Standardizing STEMI Transfers: 4-Step Protocol Improves Care Processes and Survival

For patients with ST segment-elevation myocardial infarction (STEMI), the time from first medical contact to reperfusion remains the most critical determinant of clinical outcomes. While national quality initiatives have successfully shortened door-to-balloon times (D2BTs) for patients presenting directly to percutaneous coronary intervention (PCI)-capable centers, patients requiring transfer from non-PCI facilities still face significant hurdles. National registry data reveal that only 17% of transferred STEMI patients in the U.S. met the D2BT goal of ≤ 120 minutes between 2018 and 2021.

A recent study by Cleveland Clinic investigators (J Am Heart Assoc. 2025;14[9]:e034054) demonstrates that a standardized, comprehensive STEMI protocol can address this issue, significantly improving care process metrics and, most notably, halving the 30-day mortality risk for patients who achieve guideline-recommended targets for treatment timing.

Implementation of the protocol, a four-step care model for STEMI transfers, was associated with a dramatic rise in patients reaching the D2BT benchmark of ≤ 120 minutes, increasing from 55.7% to 80.1%. Meeting this 120-minute goal within the protocol framework was linked to a 50% relative reduction in 30-day mortality (adjusted odds ratio = 0.50; P = .04).

“These findings underscore that the delays inherent in the transfer process are not inevitable and that systemwide standardization is a potent tool for improving survival in this high-risk population,” says the study’s senior and corresponding author, Umesh Khot, MD, Director of Regional Cardiovascular Medicine at Cleveland Clinic.

The persistent challenge of STEMI transfers

Timely PCI is the gold standard for STEMI, but the logistical synchrony needed to move a patient between facilities often fails. While D2BT for direct arrivals has improved over the past 20 years, the same progress has not been seen for transfer patients.

These delays result in irreversible myocardial damage and higher death rates. The American Heart Association has called for regional protocols to address these delays for STEMI transfers, a challenge Cleveland Clinic met by developing its standardized comprehensive STEMI protocol.

Study design: Evaluating the four-step protocol

Dr. Khot and colleagues conducted an observational cohort study of 1,274 consecutive STEMI patients transferred to Cleveland Clinic’s Main Campus between 2011 and 2019. Based on the protocol’s launch date of July 15, 2014, they compared outcomes between the pre-protocol era (499 patients) and the post-protocol era (775 patients).

The four-step protocol was designed to eliminate common bottlenecks as follows:

1. ED-driven cath lab activation. Emergency department (ED) physicians were empowered to activate the catheterization laboratory immediately based on specific criteria, removing the delay previously caused by waiting for a cardiology consultation.
2. STEMI Safe Handoff Checklist. This tool standardized early triage and ensured administration of guideline-directed medical therapy (GDMT) before the patient reached the cath lab. It also clarified nursing and physician roles to allow for simultaneous high-acuity assessments.
3. Direct cath lab transfer. A policy was implemented to move patients immediately to an available cath lab upon arrival, bypassing unnecessary stays in the ED or inpatient units unless active resuscitation was required.
4. Radial-first approach. Clinicians were strongly encouraged to use the radial artery for vascular access, an approach known to reduce major bleeding and mortality relative to femoral access.

Key results: Faster reperfusion, better care

In addition to the 50% reduction in 30-day mortality for patients with a D2BT ≤ 120 minutes, the study found statistically significant improvements following protocol adoption across every key process metric analyzed:

• Door-to-balloon time. The median D2BT dropped from 114 minutes to 97 minutes (P < .001). This was achieved by reducing both the time from first facility presentation to arrival at the cath lab and the time from arrival to device activation.
• Medical therapy compliance. The proportion of patients receiving full GDMT before PCI rose from 84.6% to 93.9% (P < .001).
• Vascular access. The use of radial access saw a greater than fourfold increase, from 19.0% to 77.7% (P < .001).
• Discharge to home. A higher share of patients were able to be discharged directly home, rising from 88.0% to 91.9% (P = .03).

A blueprint for transfer care – and remaining challenges

“This study offers a blueprint for managing STEMI transfer patients, who represent a uniquely vulnerable population,” Dr. Khot observes. “STEMI care requires the perfect coordination of many moving parts, and focusing solely on the transfer itself can lead providers to overlook the critical early administration of guideline-directed medical therapy. Our use of a checklist ensures that antiplatelet agents begin their work before and during the transfer, potentially limiting thrombus propagation.”

“The results also underscore the importance of the radial-first strategy in patients with STEMI,” adds study co-author Grant Reed, MD, MSc, Basler Family Endowed Chair in Interventional Cardiology and Interventional Cardiology Fellowship Program Director at Cleveland Clinic. “By reducing bleeding complications and eliminating the need for strict bedrest post-procedure, radial access speeds recovery without negatively impacting door-to-balloon time.”

While the comprehensive STEMI protocol significantly improved outcomes, the researchers acknowledge that 20% of patients still did not meet the 120-minute D2BT goal, and these patients continued to experience higher mortality rates.

“This shows that while the protocol is powerful, further efforts are needed to address the most extreme transfer delays,” Dr. Reed notes. “In cases where a significant delay in transfer is anticipated, clinicians should consider a strategy of up-front thrombolytic therapy, which is underutilized but has been shown to improve mortality when PCI is delayed.”

“Despite the need for additional strategies for the most challenging cases,” Dr. Khot concludes, “the Cleveland Clinic experience broadly shows that a standardized, regionalized approach can overcome the systemic barriers that have long plagued STEMI transfer care. As hospitals continue to consolidate into larger networks, implementing comprehensive protocols like this will be key to ensuring that every STEMI patient, regardless of where they first seek care, has the best chance at survival.”