TRANSFER program include:

1. 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. ³²

2. Criteria to identify patients for transfer. ³³

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

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

5. Processes to minimize delays for initiating transfer from referring hospitals after ambulance arrival. ³⁴

6. Policies to minimize disruptions in emergency ambulance coverage of communities served by ambulances used for STAT TRANSFER. ³⁵

7. Procedures at referring hospitals to meet the DIDO time goal of ≤30 to 45 minutes. ³⁶ (Locally, a system of care should decide either ≤30 or ≤45 minutes).

8. Processes to minimize patient risk during STAT TRANSFER. ³³

9. Processes to minimize delays between patient's arrival at the referring hospital to definitive intervention by ED and specialty service staff at the receiving center:

   • Activation of hospital resources before ambulance arrival including activation of the cardiac catheterization team before patient arrival at the receiving hospital.
   • 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.
   • Implementation of ED protocols that allow STAT TRANSFER ambulance crew to bring the patient directly to the cardiac catheterization laboratory (CCL) when clinically appropriate.

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

11. In regions where ≥2 SRCs 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.

12. 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. ³²

The STAT TRANSFER process may be more applicable to more heavily populated urban and suburban areas. However, in rural areas with possibly more barriers to transport of patients with STEMI, establishing STAT TRANSFER programs may have a greater impact in decreasing delays.

STAT TRANSFER Call 9‐1‐1 Transport Activation

Communities that lack rapid interhospital transport struggle with unsuccessful efforts to minimize ambulance response times. Ting et al developed a coordinated approach at Mayo Clinic that “… demonstrates the feasibility of implementing strategies to optimize the timeliness of reperfusion therapy … through coordinated systems of care for STEMI patients presenting to … 28 regional hospitals without PCI capability…”. ³⁷ , ³⁸

STAT TRANSFER provides an alternative interhospital “Call 9‐1‐1” process that may use the same EMS provider or ambulance service that responds directly to patient related 9‐1‐1 calls. The option to call 9‐1‐1 for interhospital transfer should be a formalized process with EMS agencies and not for inappropriate use of EMS. The STAT TRANSFER Call 9‐1‐1 strategy may become the primary transfer process used in referring hospitals, especially if local ambulance units are consistently unable to respond promptly to urgent transport requests. The STAT TRANSFER Call 9‐1‐1 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 be assessed by EMS agencies and regional/community SRCs for quality and outcomes with improvements made as needed. Bosson et al ²⁷ describe this process in a large urban EMS agency. Importantly, the STAT TRANSFER program is designed to make EMS agencies and other prehospital providers closer partners within existing networks.

Guidance for which patient should be considered for STAT TRANSFER is outlined for EMS transported (Figure 1) and for walk‐in or self‐transported (Figure 2) patients.

Figure 1. Guidance for transport of a patient with potential STEMI by EMS.

EMS indicates emergency medical services; FMC, first medical contact; PCI, percutaneous coronary intervention; SRC, STEMI receiving center; and STEMI, ST‐segment–elevation myocardial infarction.

Figure 2. Guidance for transport of a walk‐in or self‐transported patient with STEMI.

EMS indicates emergency medical services; FMC, first medical contact; PCI, percutaneous coronary intervention; SRC, STEMI receiving center; and STEMI, ST‐segment–elevation myocardial infarction.

STAT TRANSFER Activation Process From a Referring Hospital

Three steps are suggested:

1. ED physician in referring hospital diagnoses a STEMI based on the patient's clinical presentation and ECG.

2. ED physician at referring hospital contacts ED physician at receiving center and transmits the ECG electronically.

3. The referring hospital requests STAT TRANSFER with a Call 9‐1‐1 to the regional EMS communications center or a designated ambulance provider with expected availability in ≤15 minutes.

A physician‐to‐physician activation process has worked well. However, diversion status, transport issues, and correct ECG interpretations may impact this decision process.

