Has the Time Come for a National Cardiovascular Emergency Care System?
2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 16 Linguagem: Inglês
10.1161/circulationaha.111.084509
ISSN1524-4539
AutoresKevin J. Graham, Craig Strauss, Lori L. Boland, M. Mooney, Kevin M. Harris, Barbara Unger, Alexander S. Tretinyak, Paul A. Satterlee, David M. Larson, M. Nicholas Burke, Timothy D. Henry,
Tópico(s)Trauma and Emergency Care Studies
ResumoHomeCirculationVol. 125, No. 16Has the Time Come for a National Cardiovascular Emergency Care System? Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBHas the Time Come for a National Cardiovascular Emergency Care System? Kevin J. Graham, MD, Craig E. Strauss, MD, MPH, Lori L. Boland, MPH, Michael R. Mooney, MD, Kevin M. Harris, MD, Barbara T. Unger, RN, Alexander S. Tretinyak, MD, Paul A. Satterlee, MD, David M. Larson, MD, M. Nicholas Burke, MD and Timothy D. Henry, MD Kevin J. GrahamKevin J. Graham From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Craig E. StraussCraig E. Strauss From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Lori L. BolandLori L. Boland From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Michael R. MooneyMichael R. Mooney From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Kevin M. HarrisKevin M. Harris From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Barbara T. UngerBarbara T. Unger From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Alexander S. TretinyakAlexander S. Tretinyak From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , Paul A. SatterleePaul A. Satterlee From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , David M. LarsonDavid M. Larson From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. , M. Nicholas BurkeM. Nicholas Burke From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. and Timothy D. HenryTimothy D. Henry From the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis (K.J.G., C.E.S., M.R.M., K.M.H., B.T.U., A.S.T., D.M.L., N.B., T.D.H.); Center for Healthcare Innovation, Allina Hospitals and Clinics, Minneapolis (L.L.B.); Department of Emergency Medicine, Abbott Northwestern Hospital, Minneapolis (P.A.S.); and Allina Medical Transportation, St. Paul (P.A.S.), MN. Originally published24 Apr 2012https://doi.org/10.1161/CIRCULATIONAHA.111.084509Circulation. 2012;125:2035–2044In 2007, there were ≈4 million visits to emergency departments in the United States with a primary diagnosis of cardiovascular disease.1 Current forecasts estimate that the direct medical costs for cardiovascular disease in the United States will triple by 2030 to $800 billion dollars.2 Acute cardiovascular emergencies, including ST-segment–elevation myocardial infarction (STEMI), non-STEMI/unstable angina, out-of-hospital cardiac arrest (OHCA), acute aortic dissection (AAD), abdominal aortic aneurysm (AAA), stroke, and acute decompensated heart failure/cardiogenic shock, require rapid, complex, and resource-intensive care and confer a high risk of mortality. Regionalized systems of care enable patients with complex and urgent medical needs to be systematically directed to hospitals that can provide the highest level of clinical expertise and resources (ie, designated centers). Historically, trauma systems have used this paradigm with improved outcomes. There is a growing focus on regionalized medical care as a strategy to leverage limited resources, to manage cost, and to improve outcomes for other medical emergencies. National cardiovascular organizations have already published recommendations for the establishment of centers and regional systems of care for STEMI,3–6 cardiac arrest,7–9 and stroke.10,11The purpose of this article is to propose the concept of a cardiovascular emergency system, ie, a comprehensive regional system of care for cardiovascular emergencies led by a designated cardiovascular emergency receiving center. Over the past decade, the Minneapolis Heart Institute at Abbott Northwestern Hospital (MHI-ANW) has implemented regional systems of care for STEMI,12 OHCA,13 AAD,14 non-STEMI, and AAA. These initiatives provide a demonstration of the clinical programs and supportive network that reflect the burgeoning framework of a cardiovascular emergency system. Informed by this work, we discuss the historical perspective of, rationale for, and proposed principal elements of a cardiovascular emergency system.Historical PerspectiveTrauma systems are the prototype for regionalized systems of care in emergency medicine and provide a salient proof of concept. Systematic reviews and meta-analyses have demonstrated that trauma systems are effective15–20 and that mortality from traumatic injuries is reduced 15% to 20% in the presence of designated trauma centers.16,17 Similarly, time-sensitive therapies and well-coordinated resources are being effectively delivered to stroke patients via primary stroke centers,21 comprehensive stroke centers, and emerging regional stroke systems10,11 with documented reductions in 12-month case fatality in the presence of comprehensive stroke centers and primary stroke centers.22In recent years, there has been significant progress in the formation of regionalized systems of care for specific cardiovascular emergencies. For example, because only 25% of US hospitals are