Emergency Department Physician Activation of the Catheterization Laboratory and Immediate Transfer to an Immediately Available Catheterization Laboratory Reduce Door-to-Balloon Time in ST-Elevation Myocardial Infarction

An analysis of the door-to-balloon time in STEMI patients in an underdeveloped area of China: a single-centre analysis

OBJECTIVES

This study was conducted to break the door-to-balloon time (DTBT) into constituent elements, and compared which components prolonged markedly. We identified the factors that significantly prolonged the DTBT in an underdeveloped area of China.

METHODS

The patients were included from January 2008 to December 2010 in 301 consecutive patients presenting with STEMI in our hospital. We analysed the components of total DTB times, such as 'Diagnosis time', 'Cardiologist consultation time', 'Explain the patient's condition time', 'Transferring time', 'Preparation of the catheterisation laboratory (CL) time', and determined which factors significantly prolonged the DTBT potentially.

RESULTS

The median DTBT of all patients was 134 (98-186) min. The group was divided by the DTBT into two: ≤120 min and >120 min. In the ≤120 min group, more patients (68.1%) presented to our hospital during working hours (p=0.000), whereas in the >120 min group, more patients (63.2%) presented out of hours (p=0.000). More patients (49.3%) presented when the interventionist was on site (p=0.000) in the ≤120 min group. In the >120 min group, the times for consultation by the cardiologist and explaining the patient's condition to the family prolonged markedly, as compared to the ≤120 min group (p=0.000) when the interventionist was off-duty (OR=4.050, p=0.000) and presentation during non-working hours (OR=3.334, p=0.000) were significant predictors of >120 min DTB times.

CONCLUSIONS

In our centre, the time of consultation by the cardiologists and explaining the patient's condition to the family accounted for most of the delay in reperfusion. A lack of interventionists usually resulted in a delay during non-working hours in the CL. Several measures should be taken involving asking emergency department physicians to awake CL directly, sending the patients' information to the cardiologists, popularising medical knowledge to the citizens, and increasing the numbers of interventionists qualified to carry out primary percutaneous coronary intervention, should be developed to shorten the DTBT.

Bypassing the Emergency Department and Time to Reperfusion in Patients With Prehospital ST-Segment–Elevation

Background—

Among patients identified prehospital with ST-segment–elevation myocardial infarction, emergency medical service transport from the field directly to the catheterization laboratory, thereby bypassing the emergency department (ED), may shorten time to reperfusion.

Methods and Results—

We studied 1687 patients identified prehospital with ST-segment–elevation myocardial infarction from the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, transported via emergency medical service directly to 21 North Carolina hospitals for primary percutaneous coronary intervention between July 2008 and December 2009. Treatment time intervals were compared between patients evaluated in the ED (ED evaluation) and those transported directly to the catheterization laboratory (ED bypass). Emergency medical service transported 1401 (83.0%) patients to the ED, whereas the ED was bypassed for 286 (17.0%) patients. Overall, first medical contact to device activation within 90 minutes was achieved in 913 (54.1%) patients. Among patients evaluated in the ED, median time (25th–75th percentiles) from ED arrival to catheterization laboratory arrival was 30 (20–41) minutes. First medical contact to device activation occurred faster (75 [59–93] versus 90 [76–109] minutes; P <0.001) and was more frequently achieved within 90 minutes (74.1% versus 50.1%; P <0.001) among ED bypass patients.

Conclusions—

Among patients identified prehospital with ST-segment–elevation myocardial infarction and transported directly to a percutaneous coronary intervention hospital, only 1 in 2 achieve device activation within 90 minutes. A median of 30 minutes is spent in the ED, contributing significantly to the failure to achieve timely reperfusion. The strategy to bypass the ED is used infrequently and represents a potential opportunity to improve reperfusion times.

Cost reductions associated with a quality improvement initiative for patients with ST-elevation myocardial infarction

BACKGROUND

Efforts to reduce door-to-balloon (DTB) times for patients presenting with an ST-elevation myocardial infarction (STEMI) are widespread. Reductions in DTB times have been shown to reduce short-term mortality and decrease inpatient length of stay (LOS) in these high-risk patients. However, there is a limited literature examining the effect that these quality improvement (QI) initiatives have on patient care costs.

METHODS

A STEMI QI program (Cardiac Alert Team [CAT]) initiative was instituted in July 2006 at a single tertiary care medical center located in central Massachusetts. Information was collected on cost data and selected clinical outcomes for consecutively admitted patients with a STEMI. Differences in adjusted hospital costs were compared in three cohorts of patients hospitalized with a STEMI: one before the CAT initiative began (January 2005-June 2006) and two after (October 1, 2007-September 30, 2009, and October 1, 2009-September 30, 2011).

