Prehospital Cardiac Care Cuban Style
The Cuban national Integrated Medical Emergency System or ¡§Sistema Integrado de Urgencias Medicas¡¨ (SIUM) was formed in 1997. In 1998, the SIUM began an active out-of-hospital thrombolysis program using Heberkinasa, the only streptokinase obtained through recombinant DNA techniques, produced by the Cuban Center for Genetic Engineering and Biotechnology. An active community training program has also been implemented, standardizing training for the almost 20,000 members of the national emergency medical services.
Cuba is the largest island in the Caribbean. Eleven million inhabitants live within the 42,803 square miles that comprise the Cuban territory. Projected life expectancy at birth is 73.56 years for males and 77.51 years for females. Approximately 8% of the gross national product (GNP) is utilized in healthcare.3
The Cuban National Health System consists of a network of easily accessible institutions, which provide coverage to 100% of the population. This network consists of 281 hospitals, 11 research institutes and 442 polyclinics, with a total of 80,528 hospital beds or 7.3 beds per 1,000 inhabitants. In the U.S., there are three beds per 1,000 inhabitants.6,2
Cardiovascular Disease in Cuba
Cardiovascular disease is the leading cause of death in Cuba as in much of the world. Data from 1997 show a Cuban mortality rate from cardiovascular disease of 197.1 per 100,000 inhabitants, and 109.2 from acute ischemic heart disease. The U.S. has a rate of 525, while China scores the world¡¦s lowest recorded rate of just 116.3,1
In response to these findings, the Cuban government implemented the National Program for the Control of Ischemic Heart Disease. This program involved interventions that ranged from nutritional surveillance to out-of-hospital thrombolysis. Recent Cuban health statistics show that after the initiation of this project, there has been a reduction in morbidity and mortality secondary to heart disease.4
Cuban EMS
SIUM was formed in 1997 under a Franco-German model where a physician-based communication regulating system drives operations (rather than the EMT-based North American model), with physician-staffed emergency units being deployed under special situations.
There are 35 coordinating centers, serving 169 municipalities, and ambulances are activated and deployed by the designated community healthcare provider when a medical condition requires transport and further stabilization. The SIUM operates 600 basic ambulances, as well as 38 intermediate and 38 intensive care units, most of which are located in the capital city of Havana. These can be deployed when needed to provide transport at the municipal or ¡§inter-provincial¡¨ level.
The workforce consists of 1,009 physicians and 3,843 nurses. The main municipal prehospital coordinating center is the emergency unit at the regional polyclinic. On-site physicians offer emergency medical care, and BLS units located in each of the 169 municipalities provide transport.
An active community and provider life-support training program offered by the Education Branch of the SIUM has been implemented in Cuba to complete the circle for a national emergency medical system that comprises nearly 20,000 members. Thousands of laypersons, from school children to police officers and from teachers to workers, actively train to bring the ¡§chain of survival¡¨ to the community.
Here, training similar to BLS, ACLS and BTLS has been consolidated into a 21-day course called AVIPRE (short for Prehospital Vital Attention). Through this program the SIUM has achieved standardized training for most of its members. Additionally, individual life support courses are taught on an as-needed basis nationwide. The SIUM also has operational and education agreements with agencies outside of the National Health Ministry such as Civil Defense, the Red Cross and the Fire Department of the National Revolutionary Police (NRP). Basic and simple interfacility transport is performed at times by units operated by local Red Cross chapters.
Out-of-Hospital Cardiovascular Care in Cuba
Cuban health authorities believe development of the SIUM has significantly contributed to the decrease in morbidity and mortality rates secondary to cardiovascular disease. In 1998, the SIUM began an active out-of-hospital cardiovascular care and prehospital thrombolysis program when 22.5% of patients transported to hospitals by mobile IC units had acute ischemic heart disease.
The hallmark of the Cuban out-of-hospital cardiovascular care program is provision of prompt prehospital thrombolysis, a procedure utilizing anticoagulant medication, widely used in Europe today as well.7 This project began as a pilot study in a few Cuban provinces and, after demonstrating efficacy, was expanded nationwide. The initial protocol (see below) required the identification of clinical and electrocardiographic criteria for acute myocardial infarction (AMI) prior to prehospital administration of thrombolytics by ambulance physicians.
The thrombolytic agent, Heberkinasa, is the only streptokinase (an enzyme used to dissolve blood clots) obtained through recombinant DNA techniques. Produced by the Cuban Center for Genetic Engineering and Biotechnology (CIGB), this recombinant thrombolytic is currently being sold internationally to countries in Europe, Latin America, Africa and Asia.5
The dosage of 1,500,000 units of Heberkinasa diluted in 100 ml of saline solution is administered intravenously over 20¡V30 minutes. After administration, the patient is transferred directly to a coronary care unit for further management.
The initial pilot study performed by the SIUM showed that this program not only improved times to thrombolytic administration, with 69% of these cases receiving pre-hospital thrombolysis within 90 minutes of the onset of symptoms, but the data also showed a significant reduction in AMI mortality rates. In this study, 112 subjects were thrombolyzed in the out-of-hospital setting¡Xwithin a mean thrombolytic time of 154 minutes¡Xand only two died, yielding a mortality rate of 1.8%. Whereas, out of the 106 subjects thrombolyzed in-hospital, the door-to-drug time was higher than four hours and resulted in a mortality rate of 12.3% after 13 patients died. The difference demonstrated a strong statistical significance.6,8
Conclusion
From the highly trained and fully operational medical mobile units on one end of the EMS spectrum to the thousands of citizens on the other end trained in first aid, BLS and community injury-prevention skills, SIUM officials strive for full integration of the ¡§chain of survival¡¨ concept in their country¡¦s healthcare system.
With an active prevention, early detection and treatment model, the Cuban EMS system plays an integral role in the aggressive management of AMI patients. From community education to the implementation of an out-of-hospital thrombolysis protocol using Cuban-made recombinant streptokinase, the SIUM¡¦s active prehospital program is helping Cuba improve its care for acute ischemic heart disease. ƒÞ
References
1. The American Heart Association. International cardiovascular disease statistics. www.americanheart.org/downloadable/heart/1043250000063IntStats2003.pdf. Accessed Jun 30, 2004.
2. The Commonwealth Fund. Multinational comparisons of health systems data, 2000; Chart VII-6. International Health Policy and Practice. www.cmwf.org/programs/international/comp_chartbook_charts3.asp#chart7-6. Accessed Jun 30, 2004.
3. Pan American Health Organization. Republic of Cuba country health profile. www.paho.org/English/SHA/prflCUB.htm. Accessed Aug 21, 2002.
4. Lopez-Saura PA. Thrombolysis with recombinant streptokinase in Cuba. BMJ 326:448a; Feb 2003.
5. Riera L. Heberkinasa in a new concentration. Granma Internacional. May 2, 2002. https://granmai.cubaweb.com/ingles/marzo02-3/12biotec-i.html#subir. Accessed Jun 30, 2004.
6. Sosa A, Martinez S, Gonzalez E, Méndez A. trombolisis prehospitalaria y hospitalaria estudio comparativo. Emergencias. Vol. 12. Extraordinario, Jun 2000.
7. Stern R, Arntz HR. Prehospital thrombolysis in acute myocardial infarction. Eur J Emerg Med. 5(4):471–9; Dec 1998.
8. Toruncha CA, Yerena Rojas L, Valdés Rucabado JA, et al. Protocolo nacionál para la aplicación de la trombólisis sistémica en el IMA en Cuba con la estreptoquinasa recombinante del Instituto de Biotecnología. La Habana: Ministerio de Salud Pública, 1992.