capable of performing percutaneous coronary intervention (PCI), regional systems to improve timely access to PCI for STEMI have been proposed4–6 and successfully implemented.12 The American Heart Association has developed certification criteria for STEMI referral and receiving centers as part of its Mission: Lifeline initiative.23 With regard to acute coronary syndrome (ACS) and acute decompensated heart failure, the Society of Chest Pain Centers has instituted designations for both chest pain centers and heart failure centers. Recent AHA consensus statements regarding regionalized care for cardiac arrest emphasize the need to increase rapid access to therapeutic hypothermia (TH),7–9 and progressive cardiology centers are pioneering regional systems of care for resuscitation that focus on the delivery of this therapy.13Rationale for a Cardiovascular Emergency System DesignationAs evidence for regional systems of care for cardiovascular emergencies grows, the concept of a comprehensive cardiovascular emergency system provides a number of synergistic advantages. First, and fundamentally, it is reasonable to recognize networks that offer an extensive and integrated level of cardiovascular emergency care over those that provide care for only 1 or 2 conditions. Second, because the intersection of cardiovascular emergency protocols is common, aggregation of systems in this clinical area is pragmatic. Medical management of these events is generally afforded by a common set of providers, and high volume coupled with effective cross-management of the spectrum of emergent cardiovascular events is important for optimizing outcomes. Third, a coordinated approach promotes efficiency via shared system infrastructure. A single system surveillance tool can guide quality improvement activities for several conditions, and instruction across an integrated emergency medical services (EMS) network can be streamlined by bundling training sessions for multiple protocols. Fourth, the pressure to control healthcare costs while improving quality requires restructuring our fragmented healthcare system to provide bundled care within developing payment models. And finally, the formal designation of a cardiovascular emergency system provides a tangible, public affirmation of a synergistic, high-quality set of systems of care for cardiovascular emergencies, and such an endorsement serves to increase visibility and credibility among referral hospitals, physicians, EMS agencies, and the community. As advanced tertiary centers begin to build collections of condition-specific systems for cardiovascular emergency care, it is prudent to consider the operational and fiscal advantages of designing these systems of care within the broader framework of a comprehensive cardiovascular emergency system.Proposed Elements of a Cardiovascular Emergency SystemThe conceptual model for a cardiovascular emergency system is a series of clinical programs anchored by a cardiovascular emergency receiving center and fortified by an integrated network of partnered community hospitals and EMS providers, as well as a landscape of infrastructure elements that provide essential center- and system-level support. In this section, we propose a principal set of clinical programs that constitute the scope of cardiovascular conditions managed within a cardiovascular emergency system, with a matrix (Table 1) depicting how coordinated care for these events is provided across 3 domains: in the prehospital setting, in the emergency departments of network hospitals, and at the cardiovascular emergency receiving center. Key providers, therapies, approaches, and infrastructure elements of the system (Table 2) and receiving center (Table 3) are also introduced for consideration.Table 1. A Comprehensive System of Care for Cardiovascular EmergenciesAcute Coronary SyndromesResuscitationAortic EmergenciesADHF and Cardiogenic ShockStrokeClinical objective Protocol-driven risk stratification for diagnosis and treatment of chest pain syndromesStandardized viability assessment and use of advanced resuscitation techniquesRapid event recognition, stabilization protocols, and algorithms for definitive treatmentSeverity assessment and comprehensive treatment, including mechanical circulatory supportDetermination of symptom onset and candidacy for advanced thrombolytic or interventional therapiesPrehospital/EMS careEarly ECG assessmentShort scene timeAspirinMechanical compressionAdvanced airwaysInitiate cooling in unresponsive patients with ROSCEarly identification of CV emergency and rapid transport to appropriate facilityNitroglycerin Advanced airwaysSymptom recognitionDetermination of symptom onsetAspirinReferring/network hospitalsAppropriate triage of spectrum of chest pain syndromesDetermine need, mode, and timing of transfer to receiving centerContinue/initiate cooling in unresponsive patients with ROSCDetermine need, mode, and timing of transfer to receiving centerSymptom recognitionInitial diagnostic imagingHemodynamic managementFacilitate rapid transfer to receiving hospitalProtocol-driven medication management (continued en route)Administration of inotropic agents, diureticsRespiratory stabilizationDetermine need, mode, and timing of transfer to receiving centerDiagnostic imaging and