What performance metrics should be used for ST‑elevation myocardial infarction (STEMI) care in Asian hospitals?

Performance Metrics for STEMI Care in Asian Hospitals

Asian hospitals should implement a core set of performance metrics focused on reperfusion times, reperfusion therapy utilization rates, and region-level outcomes, with particular emphasis on measuring door-to-device times, first medical contact (FMC)-to-device times, and the proportion of patients receiving any form of reperfusion therapy. 1

Essential Time-Based Performance Metrics

Primary PCI Time Metrics

• Door-to-balloon time: Target median ≤90 minutes for patients presenting directly to PCI-capable hospitals 1
• FMC-to-device time: System goal of ≤90 minutes for direct transport to PCI-capable facilities 1
• FMC-to-device time for transfers: System goal of ≤120 minutes for patients initially arriving at non-PCI-capable hospitals 1
• Door-to-ECG time: Target ≤10 minutes from hospital arrival 1, 2

Fibrinolytic Therapy Time Metrics

• Door-to-needle time: Target ≤30 minutes from hospital arrival for patients receiving fibrinolytic therapy 1
• FMC-to-needle time: Target ≤30 minutes from first medical contact 1

Process Utilization Metrics

Reperfusion Therapy Rates

• Overall reperfusion rate: Proportion of eligible STEMI patients (symptom onset <12 hours with ST-elevation) who receive any reperfusion therapy (primary PCI or fibrinolysis) 1
• Primary PCI utilization: Percentage of STEMI patients receiving primary PCI as the preferred reperfusion strategy 1
• Reasons for non-reperfusion: Documentation of specific contraindications or patient refusal when reperfusion is not performed 1

Emergency Medical Services Integration

• EMS transport rate: Proportion of patients transported directly via EMS rather than self-transport 1
• Prehospital ECG performance: Percentage of patients with 12-lead ECG obtained by EMS at first medical contact 1
• Direct-to-catheterization lab rate: Proportion of patients bypassing the emergency department when appropriate 2

Outcome Metrics

Mortality Measures

• In-hospital all-cause mortality: Overall and stratified by reperfusion strategy (primary PCI, fibrinolysis, no reperfusion) 1
• 30-day mortality: Post-discharge mortality tracking 3
• Two-year mortality: Long-term outcome assessment 3

Secondary Prevention Metrics

• Dual antiplatelet therapy at discharge: Proportion receiving aspirin plus P2Y12 inhibitor 2
• Beta-blocker prescription: For patients with heart failure or LVEF <40% 2
• ACE inhibitor/ARB prescription: For patients with anterior MI, heart failure, LVEF ≤40%, diabetes, or hypertension 2
• High-intensity statin therapy: Initiated during hospitalization 2
• Smoking cessation counseling: Documentation for all smokers 1, 2

Quality Improvement Infrastructure

Data Collection and Registry Requirements

Hospitals should establish cloud-based information technology platforms with real-time data entry capabilities, allowing for sophisticated analytics and dashboard visualization of key performance indicators. 1 This infrastructure should:

• Enable real-time data collection from spoke hospitals and ambulances during patient transport 1
• Provide level-dependent functionalities so each facility can input relevant data appropriate to their capabilities 1
• Generate automated feedback reports comparing individual hospital performance to regional and national benchmarks 1
• Track granular process measures to identify specific bottlenecks in care delivery 1

Audit and Feedback Mechanisms

• Regular performance reporting: Quarterly or monthly feedback to participating sites on patient characteristics, process measures, and outcomes 1
• Benchmarking capability: Comparison to local, regional, and national data 1
• Quality improvement cycles: Systematic identification of care gaps and implementation of corrective measures 1

Context-Specific Considerations for Asian Settings

Resource-Appropriate Metrics

Performance metrics should be individualized based on each country's healthcare infrastructure, but must minimally include STEMI care utilization rates, actual reperfusion times, identification of delays in achieving timely reperfusion, and detailed region-level outcome databases. 1

Transfer Network Performance

Given that 24.5% of patients in China are transferred from other hospitals 4, specific metrics for transfer systems are critical:

• Inter-facility transfer time: Time from decision to transfer until arrival at PCI-capable center 1
• Post-fibrinolysis transfer rate: Proportion of patients receiving fibrinolysis who are immediately transferred to PCI-capable centers 2
• Rescue PCI rate: For patients with failed fibrinolysis (<50% ST-segment resolution at 60-90 minutes) 2

Secondary Measures to Track Workflow

• ECG-to-decision time: Interval from ECG interpretation to reperfusion decision 1
• Decision-to-catheterization lab arrival: Time from reperfusion decision to patient arrival in catheterization laboratory 1
• Catheterization lab arrival-to-balloon time: Final interval before device deployment 1

Common Pitfalls and Implementation Challenges

The most significant challenge in Asian settings is the low EMS utilization rate (10.3% in some regions) compared to self-transport (58.3%), which substantially delays treatment. 5 Additional pitfalls include:

• Poor documentation in catheterization laboratories: This is the primary barrier to accurate time measurement; standardize documentation of balloon inflation time 1
• Suburban-rural disparities: EMS usage and performance metrics are significantly worse in suburban and rural areas compared to urban centers 5
• Hospital capability variations: Tertiary hospitals demonstrate better process improvements than secondary hospitals, requiring stratified reporting 5
• Loss to follow-up: Major problem in low- and middle-income countries affecting long-term outcome measurement 1

Data collection should be designed for abstraction by non-clinicians to ensure feasibility and cost-effectiveness, though this may reduce specificity in some cases. 1 The trade-off between sensitivity and specificity in performance measure definitions must be explicitly acknowledged when interpreting results 1.