Organisational management of the time-dependent network for the treatment of acute coronary syndrome
Keywords:
Time-dependent networks; ACS; organizational modelAbstract
Introduction. Cardiovascular diseases are the leading cause of death in Italy, being responsible for 227,350 deaths in 2020, according to the National Institute of Statistics. The implementation of timely reperfusion therapy is crucial to improve patient outcomes, and time-dependent networks for the treatment of Acute Coronary Syndrome, particularly ST-elevation myocardial infarction, have been established. In Tuscany, the network for the treatment of Acute Coronary Syndrome-ST-elevation myocardial infarction covers a vast area encompassing three Local Health Authorities, including all of South-Eastern Tuscany. Key features include equity of access, patient safety, improving the quality of care, standardization, the enhancement of professional skills, technological innovation, increasing case volumes and multi-professional integration across emergency services, hospital facilities and primary care networks. The Tuscan Acute Coronary Syndrome network provides comprehensive treatment for Acute Coronary Syndrome-ST-elevation myocardial infarction in 12 hospitals with 24-hour hemodynamics laboratories and has been extended to new territories, namely Piombino and the Island of Elba. The aim of the present study was to assess the impact of an analytical system for monitoring times to reperfusion treatment and subsequent actions, in order to improve the performance of the network. Materials and Methods. In this retrospective study, we conducted an analytical evaluation of the network’s performance, including reperfusion treatment times and factors causing delay. The study utilized data on patient transport, times from symptom onset to medical contact, and outcomes from the National Outcomes Program (NOP; “Programma Nazionale Esiti” in Italian). Analytical evaluations in 2021 measured the network’s overall performance and identified the main causes of delay. The treatment process was divided into periods, from symptom onset to coronary reperfusion; interventions such as public awareness campaigns, electrocardiogram tele-transmission, and fast-track transfers were implemented in order to minimize delays.
Results. The lowest 30-day mortality rate in Acute Coronary Syndrome patients was recorded in hospitals that treated over 300
References
1. Perugini E, Maggioni AP, Boccanelli A, Di Pasquale G. Epidemiologia delle sindromi coronariche acute in Italia [Epidemiology of acute coronary syndromes in Italy]. G Ital Cardiol (Rome). 2010 Oct;11(10):718-29. Italian. PMID: 21246773.
2. Jiang M, Mao J, Pu K, He B. Timing of early angiography in non-ST elevation acute coronary syndrome. J Invasive Cardiol. 2014 Feb;26(2):47-54. PMID: 24486660.
3. Deharo P, Bode C, Cohen M, Cohen M, Cuisset T, Mehta SR, et al. Timing of angiography and outcomes in highrisk patients with non-ST-segment-elevation myocardial infarction managed invasively: insights from the TAO trial (Treatment of Acute Coronary Syndrome with Otamixaban).
Circulation. 2017 Nov 14;136(20):1895-907. doi: 10.1161/ CIRCULATIONAHA.117.029779. Epub 2017 Sep 11. PMID: 28893843.
4. Piironen M, Ukkola O, Huikuri H, Havulinna AS, Koukkunen H, Mustonen J, et al. Trends in long-term prognosis after acute coronary syndrome. Eur J Prev Cardiol. 2017 Feb;24(3):274-80. doi: 10.1177/2047487316679522. Epub 2016 Nov 19. PMID: 27856805.
5. Pell AC, Miller HC, Robertson CE, Fox KA. Effect of “fast track” admission for acute myocardial infarction on delay to thrombolysis. BMJ. 1992 Jan 11;304(6819):83-7. doi: 10.1136/bmj.304.6819.83. PMID: 1737145; PMCID: PMC1880988.
6. Nante N, De Marco MF, Balzi D, Addari P, Buiatti E. Prediction of mortality for congestive heart failure patients: results from different wards of an Italian teaching hospital. Eur J Epidemiol. 2000;16(11):1017-21. doi:
10.1023/a:1010841102298. PMID: 11421469.
7. Banerjee S, Rhoden WE. Fast-tracking of myocardial infarction by paramedics. J R Coll Physicians Lond. 1998 JanFeb;32(1):36-8. PMID: 9507439; PMCID: PMC9662960.
8. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-3826. doi: 10.1093/eurheartj/ehad191. PMID: 3762265.
9. Salari N, Morddarvanjoghi F, Abdolmaleki A, Rasoulpoor S, Khaleghi AA, Hezarkhani LA, et al. The global prevalence of myocardial infarction: a systematic reviewand metaanalysis. BMC Cardiovasc Disord. 2023 Apr 22;23(1):206. doi: 10.1186/s12872-023-03231-w. PMID: 37087452; PMCID: PMC10122825.
10. Lu L, Liu M, Sun R, Zheng Y, Zhang P. Myocardial Infarction: Symptoms and Treatments. Cell Biochem Biophys. 2015 Jul;72(3):865-867. doi: 10.1007/s12013-015-0553-4. PMID: 25638347.
