Puerto Rico Infarction National Collaborative Experience (PRINCE)

SUFFERING A MYOCARDIAL INFARCTION
ST segment elevation myocardial infarction or STEMI occurs when a coronary artery becomes suddenly occluded by clot and is the most dreaded manifestation of cardiovascular disease.  It is estimated that 25 to 35% of patients with STEMI die before reaching the hospital.  Of those who do make it, 10-20% may die in-hospital and many survivors will suffer from heart failure.

TIME IS MUSCLE
Reducing the time to reperfusion in patients with acute STEMI reduces mortality.  Best outcomes in both morbidity and mortality are obtained with a door-to-needle time <30 minutes or a door to balloon time <90 minutes.3  Therefore, the early symptom recognition and response by the patient, rapid response and transport by an EMS system, and rapid emergency room triage and effective reperfusion treatment are the core links in the STEMI survival chain.

TREATING A STEMI
The treatment of STEMI is centered in the concept of prompt restoration of myocardial perfusion or reperfusion therapy, either pharmacological with IV thrombolysis or mechanical with immediate percutaneous coronary intervention (PCI) as the primary mode of mechanical reperfusion.  It is well established that, when performed by experienced operators in a timely manner, PCI is superior to thrombolysis.  Moreover, as many as 25% of STEMI patient may have a contraindication to thrombolytic therapy.

PATIENT RESPONSE TO HEART ATTACK SYMPTOMS
The longer the duration of a coronary occlusion (treatment delay) in STEMI, the higher the myocardial damage and the consequent morbidity and mortality.  The most difficult challenge in reducing time to treatment is reducing the time from symptom onset to hospital arrival, which may range from 3 to 7 hours in most studies.  In fact, in a single center experience in San Juan, only 23% of patients with STEMI arrived within 12 hours of the onset of symptoms, at which time the benefit of reperfusion therapy is limited. 

USE OF EMS AND 911
It is well established that patients with a heart attack who arrive at the hospital by ambulance are diagnosed and treated faster than those who self-transport.  Unfortunately, in Puerto Rico, an epidemiologic study showed that only 1 in 10 patients a admitted to the hospital arrived by ambulance. 

ROLE OF EMERGENCY MEDICAL SERVICES IN STEMI
STEMI patients arriving by EMS have potentially life-saving advantages such as earlier identification and triage, shorter times to reperfusion, better access to PCI-capable hospitals, and immediate advanced cardiac life support in the event of pre-hospital cardiac arrest.  In fact, only by using the EMS system can a patient benefit from the pre-hospital ECG that in turn allows for pre-hospital Cath Lab activation

WHAT IS PRINCE
The Puerto Rico Infarction National Collaborative Experience (PRINCE) Working Group was established in 2010 by a group of local interventional cardiologists in collaboration with the STEMI-PCI expert advisor Dr. Sameer Mehta and in partnership with the Puerto Rico Chapter of the American College of Cardiology to help address the need to improve outcomes of STEMI in Puerto Rico of STEMI in Puerto Rico.  The PRINCE initiative therefore constitutes the ACCS’s Door-to-Balloon Alliance initiative in Puerto Rico. 

WHAT IS THE PRINCE OBJECTIVE
The PRINCE Working Group hypothesized that a coordinated effort of “National Collaboration” among physicians, hospitals, EMS system, industry and government could be developed and sustained as to impact STEMI mortality in Puerto Rico by optimizing and expanding the reach of the timely implementation reperfusion therapy.

HOWS DOES PRINCE WORK
The PRINCE working group consists of a 12-member volunteer executive board integrated by physicians with representation from all six PCI hospitals and the EMS system, and which serves as “think-tank” to advise hospitals, the EMS system and the government to help develop a nationwide STEMI-PCI network that results in lower door-to-balloon times, lower total-ischemia time, lower mortality from STEMI and improved access to STEMI care across Puerto Rico. 

WHY A STEMI-PCI NETWORK IN PUERTO RICO
If a patient with a STEMI can be transported to a PCI center within one hour, that strategy is superior to administering thrombolysis.  In Puerto Rico, practically every region is within a 1 hour radius from its nearest PCI center, which supports PRINCE ambition to establish a Nationwide STEMI-PCI Network.

WHICH HOSPITALS ARE PART OF PRINCE
Six hospitals actively collaborate in this initiative: The greater San Juan Metro area, with a population of 1.5 million, is served by Auxilio Mutuo Hospital, Centro Cardiovascular de Puerto Rico y el Caribe, Hospital HIMA San Pablo, Hospital Metro Pavia Santurce , and the San Juan VA medical Center.  The south, central and western part of Puerto Rico is sereved by Hospital San Lucas in Ponce.