STAT TRANSFER Responsibilities of Community Health Care Leaders

Regional EMS agencies, referring hospitals, and SRCs participate in delivering emergency care and are responsible to show timely, dependable, safe, and sustainable transport policies. ³⁵ , ³⁹ Antman et al ⁴⁰ in 2008 updated the American College of Cardiology/AHA STEMI Guidelines and highlighted the importance of EMS agencies in prehospital care. The AHA Mission: Lifeline program emphasizes use of local EMS as the primary agency to oversee development and coordination of the STAT TRANSFER process. This process includes participants from the prehospital, ED, specialty service, and government and regulatory areas, in addition to community engagement, education, and volunteers to develop, implement, monitor, and have responsibility for STAT TRANSFER programs. In addition, Mission: Lifeline recommends designated local or regional review committees, usually centered at SRCs, to develop effective systems of emergency care that efficiently integrate the efforts of EMS, referring hospitals, and receiving centers.

STAT TRANSFER Responsibilities of EMS/Communications Call Centers

With thousands of EMS agencies and other call centers in the United States, differences in prehospital care and patient transport decisions are common. In addition, variation may exist among regions as to which agency or agencies run communication hubs and what ambulance services they dispatch. The Mission: Lifeline program suggests that the STAT TRANSFER process be used to formalize which EMS or communication centers take the initial 9‐1‐1 calls for different areas and which ambulance services take calls for requests separate from the 9‐1‐1 system.

All EMS agencies and communications centers should be involved in the initial development of a new STAT TRANSFER program. This is particularly true if the 9‐1‐1 ambulance service provider is different from those that provide routine interhospital transfers and STAT TRANSFER service. Commonly, the designated 9‐1‐1 ambulance service also provides STAT TRANSFER service, but this process may be managed by a privately operated interfacility ambulance service or a combination based on ambulance availability and proximity at the time of the request. A STAT TRANSFER request confirms a medical emergency and ambulance units must be appropriately staffed and equipped to transport higher‐acuity patients.

Call center personnel should be trained on the priority of STAT TRANSFER and the associated processes, policies, and documentation. Success of an integrated emergency STAT TRANSFER program involves EMS administration, as well as 9‐1‐1 dispatch center personnel, and local medical directors to ensure that calls are prioritized appropriately with response levels set in advance. Having hospital staff activating the Call 9‐1‐1 service directly will work in most areas, but in others, a designated phone number that directly calls the ambulance communication center may be more effective.

The communications center usually decides the use of lights and siren; otherwise, it is at the discretion of the responding EMS unit. ⁴¹ , ⁴² But lights and siren may be unnecessary, or even counterproductive, as this type of response poses significant risk to the ambulance crews and other drivers. Lights and siren do not provide a significant difference in travel time unless there are extremes in traffic or other factors that affect estimated time of arrival. If lights and siren are not used, STAT TRANSFER protocols should require an immediate response without diversion to other calls, except for known critical patients (eg, cardiac arrest) near the ambulance. Any diversion should be communicated to referring hospitals and receiving centers to keep their confidence in the STAT TRANSFER process, and protocols must reflect these issues. An EMS agency is responsible for monitoring and measuring results in prehospital communication.

STAT TRANSFER Responsibilities of the Initial Ambulance Response Provider

The Mission: Lifeline System of Care program recommends that EMS agencies develop local destination protocols with specific criteria for bypassing a referring hospital with an expected short transport interval (eg, <30 minutes in urban/suburban settings) to achieve primary PCI within 90 minutes. ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ Ambulances should bypass referring hospitals if chest pain or equivalent symptoms are present and the prehospital ECG suggests a STEMI and transport the patient directly to an SRC. Early notification to the receiving center from the field is expected.

