BaSSaL: Bahrain Stent Save a Life Program: A National Primary Percutaneous Coronary Intervention Initiative in Bahrain

INTRODUCTION Cardiovascular diseases (CVDs) are the leading cause of death in the Kingdom of Bahrain. Over the last decade from 2009 to 2019, there was a 48% increase in the number of deaths from CVD, with 28% of the 2800 annual deaths related to it.[1] ST-segment elevation myocardial infarction (STEMI) is a major contributor to acute coronary syndromes with the need for timely diagnosis and treatment to mitigate death, disability, and complications.[2] A strategy of primary percutaneous coronary intervention (PPCI) is the gold standard for the treatment of STEMIs and has been endorsed by all the international guidelines as the treatment of first choice if available in percutaneous coronary intervention (PCI) capable centers that are able to provide around the clock coverage and within the acceptable time framework (First medical contact -FMC- to device time of < 120 min).[3] Many countries have adopted PPCI as their strategy for STEMI management with thrombolysis only being used if PPCI is not available or would be delayed for more than 120 min.[3] Several registries in the Arabian Gulf have shown that there is a wide discrepancy in the adoption of revascularization strategies for STEMI. The most recent studies have shown that PPCI rates for STEMI range from 42% to 46%, whilst a third receive thrombolysis and the remainder receive neither (STARS; GulfRACE 3).[4,5] Some countries have adopted nationwide PPCI coverage and joined the Stent Save -a Life initiative to facilitate greater adoption of PPCI as part of a national STEMI program (e.g. Qatar and Saudi Arabia).[6] STENT SAVE A LIFE PROGRAM IN THE KINGDOM OF BAHRAIN To reduce heart disease-related disability and death, the Stent Save a Life (SSaL) program in the Kingdom of Bahrain is a nationwide PPCI initiative, aiming to provide all STEMI patients in the nation with prompt and precise diagnosis and treatment. All citizens and expatriates would be eligible for this program, which would make the best use of the health-care assets at its disposal. With the planned program starting on January 1st, 2022, it would need to evaluate how STEMI care was provided beforehand and expand its coverage to become a national program. For the operation and eventual success of this national initiative, the logistics and design of a STEMI network to connect each health-care facility (HCF) to the sole tertiary government cardiac facility (MKCC: Mohammed Bin Khalifa Specialist Cardiac Centre) in Bahrain will prove to be crucial [Figure 1].Figure 1: Setting up a national ST-segment elevation myocardial infarction (STEMI) program (The logistics and planning of a STEMI network to join all health-care facilities to the only tertiary governmental cardiac center). NA: National Ambulance, PHC: Primary Health Care, STEMI: ST-segment elevation myocardial infarctionHEALTH-CARE FACILITIES IN THE KINGDOM OF BAHRAIN About 1.5 million people live in Bahrain’s principal islands, which comprise an archipelago with a total area of 788 square kilometers (Census 2020).[1] The health-care facilities in the Kingdom of Bahrain provide access to comprehensive primary care coverage with a structured referral system to secondary hospitals. MKCC provides tertiary cardiac care for referrals from secondary care, with localized primary care referrals in its catchment area. In the past, PPCI coverage was only available in the region served by the Bahrain Defense Force Hospital, where MKCC was headquartered. There was no nationwide STEMI network during this time, and the other governmental secondary care hospitals had thrombolysis as their primary reperfusion strategy. Before the national program began, it was thought that 50% of STEMI patients across the nation were getting thrombolysis. As a freestanding cardiac facility, MKCC moved to its new location in Awali on January 1, 2022, to coincide with the start of the countrywide STEMI initiative. Over the past 10 years, MKCC has had a seven-fold increase in the number of PPCIs performed, from 66 cases in 2009 to 410 PPCIs a year in 2019, with the latter number equivalent to 250 PPCIs for every million people. One would anticipate that after the national program begins, 800 PPCIs per year would be performed, equivalent to 500 PPCIs per million, given the existing population size and worldwide PPCI rates [Figure 2].Figure 2: Over the last decade, the number of primary percutaneous coronary interventions in Mohammed Bin Khalifa Specialist Cardiac Centre has increased 7-fold (250 per 1,000,000 inhabitants). In 2022, the national ST-segment elevation myocardial infarction program doubled the number of cases performed. PPCI: Primary percutaneous coronary intervention, BaSSaL: Bahrain Stent Save a LifeAlong with 26 primary health-care facilities spread across the Kingdom’s governorates, the public health-care facilities also comprise three non-PCI governmental hospitals. In addition, a sizable private health-care sector exists, with over 20 multispecialty medical private clinics and private hospitals that serve everyone in the community but are especially helpful to expatriates residing in the highly populated areas of the cities. Catheterization services are only offered by one private hospital. ESTABLISHMENT OF A ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION HOTLINE AND NETWORK The ideal network to connect all the HCFs in the Kingdom of Bahrain to MKCC was envisioned as a hub-and-spoke concept. The first link was the