RESULTS

Before the CAT initiative, the average direct inpatient costs related to the care of these patients was $14,634, which decreased to $13,308 (-9.1%) and $13,567 (-7.3%) in the two sequential periods of the study after the CAT initiative was well established. Mean DTB times were 91 minutes before the CAT initiative and were reduced to 55 and 61 minutes in the follow-up periods (p < .001). There was a nonsignificant reduction in LOS from 4.4 days pre-CAT to 3.6 days in both of the post-CAT periods (p = .11).

CONCLUSIONS

A QI program aimed at reducing DTB times for patients with a STEMI also led to a significant reduction in inpatient care costs. The greatest reduction in costs was related to cardiac catheterization, which was not expected and was likely a result of standardization of care and identification of practice inefficiencies.

Reduction in treatment times through formalized data feedback: results from a prospective multicenter study of ST-segment elevation myocardial infarction

OBJECTIVES

This study sought to evaluate the effect of systematic data analysis and standardized feedback on treatment times and outcome in a prospective multicenter trial.

BACKGROUND

Formalized data feedback may reduce treatment times in ST-segment elevation myocardial infarction (STEMI).

METHODS

Over a 15-month period, 1,183 patients presenting with STEMI were enrolled. Six primary percutaneous coronary intervention hospitals in Germany and 29 associated nonpercutaneous coronary intervention hospitals participated. Data from patient contact to balloon inflation were collected and analyzed. Pre-defined quality indicators, including the percentage of patients with pre-announced STEMI, direct handoff in the catheterization laboratory, contact-to-balloon time <90 min, door-to-balloon time <60 min, and door-to-balloon time <30 min were discussed with staff on a quarterly basis.

RESULTS

Median door-to-balloon time decreased from 71 to 58 min and contact-to-balloon time from 129 to 103 min between the first and the fifth quarter (p < 0.05 for both). Contributing were shorter stays in the emergency department, more direct handoffs from ambulances to the catheterization laboratory (from 22% to 38%, p < 0.05), and a slight increase in the number of patients transported directly to the percutaneous coronary intervention facility (primary transport). One-year mortality was reduced in the total group of patients and in the subgroup of patients with primary transport (p < 0.05). The sharpest fall in mortality was observed in patients with primary transport and TIMI (Thrombolysis In Myocardial Infarction) risk score ≥ 3 (n = 521) with a decrease in 30-day mortality from 23.1% to 13.3% (p < 0.05) and in 1-year mortality from 25.6% to 16.7% (p < 0.05).

CONCLUSIONS

Formalized data feedback is associated with a reduction in treatment times for STEMI and with an improved prognosis, which is most pronounced in high-risk patients. (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction [FITT-STEMI]; NCT00794001).

Impact of the prehospital activation strategy in patients with ST-elevation myocardial infarction undergoing primary percutaneous revascularization: a single center community hospital experience

The strategy of prehospital activation by the emergency medical system (EMS) in patients with ST-elevation myocardial infarction (STEMI) has been poorly adopted among the US hospitals that currently offer 24/7 primary percutaneous coronary intervention. In this study, we report a single center experience after the implementation of this strategy. From 2008 to 2011, we identified a total 188 STEMI patients (age 65 ± 15 years) presenting via EMS for primary percutaneous coronary intervention. Of these, 112 (59.6%) underwent prehospital activation (EMS group), whereas the remaining 76 (40.4%) underwent emergency department activation [emergency department (ED) group]. Baseline demographic characteristics were similar between both groups. The overall median door-to-balloon (DTB) time was 49 ± 14 minutes. Patients undergoing prehospital activation had on average significantly lower overall DTB times (EMS 44 ± 11 minutes vs. ED 57 ± 15 minutes; P < 0.001). Concordantly, DTB times <60 minutes were much more commonly achieved with this strategy (EMS 95.5% vs. ED 64.5%; P < 0.001). Fallouts beyond the recommended 90-minute DTB time were seen among ED patients only. No difference in in-hospital death (EMS 5.4% vs. ED 6.6%; P = 0.75) or cumulative 30-day mortality (EMS 6.3% vs. ED 7.9%; P = 0.68) was observed between both groups. However, on average, EMS patients had higher postinfarct left ventricular ejection fraction (EMS 48 ± 9.5% vs. ED 39 ± 14.6%; P = 0.004). Differences in DTB time and left ventricular ejection fraction remained significant after adjusting for differences in baseline characteristics. In conclusion, the prehospital activation strategy is largely effective and should be systematically adopted in the treatment scheme of STEMI patients to lower mechanical reperfusion times and reduce the potential for untoward clinical outcomes.

STEMI Interventions: The European Perspective and Stent for Life Initiative

The Stent for Life Initiative was launched by the European Association of Percutaneous Cardiovascular Interventions (a registered branch of the ESC) and EuroPCR. The purpose of the initiative is to support the implementation of European Society of Cardiology guidelines on management of acute myocardial infarction, help identify barriers to implementation of guidelines, and define actions to ensure that the majority of ST-segment elevation myocardial infarction (STEMI) patients in Europe have access to primary percutaneous coronary intervention. The key objectives are to define the countries with an unmet medical need in the optimal treatment of STEMI and implement an action program to increase patient access to primary percutaneous coronary intervention.