STAT TRANSFER Responsibilities of the STAT TRANSFER Ambulance Provider

EMS agencies or other ambulance providers are expected to assure prompt high‐priority responses when a STAT TRANSFER is requested. ⁴⁸ , ⁴⁹ Call 9‐1‐1 or an equivalent system should be the first option to start the STAT TRANSFER process, especially if other ambulance services in the past have not responded in <15 minutes. Any EMS or ambulance service contacted to provide STAT TRANSFER service must provide a patient care report, and an accurate estimated time of arrival that can be reviewed for quality assurance/quality improvement (QI) purposes by EMS, the referring hospital, and SRC as discussed by Zegre‐Hemsey et al. ⁵⁰

STAT TRANSFER requests are typically managed by EMS in a comparable manner to an out‐of‐hospital emergency response request. It is important for interhospital STEMI transfer protocols to avoid intravenous infusions, if possible, and for medications to be given as bolus doses before transfer (eg, heparin and fibrinolytic). Otherwise, an advanced life support ambulance may be needed for management of intravenous infusions, which may delay the transfer. The level of ambulance service used for emergency STAT TRANSFER also may depend on state law, local protocols, availability, and the patient's condition.

The regional EMS system should consider all available resources when developing STAT TRANSFER policies and procedures. For example, if only a basic life support unit is readily available, immediate transport by basic life support with at least automated external defibrillator capability may be preferred rather than waiting for the delayed arrival of an advanced life support unit. Ross et al ⁵¹ proved that trained emergency medical technicians could bypass non‐PCI facilities safely and effectively with no substantial increase in transport time.

Air Ambulance Services

EMS or communications centers should consider if an air ambulance is a better possibility for transfer than ground ambulance. ⁵² Air ambulance services usually have advanced life support training and may be better prepared to offer more advanced levels of care than ground ambulances for safe transfer. Ground and air ambulance centers should know about unit availability, proximity, and reasonably accurate facility and travel time estimates, including total time needed from air ambulance request, arrival including pickup, flight time, and movement from landing pad to ED or directly to the specialty care unit. Time needed before and after flight can make air ambulance service slower than ground units, despite faster air travel times. Helicopter (air) ambulances or fixed‐wing planes can be useful but at significantly higher cost, although effect of transport mode on mortality reduction is unclear. Weather is often a crucial factor to consider in requesting an air ambulance. Stand‐alone communications centers may involve EMS agencies to help with these decisions.

The EMS agency or regional system‐of‐care QI committee is a suitable venue for development of policies to guide use of air versus ground ambulances for STAT TRANSFER. Decisions about use of air versus ground ambulances may affect a larger area and benefit from regional policies. ⁵²

STAT TRANSFER Responsibilities of the Referring Hospital

All acute care hospitals with an ED are STEMI‐capable facilities if they evaluate patients for suspected acute coronary syndrome. Referring hospitals have responsibilities for diagnosis and initial management of a patient with suspected STEMI who arrived by ambulance or self‐transport, including treatment for significant arrhythmias, hemodynamic instability, and airway compromise. Referring hospitals must develop timeline goals involving recognition, assessment, and primary care of potential transfer patients. Referring hospitals are responsible and must facilitate efficient transport by diagnosing STEMI early, with an ECG performed <10 minutes from arrival, assessing the patient's acuity, deciding transfer to a higher level of cardiovascular care, and then requesting immediate STAT TRANSFER. A referring hospital is expected to manage a patient with STEMI with a DIDO time ≤30 to 45 minutes with minimum adherence of 90% predictability. Measurement of the DIDO in the referring hospital provides a framework to assess overall effectiveness and efficiency in the STAT TRANSFER process of care and should be shared with EMS and the SRC network.