neurological assessmentInitiate thrombolytic therapy as advised by tertiary centerAppropriate rapid transport for thrombolytic or neurointerventional therapyCV emergency centerEmergent therapy for STEMIUrgent therapy for non-STEMICoordination of short-term outpatient follow-up for nontransferred patientsCertified chest pain center with network hospital affiliatesProtocol-driven therapeutic hypothermia and rewarmingComprehensive neurological assessment, monitoring, and rehabilitationCertified resuscitation centerSurgical and endovascular intervention for AAD, AAA, and critical limb ischemiaCoordinated medical therapy and follow-up imagingComprehensive advanced circulatory supportHeart transplantationCertified heart failure centerProtocol for transferNeurointerventional radiologyCertified stroke centerADHF indicates acute decompensated heart failure; EMS, emergency medical services; ROSC, return of spontaneous circulation; CV, cardiovascular; STEMI, ST-segment–elevation myocardial infarction; AAD, acute aortic dissection; and AAA, abdominal aortic aneurysm.Clinical ProgramsAcute Coronary SyndromeACS results in ≈610 000 emergency department visits in the United States annually.24 Optimal care of the ACS patient includes prehospital recognition of early symptoms by EMS providers, appropriate triage, reperfusion therapy and monitoring in the acute care setting, and ultimately cardiac rehabilitation. Hospitals designated cardiovascular emergency centers will have a highly integrated system of care that achieves rapid transport of STEMI patients to the center for emergent PCI, efficient transfer of appropriate non-STEMI/unstable angina patients for early invasive PCI within 24 to 48 hours, and guideline-directed stress testing or computed tomographic coronary angiography for chest pain syndromes. Formal accreditation of the receiving center ensures appropriate triage and treatment of the spectrum of chest pain syndromes.ResuscitationOHCA is a life-threatening event affecting nearly 295 000 Americans annually,1 and ensuring broad, uniform access to state-of-the-art resuscitation therapies should be a primary focus of a cardiovascular emergency system. The most progressive resuscitation protocols will include techniques to augment the effectiveness of conventional cardiopulmonary resuscitation; TH after return of spontaneous circulation, including initiation of early cooling in the prehospital setting; and comprehensive neurological assessment and follow-up in survivors.Aortic and Vascular EmergenciesRecently published inaugural guidelines on the diagnosis and management of AAD and AAA25 highlight the challenges of detecting and managing these uncommon but catastrophic events. The guidelines underscore the need for improved symptom recognition, rapid use of appropriate diagnostic imaging to hasten definitive diagnosis, early hemodynamic control, and efficiencies to surgical intervention. Cardiovascular emergency systems will engage in system-wide provider education campaigns on risk factors and symptom recognition and implement standardized treatment protocols aligned with AHA/American College of Cardiology recommendations. The cardiovascular emergency receiving center will offer advanced surgical techniques for AAA, AAD, and acute limb ischemia.Acute Decompensated Heart Failure/Cardiogenic ShockHeart failure affects 5.8 million Americans, with total costs of $39.2 billion annually.1 As the mortality for myocardial infarction declines and the population ages, the number of patients with advanced heart failure continues to increase, and heart failure now accounts for 1.1 million US hospital discharges per year.1 Advanced heart failure with symptoms warranting urgent medical attention often requires hospitalization and advanced medical therapies such as ultrafiltration, inotropic and vasodilator management, and, in severe cases, mechanical circulatory support and cardiac transplantation. A cardiovascular emergency system will provide adept assessment of the severity of these episodes, with appropriate respiratory stabilization and rapid transport to the receiving center. The cardiovascular emergency center offers patients the most advanced short- and long-term surgical therapies, including implantation of mechanical circulatory support devices as a bridge to heart transplantation.26StrokeStroke represents the leading cause of long-term disability and the third leading cause of death in the United States. Each year, there are >637 000 emergency department visits for stroke symptoms with total direct and indirect costs of $73.7 billion dollars in 2010.1,24 The time-sensitive guidelines for thrombolytic therapy underscore the need for efficient diagnosis, direct access to neurology consultation, and a comprehensive treatment program that incorporates acute percutaneous intervention and ongoing speech and physical rehabilitation.System InfrastructureCriteria for a regional cardiovascular emergency system can be organized according to 6 distinctive features: (1) a network of collaborative providers; (2) a standardized, coordinated approach to high-quality care; (3) streamlined access to care and exchange of information; (4) effective delivery of provider, patient, and community education; (5) program monitoring and quality