three non-PCI secondary care governmental hospital emergency departments that received most of the emergency cardiac cases. The second link was the 26 primary health-care centers across the country whereby patients had easy and quick access to health care in their community. The third link was the private hospitals and clinics, especially those in the densely populated inner cities. The fourth and final challenging link was the prehospital activation for STEMI patients from the home or the field. The latter would mean that for any person who called for emergency ambulance service by dialing 999, the paramedics would be able to assess the patient in the home, perform a 12-lead electrocardiogram (ECG), transmit the ECG to MKCC, have the diagnosis of STEMI confirmed, and directly transfer the patient from home to MKCC for PPCI. The logistical challenge of training the paramedics and transferring the ECG from the home or field had to be ironed out before this could become possible. A complete 12-lead ECG may be recorded and conveyed employing LifeNet technology using LIFEPAK 15 monitors, which are provided to the national ambulance system. Before LifeNet technology being completely operational and during the early phases of the national STEMI initiative, the paramedics snapped a picture of the ECG and submitted it to MKCC over WhatsApp while maintaining patient privacy. ECGs were sent electronically through a wireless Internet connection to the STEMI hotline after LifeNet began running in the middle of the 1st year. All other HCFs used WhatsApp to send their ECGs because their institutions did not have LifeNet equipment. Through the STEMI hotline, which was manned around the clock by a cardiology registrar and the invasive cardiologist on call, all medical facilities and the national ambulance that are a part of the STEMI infrastructure are connected to MKCC. A specific landline number, the STEMI hotline, supports WhatsApp communication. All STEMI hotline callers would be required to transmit an ECG and talk with the on-call cardiologist. The national ambulance would transfer the case to MKCC after it was determined to be an appropriate STEMI. The patient would either stay in the government hospitals or be moved there from any medical institution or private HCF if the patient failed to satisfy STEMI criteria. Regardless of whether the patient was ultimately accepted or not, both ECGs and patient histories were captured and preserved in the HIS system. The Cath Lab staff would be activated as soon as a STEMI case had been accepted for transfer. The patient would then be transported to the cardiac transfer clinic (CTC) in MKCC through the national ambulance, where they would be stabilized, if necessary, before being transferred to the Cath lab. A STEMI protocol outlining the above pathway was constructed and shared with all the relevant stakeholders well in advance to commencing with the national program [Figure 3]. Individual meetings with the emergency room physicians of both public and private hospitals, as well as family physicians in primary health care, were held to explain the pathway. Private hospitals were also contacted, and the relevant information was disseminated. Last, but not least, the national ambulance paramedics underwent intensive training with workshops on STEMI symptoms and signs, ECG recording and interpretation, as well as ECG transfer from the field to MKCC through LifeNet. The latter helped start the prehospital activation for STEMI referrals from the home or field, bypassing any non-PCI emergency department, and bringing the patient directly to MKCC for primary PCI. What was essential was integration with new HCFs that previously had not directly sent STEMI patients to MKCC, especially primary health care, private hospitals, and clinics, as well as the national ambulance paramedics. This required lots of discussion and preparation, including educational workshops, ECG reading, and interpretation, as well as initial management of STEMI. This was especially important given that this subset of referring centers required more training and support compared to the consultant emergency room physicians that were very experienced in dealing with STEMI in the past.Figure 3: National ST-segment elevation myocardial infarction program pathwayThe importance of “time is muscle” and first medical contact to device time of < 120 min was stressed among all the stakeholders, especially as it pertains to the required time standards of first medical contact to first ECG, ambulance transport times, and first medical contact to device time. The ESC 2017 STEMI guidelines were used as a benchmark to try and attain these international standards at every junction of the patient’s journey from presenting to any medical institution to performing PPCI.[7] An audit of the first 6 months was shared with all the stakeholders, with avenues to improve in every time category to get to the goal of <120 min. A continuous quality improvement program and an auditing of transfer times would be essential if international standards are to be met to avail the best possible STEMI primary PCI results. Out-of-hospital cardiac arrest (OHCA) patients were referred for emergency PPCI through the STEMI hotline having attained ROSC. A separate pathway for OHCA survivors was made, keeping in mind the latest evidence and what criteria are to be used to accept patients for PPCI without prohibitive neurological risks or multi-organ failure [Figure 4]. The CAHP risk score was used to define prohibitive risk, and which patients would be excepted for referral post-OHCA if there is STEMI on their ECG.