Fibrinolysis for Acute STEMI in an Emergency Department Cardiac Care Unit in a Humanitarian Setting: Operational Experiences and Patient Outcomes

Treatment of acute coronary syndromes (ACS) and critically ill cardiac patients can be resource intensive and may not be available in humanitarian settings. If reperfusion therapy is available for an acute ST segment elevation myocardial infarction (STEMI) in humanitarian settings, it is generally performed with fibrinolysis. We report our experience of implementing a package of care for ACS and STEMI including training, treatment algorithms, resources, and infrastructure in a remote region of Pakistan, its implications on both cardiac and non-cardiac critically ill patients, and patient outcomes. This was a descriptive study of acute STEMI patients receiving streptokinase in an emergency department in Timergara district hospital, using routine monitoring data and patient follow-up by phone interviews at 1 and 3 months after discharge. From July 2015 to December 2016, 739 STEMI patients presented to the emergency department, of whom 567 received streptokinase. Post-fibrinolysis, there were 527 patients admitted to the hospital and 440 were subsequently discharged home. At 1 month after hospital discharge, 317 patients were contacted, of whom 304 were alive. At 3 months after hospital discharge, 281 patients were contacted, of whom 280 were alive. Implementing a package of care for ACS and STEMI in a humanitarian setting was feasible but associated with challenges inherent in providing advanced post-reperfusion care. Operational considerations when implementing specialized medical activities, such as fibrinolysis, in humanitarian settings should focus on regional and cultural contexts as well as the entire patient care continuum from emergency department presentation to hospital discharge.