A patient surviving a cardiac arrest should have spontaneous circulation with adequate blood pressure, with or without vasopressor agents, before transfer to a receiving center. However, if immediate and adequate medical assistance is unavailable, transport of the patient to a receiving center for a higher level of care should occur. ⁵³

Referring hospitals reduce transfer times by simplification of the level of care needed during the transfer process, by minimizing or ending medication infusions, reducing or stopping special equipment needs, and eliminating locally developed medication protocols not supported by standard national guidelines. ⁵⁴ , ⁵⁵ , ⁵⁶ Bolus‐only administration of a fibrinolytic agent, if indicated, is suggested to simplify transport. When the STAT TRANSFER ambulance arrives, ED and ambulance personnel should expedite efforts to complete the verbal report to ambulance staff, secure essential documents, and safely move the patient and equipment to the ambulance gurney. If transfer documents are not ready, electronic transfer or faxing of documents can be done.

If necessary, the referring hospital should be aware if specially staffed and equipped “critical care transport” ambulances are readily available to minimize the need for hospital staff. Many ambulance services provide added training and equipment to accommodate the safe management of infusions and equipment during these transfers. The ED physician must make the decision to balance the risk of stopping any treatment and the need for hospital staff or a specialty ambulance to go with the patient en route against the benefits of earlier transfer.

It is vitally important for the referring hospital to inform the receiving center about the transfer—even while the patient is still en route to the referring hospital or later to the receiving center. This initial communication may include activation of the CCL with description of the patient's condition. Prehospital registration at the referring hospital or while en route to the receiving center also speeds up care. Any report to the receiving center should not delay patient departure (Table 1).

Table 1.

“Call 9‐1‐1 STAT TRANSFER” Checklist to Safely and Rapidly Transfer a Patient With STEMI

Readiness checklist for EMS, referring hospitals, and receiving centers to implement STAT TRANSFER “Call 9–1‐1” protocols
□ Early STEMI diagnosis with ECG obtained <10 minutes
□ Assessing patient's acuity
□ Decision to transfer for a higher level of cardiovascular care
□ Requesting immediate STAT TRANSFER
□ Simplifying level of care for transfer process by avoiding infusions and special equipment
□ Eliminating locally developed medication protocols not supported by national guidelines
□ ED and ambulance personnel expedite verbal report and essential documents and safely move patient to ambulance
□ ED physician responsible to decide risk of stopping any treatment and need for a specialty ambulance or hospital staff to go with patient compared with benefits of earlier transfer
□ If transfer documents not ready, electronically transfer or fax documents
□ Referring hospital responsible to inform SRC about transfer
□ Referring hospital to document a DIDO ≤30–45 minutes

DIDO indicates door‐in–door‐out; ED, emergency department; EMS, emergency medical services; SRC, STEMI receiving center; and STEMI, ST‐segment–elevation myocardial infarction.

In most cases, the patient awaiting STAT TRANSFER is still in the ED. If a patient admitted with a suspected STEMI is no longer in the ED, they should not be included in the STAT TRANSFER process, unless previously agreed to by both facilities. Application of the STAT TRANSFER process simply to speed up a lower priority case poses a risk to the public by inappropriately diverting an emergency resource. EMS, hospital, and regulatory officials should monitor and address any inappropriate use of the STAT TRANSFER process as a significant issue.

Inappropriate STAT TRANSFER practices may also have a negative long‐term impact on this process and delay future ambulance service responsiveness.

Delays experienced in the STEMI system, including referring hospitals, are listed in Table 2. ³⁴ , ⁵³ , ⁵⁶ Specific delays related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes are common. Improvement in the transport process is more likely to occur with monthly or quarterly meetings that include all participants involved in the STEMI system of care.

Table 2.

Common Factors in Delay From Symptom Onset to Device Time for Patient With Suspected STEMI Who Presents to or Is Transported Initially to a Referring Hospital