WHAT ARE THE PRINCE CHAMPIONS
Each of the participating PCI hospitals has a physician champion who is the liaison between the working group and the hospital and, together with an appointed hospital STEMI coordinator is responsible for three critical steps:

  1. Help  execute the quality improvement processes in the ED and Cath Lab
  2. Lead a monthly quality management committee meeting where representatives from the ER, Cath Lab, and hospital administration review the time performance and outcome of the most recent cases.
  3. Provide feedback on performance to members of the healthcare team.   

WHAT ARE THE FOUR PILLARS OF PRINCE
The PRINCE Working Group is leading a concerted collaborative effort to implement a staged renovation of STEMI care processes based on these four pillars:

  1. Hospital processes that reduce door-to-balloon time:
    Implementation of standardized STEMI PCI protocols in all PCI-capable hospitals in PR along with education and training of physicians, staff, and paramedics who work in the line of STEMI care.
  2. Integrate the EMS system into a strategic network of care:
    Revise and optimize processes in the EMS response system to include pre-hospital diagnosis, triage and intervention and integrate these into a coordinated regionalization of  STEMI PCI care including both on-field and inter-hospital transfer response.
  3. Measure treatment patterns and outcomes:
    Conduct prospective data collection and analysis on patterns of care and short-term and long-term mortality from STEMI in patients undergoing STEMI PCI (Puerto Rico STEMI-PCI Registry).
  4. Improve patient response and utilization of 911:
    Educate the population on the early recognition of STEMI symptoms and increase the utilization of the EMS system.

CORE QUALITY ELEMENTS IN THE CATH LAB
As part of the PRINCE quality improvement initiative we sought to standardize the STEMI-PCI procedure among centers to promote the use of evidence-based best practices by the interventional operators.  Such best practices include performing aspiration thrombectomy when feasible, choosing the optimal antithrombotic and antiplatelet regimen, and using intracoronary vasodilators to improve reperfusion at the level of the microcirculation, among others.

CORE QUALITY ELEMENTS IN THE ER
Also part of the first pillar of PRINCE is to incorporate core quality elements known to help reduce the door-to-balloon time.  These include:

  1. Rapid triage of patients presenting with chest pain to the ED and immediate availability of an ECG machine.
  2. Ability of the emergency physician to directly activate the STEMI team with a single call to the operator with the need to first contact the interventional cardiologist
  3. Expecting the Cath Lab staff to arrive within 20 to 30 minutes of receiving the activation.
  4. Incorporating the help of the ER nursing staff to prepare and transport the patient to the Cath Lab upon command.

CORE QUALITY ELEMENTS IN THE AMBULANCE
The aim of the second pillar of PRINCE is to mediate a coordinated collaborative effort between independently operated municipal and state EMS systems and the PCI-capable institutions to establish a national STEMI-PCI network with a standardized approach to 911 response and triage. 

Core quality elements aimed at the integration of this EMS system include:

  1. Capability of PCI hospitals to receive wireless ECG transmissions
  2. The designation of GPS-enabled ambulance units specialized in the care of suspected STEMI patients equipped with capability to perform an ECG on the field,
  3. Ability to interpret and transmit the ECG to their designated PCI center
  4. Established transfer algorithms between EMS, STEMI referring hospitals, and STEMI receiving centers to transfer the patient to the nearest PCI center instead of the nearest hospital.  

MEASURING RESULTS IN PRINCE
The third pillar of PRINCE is the prospective acquisition and analysis of treatment, time intervals, and outcomes data in all patients presenting within 12 hours of an acute STEMI who arrive at one of the six participating PRINCE STEMI-PCI institutions.  These quality performance indicators are being collected prospectively since the beginning of the program in order to evaluate the effects over time of the quality improvement processes. 

EDUCATION OF THE PUBLIC
The fourth pillar of PRINCE aims directly at reducing the time to presentation after the onset of a STEMI and in that way further reduce the damage cause by STEMI.  We plan a public education campaign in collaboration with multiple stakeholders to education the public about how to identify the symptoms of a heart attack and on the importance of calling 911 immediately.  At the time of full implementation of our Nationwide STEMI-PCI Network, a call with chest pain to 911 will be the fastest route to the pre-hospital diagnosis, appropriate triage to a PCI center, and the shortest door-to-balloon time, thus minimizing myocardial damage, and improving survival and return to a healthy life. 

LEAVING A LEGACY
The success of the PRINCE initiative will be determined by the sustainability of the collaborative implemented, which should result in improved care and lives saved from acute myocardial infarction.  An even broader impact may result by stimulating similar collaborative initiatives in other areas of health and social need for the betterment of our Island.

Authored on behalf of the PRINCE Working Group by:
Orlando Rodriguez-Vila, MD, FACC
Governor, ACC Puerto Rico Chapter
Co-Chair, PRINCE Working Group