improvement activity; and (6) robust data management mechanisms, including integrated electronic systems (Table 2).Table 2. Key Elements of a Regional System for Cardiovascular Emergency CareProviders EMS Air and ground transport vehicle fleets and personnel (dispatchers, paramedics, EMTs) Local first responders (law enforcement, firefighters) Emergency departments at participating network hospitals Centralized, tertiary cardiovascular emergency receiving centerApproach to clinical care Evidence-based, standardized protocols Predetermined plan for mobilization of staff and work flow Care coordination Well-defined individual roles Elimination of redundancies in care Coordination among supporting clinical services (eg, laboratory, imaging) Standardized transfer protocolsAccess and communications Protocols activated by a single, 1-step communication Immediate phone access between regional care teams and cardiovascular emergency receiving center Rapid patient transport optimized by local protocols Continuous communication during patient transport Reporting templates for transfer of patient information between care teamsEducation Community education (eg, campaigns for AED use, compression-only CPR, symptom recognition) Provider education Recognition of clinical signs and symptoms Protocol training (eg, medications, appropriate diagnostics) Established clinical criteria on the appropriateness of transfer Conducted at all participating hospitals and transport bases Patient education (eg, condition information, follow-up monitoring schedules)Quality Established set of metrics for performance evaluation Detailed analysis of outcomes, complications, and quality measures Protocol improvement driven by system evaluation and new research Performance review with referral hospital and transport team within 24 h of eventData management Electronic health record system with regional interconnectivity capability Registry for tracking patients and monitoring performance indicators Transfer of diagnostic imaging between network hospitals via PACS Emerging telemedicine technologiesEMS indicates emergency medical services; EMT, emergency medical technician; AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; and PACS, picture archiving and communications systems.An organization of highly-trained providers in 3 care domains—the prehospital setting, the referral hospital, and the receiving center—is the foundation of the system, and these entities in concert provide lifesaving first response, early diagnostics and stabilization, rapid transport, and advanced tertiary care. Standardized, evidenced-based protocols and clearly articulated individual roles promote a coordinated and consistent approach to care. Importantly, event-specific protocols are activated within the system by a simple, multipoint notification mechanism that enables providers to mobilize and initiate care preparations, expediting patient transfer and receipt. Care teams have immediate and continuous access to specialists at the receiving center and use standardized templates to ensure the exchange of vital patient information. System-wide provider education focuses on symptom recognition, protocol training and adherence, and clinical guidelines for the appropriateness of patient transfer to the cardiovascular emergency center. Patients and families receive condition-specific education about disease management and follow-up care, and community education campaigns emphasize early warning signs and the importance of bystander intervention and EMS activation. The system is committed to capitalizing on emerging health information technologies to improve event communications, to promote electronic health record interoperability, to ensure consistent point-of-care clinical decision support, to monitor system quality, and to aid patients with Web-based health tools.Prehospital CareWith direction from the cardiovascular emergency center and its program committees, EMS providers across the cardiovascular emergency system coordinate training and education around symptom recognition, critical early interventions, and prescriptive transport protocols based on specific patient and facility criteria. Effectuating a standardized EMS base across a cardiovascular emergency system presents a significant challenge, however. EMS agencies are notoriously underresourced, and the current milieu of EMS care across any broad geographic area is a collection of fragmented agencies with highly variable care models, resources, and competencies. Because EMS serves as the point of entry into the cardiovascular emergency system for the majority of patients, it is crucial to provide appropriate initial support as agencies establish their membership with the system and to ensure the quality of system-related care going forward.Referral HospitalsHospitals across the system are responsible for the assessment, stabilization, and initiation of standardized treatment protocols and for the rapid transfer of appropriate patients to the tertiary hospital. As with other systems of care, available staffing, facilities, and technology at network hospitals should dictate predetermined criteria and plans for patient transfer. In contrast to single-condition systems of care (eg, the Mission: Lifeline model for