Common delays for a patient with suspected STEMI at a referring hospital
Time segment	Responsibility	Common reasons and consequences of delays
Symptom onset to activation of 9‐1‐1	Patient; bystanders	Patient denial: Lack of awareness of symptoms and the need to seek immediate medical attention
Activation of 9‐1‐1 to first medical contact	Patient; bystanders; environmental; dispatch agency; ambulance service	If patient arrives at the referring hospital by personal vehicle, the opportunity is lost for field triage of STEMI and preactivation of the receiving center
First medical contact to ECG	EMS; hospital	EMS fails to promptly obtain ECG on presentation of symptoms; ED staff fails to obtain ECG for non‐EMS arrivals
ECG performed ≤10 minutes after arrival, if not performed prehospital	Hospital	Failure of ED staff to perform ECG promptly; poor communication within ED for walk‐in arrivals; lack of appropriate triage
After ECG read as diagnostic of STEMI to decision for preactivate CCL	Hospital	Poor communication within the ED for EMS or non‐EMS arrivals; delay by ED staff at referring hospital to notify receiving center of the STEMI alert reported by EMS
STEMI referring hospital decision for patient transfer to ambulance request	Hospital	Miscommunications inside the referring hospital ED that delays a prompt request for the STAT TRANSFER ambulance
STAT TRANSFER call request for ambulance response recorded	Ambulance service and communications centers that are involved	If the call is made to other than the same communications center where the ambulances are dispatched, there may be delays with call transfers between communications centers
STAT TRANSFER request received to time ambulance dispatched	Ambulance service	The call priority policies may put the STAT TRANSFER as low priority, which would create delays between call received and when an ambulance was dispatched
Ambulance dispatch to arrival at referring hospital (if no reassignment)	Ambulance service and environmental	Distance, weather, and traffic can be a factor; added delay may occur if a higher priority call reassigns the original ambulance; reassignment may work if the call involves a closer unit
Ambulance arrival time at referring hospital bedside to departure from referring hospital	Hospital	If the hospital does not have the patient ready for immediate transfer when the ambulance arrives, this causes added delays, as well as EMS unit leaving ED for another urgent call. The QI process should assess DIDO times routinely
Departure from referring hospital to receiving center arrival	Environmental	Distance, weather, and traffic between hospitals may be a factor

CCL indicates cardiac catheterization laboratory; DIDO, door‐in–door‐out; ED, emergency department; EMS, emergency medical services; QI, quality improvement; and STEMI, ST‐segment–elevation myocardial infarction.

Transfer agreements between STEMI referring hospitals (nonapproved SRCs and non–PCI‐capable facilities) and approved SRCs are the best practice to facilitate the transfer process. These agreements include an administratively approved document agreed on between a referring hospital and a receiving center. This agreement codifies acceptance of the transfer process by the administration, EMS, ED, Cardiology, director of the CCL, and others involved in the transfer process. The agreement may include financial conditions, automatic acceptance by the receiving facility 24/7 unless on diversion, and other locally required conditions. A referring hospital may have agreements with >1 SRC. Agreements may allow transport units to bypass the most accessible SRC to a prearranged receiving SRC within 30 minutes, as may occur within a system of hospitals.

The Emergency Medical Treatment and Labor Act obligations for STEMI include a physician approval and communication of transfer, even with STAT TRANSFER Call 9‐1‐1. Although a STEMI referring hospital can transfer a patient by 9‐1‐1, they are required to meet Emergency Medical Treatment and Labor Act standards, including a medical screening examination and transfer to a higher level of cardiovascular care.

STAT TRANSFER Responsibilities of the Receiving Center

Regional and statewide STEMI systems of care have successfully developed strategies to manage patients with STEMI by providing timely access to primary PCI. ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² Jacobs et al ⁶³ described improving access to timely STEMI care. Rokos et al ⁶⁴ described a rationale for establishing regional STEMI networks. However, only a minority of US hospitals can perform primary PCI, and any delay in time to reperfusion or door‐to‐device time after hospital arrival is associated with a higher adjusted risk of hospital mortality in a continuous, nonlinear fashion. ³⁴ Strict time goals for reperfusion may not always be relevant or possible for patients who have a reason for delay, including initial uncertainty about diagnosis, the need for evaluation and treatment of other life‐threatening conditions such as acute respiratory failure or cardiac arrest, delays involving informed consent, and long transport times because of geographic distance or adverse weather.