11. Guerchicoff A, Brener SJ, Maehara A, Witzenbichler B, Fahy M, Xu K, et al. Impact of delay to reperfusion on reperfusion success, infarct size, and clinical outcomes in patients with ST-segment elevation myocardial infarction: the INFUSE-AMI trial (INFUSE-Anterior Myocardial Infarction). JACC Cardiovasc Interv. 2014 Jul;7(7):733-40.
doi: 10.1016/j.jcin.2014.01.166. PMID: 25060015.
12. Cannon CP, Brindis RG, Chaitman BR, Cohen DJ, Cross JT Jr, Drozda JP Jr, et al. 2013 ACCF/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes and coronary artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Acute Coronary Syndromes and Coronary Artery Disease Clinical Data Standards). Circulation. 2013 Mar 5;127(9):1052-89. doi: 10.1161/CIR.0b013e3182831a11. Epub 2013 Jan 28. PMID: 23357718.
13. Pignone M, Alberts MJ, Colwell JA, Cushman M, Inzucchi SE, Mukherjee D, et al. Aspirin for primary prevention cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation. 2010 Jun 22;121(24):2694-701. doi: 10.1161/CIR.0b013e3181e3b133. Epub 2010 May 27. PMID: 20508178.
14. Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristofini P, et al; Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) Investigators. Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty. Data From the CAPTIM Randomized Clinical Trial. Circulation. 2023 Dec 9;108(23):2851-2856. doi:
10.1161/01.CIR.0000103122.10021.F2. Epub 2003 Nov
17. PMID: 14623806.
15. Decreto Ministeriale 2 aprile 2015, n. 70. Regolamento recante definizione degli standard qualitativi, strutturali, tecnologici e quantitativi relativi all’assistenza ospedaliera. GU 4 giugno 2015, n. 127. Available from: https://www. camera.it/temiap/2016/09/23/OCD177-2353.pdf [Last accessed: 2025 Feb 2].
16. Accordo Stato-Regioni del 24 gennaio 2018. Linee guida per la revisione delle Reti cliniche – Le Reti Tempo – Dipendenti”. Available from: http://archivio.statoregioni.it/Documenti/DOC_063280_P.%209%20%20CSR%20Atto%20 Rep.%2014%20%2024gen2018.pdf [Last accessed: 2025 Feb 2].
17. DGRT n. 958/2018. Linee di indirizzo per le reti cliniche regionali. - Allegato A. Available from: http://www301. regione.toscana.it/bancadati/atti/Contenuto.xml?id=519134 5&nomeFile=Delibera_n.958_del_27-08-2018-Allegato-A [Last accessed: 2025 Feb 2].
18. DGRT n. 1378/2016. Reti cliniche tempo dipendenti di cui al D. M. 70/2015. Approvazione linee di indirizzo per la realizzazione delle reti regionali. Available from: http:// www301.regione.toscana.it/bancadati/atti/DettaglioAttiG. xml?codprat=2016DG00000001704 [Last accessed: 2025 Feb 2].
19. Regione Toscana, Italy. Linee di indirizzo regionali per le reti cliniche tempo-dipendenti- rete emergenze cardiologiche infarto miocardico acuto- organismo toscano governo clinico, decisione numero 42/2023 del 09/11/2023. Available from: https://www. regione.toscana.it/documents/ 10180/153838593/All+A++Decisione+42_Rete Cardio.pdf/879f23ff-8da8-e2ed-9998 -9ddcf20fe418?t=170081936659 [Last accessed: 2025 Feb 2].
20. AGENAS. Programma Nazionale Esiti Agenzia Nazionale per i Servizi Sanitari Regionali. Available from: https://pne. agenas.it/home [Last accessed: 2025 Feb 2].
21. Dati PROSE-ARS TOSCANA- IMA STEMI: PTCA entro 90 minuti- erogazione. Available from: https://www.ars. toscana.it/banche-dati/dettaglio_indicatore-2501-imastemi-ptca-2-g?provenienza=prosero_elenco_indicatori_sintesi&par_top_geografia=09062601&dettaglio=ri c_anno_geo_prosero [Last accessed: 2025 Feb 2].
22. Ramacciani Isemann C, Salini C, Nante N. Differenze di ricorso al pronto soccorso tra aree urbane e rurali: analisi retrospettiva nella Toscana meridionale [Emergency department overuse amongst urban and rural areas: a retrospective descriptive analysis in Southern Tuscany.]. Recenti Prog Med. 2023 Jan;114(1):802-814. Italian. doi:
10.1701/3939.39229. PMID: 36573532
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Elena Capitani, Nicola Nante, Emanuele Montomoli, Ugo Limbruno, Antonio Biancofore, Elio Aiola, Ahmed Mohammed, Federico Taddeioni, Sandro Limaj, Maria Giovanna D'Amato, Roberto Turillazzi, Assunta De Luca, Antonio D'Urso (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.