[8]Figure 4: Algorithm for risk stratification of comatose outof-hospital cardiac arrest patientsSTAKEHOLDER PARTICIPATION Before the program’s launch, the Supreme Council of Health and the National Health and Regulatory Authority (NHRA) in the nation were informed about it to get their respective inputs and approvals as well as a shared understanding of the program’s objectives. The STEMI pathway must be well understood by emergency department doctors to facilitate quick diagnosis and transfer. The NHRA officially instructed all HCFs to implement the STEMI pathway, launching the nationwide initiative. The success of the STEMI network depended on the crucial and complete participation and integration of the national ambulance. The paramedics received recurrent and frequent training seminars on how to identify STEMI warning signs as well as how to conduct and send the ECG from the patient’s residence. It was necessary to inform the Ministry of Health of its distinct contribution and responsibilities [Figure 5].Figure 5: Patient education and stakeholder involvement phase of Bahrain Stent Save a Life programCAMPAIGN IN THE MEDIA The patient is a crucial additional stakeholder. Alongside the launch of the national STEMI program, a media campaign called “Treasure Your Heart” was launched. The objectives were to inform the public about cardiac disease, risk reduction strategies, heart attack symptoms, and what to do if one has symptoms that might be a myocardial infarction. This is a 1-year campaign with every phase covering a different aspect about heart disease and myocardial infarction. There was also information about the cardiac center and its role in this national STEMI program. The public was advised to call for the ambulance on 999 if they had symptoms of ischemic chest pain and to avoid driving alone to any HCF. Avoiding delays in seeking medical attention and using the fastest method to get medical attention were stressed. The notion of time is the muscle and every minute counts, with the first golden 2 h being vitally important in decreasing death and disability, was disseminated in both English and Arabic as part of this media campaign. Social media, national newspapers, and national radio and television stations were used to spread information. To achieve a symptom-onset-to-device time of < 120 min (our median symptom onset to FMC had been 120 min), patient delays in seeking medical attention—whether by calling 999 or reaching HCFs—had to be addressed. FMC-TO-DEVICE TIME AUDITING All patients who were treated as part of the STEMI program were included in a registry, and all pertinent time periods (from the beginning of symptoms to device) were calculated for each medical institution across the nation, even prehospital engagement from the patient’s home. To assess approaches to reduce total ischemic time and how to enhance the system procedures for achieving and exceeding international standards, interim analyses for HCFs were reviewed with the pertinent stakeholders. We also looked at our own performance after the patient reached our center, and how long it took to establish flow (device time). Even though the Cath lab callout would occur whilst the STEMI patient is still in transfer from other HCFs, we noted initial delays in the CTC before transfer to the Cath lab and worked on ways of shortening these times. We are working on a single push alert to all the Cath lab team members instead of individual calls, to avoid delays and inadvertently missing to inform a member of the team. Having the appropriate support services available, including in-house cardiac anesthesia and perfusionists, as well as backup nursing staff should the workload mandate opening two emergency concurrent Cath labs. The dictum of “time is muscle,” with rapid recognition, timely transfer, and expedient treatment in experienced PPCI centers had to be factored in the continuous evaluation and improvement of this program. STENT SAVE A LIFE PROGRAM SSaL is a global project designed to provide PPCI for STEMI patients in accordance with guidelines to lower deaths and fatalities. This project has the support of more than 32 nations and various interventional associations, notably SOLACI, EAPCI, and APSIC.[9] Being a member of the SSaL program made it easier to exchange ideas and learn from other nations that had launched national STEMI programs, particularly regarding setting up the systems and network procedures necessary to launch and manage such a large-scale project. Learning how other nations overcame obstacles and how to do so facilitates the transfer of that information to all other initiatives throughout the world. With meetings at EuroPCR and GulfPCR, SSaL has made it possible for us to connect with coworkers and discuss difficulties and experiences. CONCLUDING REMARKS A total of 817 PPCIs were completed before the 1st year’s end. Any national STEMI program’s objectives must be achieved through a collaborative effort from all stakeholders. Any difficulties that arise while beginning any project initially will be mitigated by keeping those objectives in mind. All attempts to offer the best health care for STEMI patients should be driven by constructive criticism and ongoing self-improvement to reduce mortality and morbidity. As we traverse the path toward improved cardiac patient care in the Kingdom of Bahrain, the 1st year of SSaL has proven to be equally challenging and satisfying. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.