Comprehensive protocols for triage, diagnosis, and CCL prehospital activation established by the receiving center should proactively involve EMS. The receiving center must be equipped 24/7 to treat patients with STEMI with appropriate personnel. SRC, EMS agencies, and referring hospitals are responsible for establishing, monitoring, supporting, and reviewing their systems of care and policies that safely and prompt transport acutely ill patients.

Policies and Procedures for STEMI Receiving Centers

The STEMI Receiving Center has additional responsibilities to ensure a successful STAT TRANSFER process. These measures include:

1. A single “activation” phone call should alert the entire CCL team.

2. Provide early notification and preactivation of the SRC while the patient is en route. ⁵⁶

3. Establish criteria for EMS activation of the CCL via protocol.

4. The receiving center should be available 24 hours/7 days a week to perform primary PCI.

5. Develop a “Direct to CCL” policy for patients with particularly clear signs of STEMI without disqualifying or complicating factors, if possible.

6. Universally accept of all patients with STEMI (no diversion) if another receiving center is not available, as commonly used with major trauma protocols.

7. CCL staff, including interventional cardiologist, should arrive within 30 minutes from time of activation.

8. Interventional cardiologists should meet American College of Cardiology/AHA criteria for competence.

9. Preestablish contingency plans for triage and treatment of >1 STEMI patient simultaneously, to include establishment of a temporary diversion policy (2–4 hours) if another receiving center is available promptly.

10. Participate in a STEMI registry (eg, GWTG‐CAD [Get With the Guidelines–Coronary Artery Disease], Chest Pain–MI).

11. Establish a formally designated STEMI QI team that includes Cardiology, Nursing, ED, administration, and EMS. The team should include a physician champion and a STEMI program coordinator.

12. Monthly or quarterly STEMI QI Team meetings should evaluate outcomes and QI data. Operational issues should be reviewed, problems identified, and solutions assessed and implemented.

13. Participate in regional meetings with all stakeholder participants.

STEMI Related Delays in Receiving Centers

Lambert and colleagues ⁶⁵ developed a comprehensive list of time intervals. It is critical that each step of the process is considered with the greatest potential of reducing delay in transfer times evaluated. Tables 2 and 3 highlight major delays in STEMI care.

Table 3.

System Challenges to STAT TRANSFER of Patients With STEMI

System challenges to STAT TRANSFER
Challenges	Potential solutions and strategies
Ability to perform prehospital 12‐lead ECG	Ensure policies that allow 12‐lead ECG to be performed by all EMS personnel, including basic life support personnel where needed; 12‐lead ECG equipment available at all scenes; transmission capabilities preferred
Speed and dependability, particularly with calls being transferred between communication call centers	Centralization of dispatch and 9‐1‐1 communication call centers
Extremely long response/travel times from the scene to first hospital	Consideration for centralized referring hospitals capable of giving fibrinolytic agents
Coordination between air and ground transport	Air vs ground ambulance protocols, which may include delineation of geographic zones around receiving centers (assuming favorable weather and road conditions)
Delay in transfer to receiving center	STAT TRANSFER and Call 9‐1‐1 policies in place to minimize delays; proper use and timing of a fibrinolytic agent at the referring hospital if first medical contact to device time is expected to be ≥120 minutes
Variability in availability of fibrinolytic agent	Ensure availability of a bolus fibrinolytic agent in certain referral hospitals that are designated with state protocols
Consistency of treatment with fibrinolytic agent, as measured by the door‐to‐needle time	Establish fibrinolytic agent dosing protocols through a STEMI referring hospital certification process
Unable to transfer with intravenous infusions.	Fibrinolytic agent given as single bolus pretransfer

EMS indicates emergency medical services; and STEMI, ST‐segment–elevation myocardial infarction.