STEMI care), the evaluation and planning process for referral hospitals in a cardiovascular emergency system is further complicated by the need to develop and follow condition-specific transfer protocols for each of the clinical event types treated by the system. For example, a specific network hospital might be capable of optimally managing the majority of STEMI patients but might need to have transfer protocols in place for OHCA, cardiogenic shock, or AAD. Disease-specific committees across the system ideally would systematically assess and categorize network hospitals on the basis of resources and ongoing quality assessment. Clearly defined facility ratings for each condition and strong point-of-care decision support tools can assist in managing this complexity clinically, but the implications for reimbursement need to be elucidated further.The Cardiovascular Emergency Receiving CenterThe cardiovascular emergency center is the tertiary hospital that serves as the hub of the system, providing direction, oversight, education, infrastructure, resources, and, most important, the most advanced clinical care provided by the system (Table 3). Within the center, patients have immediate, 24-hour access to a range of specialty providers with expertise in emergent and chronic cardiovascular care and radiological interpretation. The receiving center must deliver state-of-the-art clinical care, including PCI, a full spectrum of cardiac and vascular surgeries such as mechanical support and cardiac transplantation, formal TH, electrophysiology, and comprehensive rehabilitation services.Table 3. Key Elements of a Cardiovascular Emergency Receiving CenterImmediate access to specialty services 24/7 Availability Cardiologists (general, interventional, electrophysiology, advanced cardiac imaging) Radiologist (immediate interpretation and consultation) Intensivist Hospitalist Anesthesiologist Neurologist Within 30 min Surgeons (cardiothoracic, vascular, transplant) Heart failure specialist LVAD coordinator Neurointerventional radiologistAdvanced therapies Advanced percutaneous intervention Coronary, endovascular, peripheral, cerebrovascular Temporary percutaneous circulatory support (eg, Impella device) Comprehensive cardiovascular surgery Coronary artery bypass graft Major vascular surgery (eg, ascending aorta, femoral bypass) Valvular repair Implanted LVAD as a bridge to transplantation/destination Cardiac transplantation Therapeutic hypothermia Electrophysiology (eg, implantable cardiac defibrillators) Comprehensive rehabilitation servicesCoordinated approach to care Evidence-based standardized protocols Multidisciplinary care teams Communication with PCP (acute care results, discharge plan, follow-up recommendations) Patient and family education around condition and monitoringAdministration and oversight Dedicated multidisciplinary committees to develop, direct, and monitor the center Subspecialty-led clinical program directorsDemonstrated leadership in research and clinical quality for cardiovascular emergency care Outcomes and process analysis and continuous quality improvement programs Participation in cooperative national registries Peer-reviewed publications Collaborative exchange with peer networks Leaders in cutting-edge technologies and therapeutic approachesLVAD indicates left ventricular assist device; PCP, primary care physician.In addition to technical excellence in cardiovascular care, hospitals with this distinction will assume responsibility for operationalizing, managing, and advancing the cardiovascular emergency system. Cardiovascular leadership at the receiving center will have core accountabilities for clinical program development and implementation, care coordination, affiliations with system providers, and scientific inquiry and dissemination. Each of the clinical programs of the system will be developed and monitored at the center by a multidisciplinary committee and program director. A highly coordinated care experience is achieved through the use of multidisciplinary care teams and evidence-based institutional protocols that both guide clinical decision-making and facilitate processes such as interprovider communications and patient/family engagement. The cardiovascular emergency center is responsible for forging critical partnerships with hospitals and EMS providers throughout the region and directing system-wide training and education. It is expected that cardiovascular researchers at the center will participate in consortium registries, will engage in collegial exchange with other cardiovascular emergency systems, and will be actively committed to the broader advancement of cardiovascular emergency care. The receiving center should be a regional leader in innovative health information technologies and use a suite of integrated electronic tools to enhance communications, to facilitate system surveillance, and to improve the quality of care.Early Model of a Cardiovascular Emergency System: The Cardiovascular Emergencies Program at the Minneapolis Heart InstituteOverviewAs a byproduct of longstanding relationships with a broad network of hospitals throughout the upper Midwest, MHI-ANW has formally defined a network of >50 community hospitals and c
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