Rural/Frontier Barriers

O'Connor et al ⁶ observed “that metropolitan areas have greater access to resources, including funding or access to content expertise, to support the key elements of prehospital STEMI care, whereas rural areas do not. The largest impact may occur by improving programs in the rural areas where hospital distance is a limiting factor to reaching time to treatment thresholds. …”

Decreasing STEMI delays in rural areas is a more difficult goal to achieve because of unique barriers including distance, lack of communication, fewer referring hospitals, lack of a comprehensive evaluation of the size of the problem, and absence of any national initiatives to improve performance.

Barriers to efficient STEMI care in rural settings begin with extended scene response times and the variability of care in local health care facilities. ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² Rural ED patients need interhospital transfer for definitive care at 6 times the national rate, yet transfer decision making is highly variable. ⁶⁶ Transfers from rural hospitals have the added challenge of dealing with the unpredictable and often fragmented situations that are common in these STEMI networks. The rural STEMI network is more likely to work efficiently and consistently if a local referring hospital can engage a receiving center for initiation of STAT TRANSFER. This is most likely to occur if there is a clearly defined transport protocol agreed to in advance by all stakeholders, including telemedicine options. STAT TRANSFER is one solution to organize this process.

Rural/frontier EMS agencies often have fewer training opportunities, limited continuing education support, inadequate funding, and difficulty in getting actionable QI feedback. ⁶⁶ As a result, rural EMS providers may not be trained or equipped to perform or interpret a 12‐lead ECG, as volunteers often staff many of these EMS agencies. Also, they may have limited exposure to patients with STEMI and may be out of range for transmission of the ECG. Many locations have poor or absent cellular coverage and have no 9‐1‐1 telephone networks in place. Increased funding and training of rural/frontier EMS providers is needed to improve efforts to identify STEMI in the field and apply protocols for bypassing referring hospitals in favor of receiving centers. New federally funded infrastructure funds may help these communities.

When a 9‐1‐1 call is placed via cell phone, the configuration of cell towers may result in the call received by a dispatcher serving a different authority than the location of the patient. The dispatcher may be working alone and may not be familiar with the location of the call or which ambulance or nontransport medical first response service has responsibility for coverage of the patient's location. In addition, there may not be street names or addresses. Often, directions to the patient's location are based on geographic landmarks. Because of these complicating factors, family members or neighbors may decide to transport patients to the ambulance or fire station rather than waiting at home for an unpredictable EMS response. Where possible, the STEMI receiving centers need to accept diverse ways of prehospital notification including radio transmission, telephone notification, or simply text transmission of the crew/ECG device interpretation. Importantly and just beginning, billions of dollars are being invested in a new generation of satellites that orbit the Earth at a low altitude. Low‐Earth‐orbit satellites are expected to improve communication in remote and inaccessible rural regions in the United States. As of April 27, 2021, Starlink, a constellation being built by SpaceX, has already launched 1445 satellites, with service in North America. ⁷³ , ⁷⁴

Rural systems of STEMI care have additional and unique challenges to timely care. ³ Distance and weather conditions are often factors resulting in delays. If an SRC is considered too distant for prompt air or ground transport, the patient may be transported to a facility where fibrinolytic therapy can be administered. If both facilities are outside of this time range, transport to the nearest PCI center is recommended, although usually at a longer distance. These complexities may complicate a decision to call 9‐1‐1 for STAT TRANSFER. In rural areas there are local initiatives under way, including planning that improves unit availability to support long‐distance STAT TRANSFER.

Mission: Lifeline is focused on improving STEMI performance in both rural and urban referring hospitals by removing barriers to more reliable transport, improving communication capabilities, increasing funding where possible, and using STAT TRANSFER protocols to reduce delays and provide earlier treatment of the patient with STEMI. If a local facility can give fibrinolytic treatment, they are encouraged to pursue designation as a STEMI referring hospital and agree to implement the processes needed to ensure predictable patient outcomes.

System Challenges With STAT TRANSFERS

Delays in treatment times highlight the need for a more rapid and reliable system for interfacility transport from facilities without PCI capabilities to comprehensive care centers. ⁷⁵ , ⁷⁶ Transfer policies work best in communities with a well‐developed “system‐of‐care” approach including engaged EMS agencies, hospitals, ambulance services, and emergency communications centers. ²³ , ⁴² , ⁶⁰ However, system challenges remain in both urban and rural areas (Table 3).

More specific and detailed reports for creating and maintaining a STAT TRANSFER process involving Quality, Accountability, Implementation and Enforcement are included in the Appendix S1. Case examples of STAT TRANSFERS in urban and rural areas are also included.

STAT TRANSFER Scorecard Tool

The AHA Mission: Lifeline EMS program is focused on recognizing EMS involvement in STEMI systems of care. An EMS recognition program measuring prompt ECG performance, ECG transmission from the field, and transport to a referring or receiving hospital are part of this initiative.

We developed a simple scorecard as a possible useful clinical tool to quantify efforts and track performance of the individual stakeholders involved specifically in the STAT TRANSFER process (Table 4). The scorecard uses a simple numerical score that credits major steps of the transfer process, with 1 point given for each completed step. Individual EMS agencies and other stakeholders have flexibility to change components of the scorecard or develop their own tracking system for local monitoring purposes. A monthly, quarterly, or yearly report of performance components could be used for recognition of the quality of care provided by EMS agencies.

Table 4.

STAT TRANSFER Scorecard Tool

Referring hospital door to ECG time <10 minutes	1
12‐lead ECG transmitted to SRC	1
Ambulance/EMS arrival at referring hospital ≤15 minutes	1
Ambulance crew time at referring hospital ≤15minute	1
DIDO ≤45 minutes	1
Ambulance notifies receiving center with estimated time of arrival	1
Bypass ED and direct to CCL at SRC	1

Six components of the STAT TRANSFER process used to assess performance of EMS agencies, communication centers, referring hospitals, and receiving centers. (A suggested recognition rating score: Excellent=7 points; Above Average=6 points; Average=5 points; Needs Improvement=≤4 points). This scorecard has not yet been confirmed. CCL indicates cardiac catheterization laboratory; DIDO, door‐in–door‐out; ED, emergency department; EMS, emergency medical services; SRC, STEMI receiving center; and STEMI, ST‐segment–elevation myocardial infarction.

Role of AHA Mission: Lifeline in STEMI Systems of Care

Mission: Lifeline was created by the AHA as a response to missed opportunities for prompt STEMI treatment. Mission: Lifeline is focused on creating STEMI systems of care and improving existing systems through regionalization and optimization. Unique to the AHA is the Quality and Systems Improvement staff found throughout the country that bring stakeholders together and provide expertise in systems implementation with a focus on the prehospital care and EMS engagement. Mission: Lifeline provides criteria for an ideal system of care, from the perspective of individual components, with tools to achieve the ideal process and outcomes, such as 60 regional reports to hospitals involved in GWTG‐CAD. Blinded hospital to hospital comparisons allows regions to identify and share best practices, as well as a national acute myocardial infarction data repository where users access a web‐based data entry portal via desktop, laptop, tablet, iPad, or smartphone with benchmarks to compare performance, filters to present data, and reports tracking adherence to guideline recommendations. GWTG‐CAD is the only approved data source for Mission: Lifeline recognition and Mission: Lifeline regional reports.

Summary

There is a wide range of differences in system parameters, resources, geography, and regulation in the United States affecting prehospital systems of care, potentially affecting the STAT TRANSFER process. Patients with time‐sensitive conditions, such as a STEMI, 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. The systematic addition of an interhospital Call 9‐1‐1 protocol may expedite this process. The STAT TRANSFER process uses a systems approach that considers diverse ways in which 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 patient with STEMI. But any processes of care, such as STAT TRANSFER or Call 9‐1‐1, 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.

Sources of Funding

None.

Disclosures

None.

Supporting information

Appendix S1