Impact of Door-to-Activation Time on Door-to-Balloon Time in Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarctions

Background—

Little is known about the components of door-to-balloon time among patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. We assessed the role of time from hospital arrival to ST-segment elevation myocardial infarction diagnosis (door-to-activation time) on door-to-balloon time in contemporary practice and evaluated factors that influence door-to-activation times.

Methods and Results—

Registry data on 347 consecutive patients diagnosed with a ST-segment elevation myocardial infarction in the emergency department over 30 months at 2 urban primary percutaneous coronary intervention centers were analyzed. The primary study end point was the time from hospital arrival to catheterization laboratory activation by the emergency department physician, and we assessed factors associated with this period. Door-to-balloon time and its other components were secondary study end points. The median door-to-activation time was 19 minutes (interquartile range, 9–54). Variation in door-to-activation times explained 93% of the variation in door-to-balloon times and demonstrated the strongest correlation with door-to-balloon times ( r =0.97). Achieving a door-to-activation time of ≤20 minutes resulted in an 89% chance of achieving a door-to-balloon time of ≤90 minutes compared with only 28% for patients with a door-to-activation time >20 minutes. Factors significantly associated with door-to-activation time include the following: prehospital ECG use (61% shorter, 95% confidence interval, −50 to −72%; P <0.001) and computed tomography scan use in the emergency department (245% longer, 95% confidence interval, +50 to +399%; P =0.001).

Conclusions—

The interval from hospital arrival to ST-segment elevation myocardial infarction diagnosis and catheterization laboratory activation (door-to-activation time) is a strong driver of overall door-to-balloon times. Achieving a door-to-activation time ≤20 minutes was key to achieving a door-to-balloon time ≤90 minutes. Delays in door-to-activation time are not associated with delays in other aspects of the primary percutaneous coronary intervention process.

Temporal associations of early patient transfers and mortality with the implementation of a regional myocardial infarction care model

BACKGROUND

In order to reduce the delays encountered through patient transfer, regional care models have been developed that directly transport subsets of acute myocardial infarction (AMI) patients to hospitals with percutaneous coronary intervention (PCI) facilities. Calgary is a Canadian city that implemented this type of model in 2004.

METHODS

The study population included 9768 AMI patients admitted to Calgary hospitals between 1997 and 2007. Administrative data were used to define patients who were directly admitted to the PCI hospital and those transferred there after initial admission to a hospital without specialized cardiac care. The differences in clinical characteristics and mortality trends of patients grouped by hospital delivery site and transfer practice are described.

RESULTS

The proportion of patients directly admitted to a PCI hospital has increased with the implementation of a regional care model. Among patients admitted to non-PCI facilities, the patients who are transferred are younger, more likely to be male, have a shorter length of stay, and have lower proportions of several comorbid conditions. The risk-adjusted in-hospital mortality odds ratio for patients who received care at the PCI hospital postmodel relative to those treated at non-PCI hospitals premodel was 0.38 (95% confidence interval, 0.31-0.47). The corresponding adjusted odds ratio was 0.60 (0.47-0.76).

CONCLUSIONS

Our results suggest changing care over time and trends toward improved outcomes. Patients' clinical characteristics appear to play a major role in the decision to transfer. Avoidance of the risk treatment paradox through refinement of regional transfer protocols ought to be a priority.

Temporal changes in geographic disparities in access to emergency heart attack and stroke care: are we any better today?

The objective of this study was to investigate temporal changes in geographic access to emergency heart attack and stroke care. Network analysis was used to compute travel time to the nearest emergency room (ER), cardiac, and stroke centers in Middle Tennessee. Populations within 30, 60, and 90 min driving time to the nearest ER, cardiac and stroke centers were identified. There were improvements in timely access to cardiac and stroke centers over the study period (1999-2010). There were significant (p<0.0001) increases in the proportion of the population with access to cardiac centers within 30 min from 29.4% (1999) to 62.4% (2009) while that for stroke changed from 5.4% (2004) to 46.1% (2010). Most (96%) of the population had access to an ER within 30 min from 1999 to 2010. Access to care has improved in the last decade but more still needs to be done to address disparities in rural communities.

Exploring strategies to improve emergency department intake

BACKGROUND

The emergency department (ED) is the point of entry for nearly two-thirds of patients admitted to the average United States (US) hospital. Due to unacceptable waits, 3% of patients will leave the ED without being seen by a physician.

OBJECTIVES

To study intake processes and identify new strategies for improving patient intake.

METHODS

A year-long learning collaborative was created to study innovations involving the intake of ED patients. The collaborative focused on the collection of successful innovations for ED intake for an "improvement competition." Using a qualitative scoring system, finalists were selected and their innovations were presented to the members of the collaborative at an Association for Health Research Quality-funded conference.

RESULTS

Thirty-five departments/organizations submitted abstracts for consideration involving intake innovations, and 15 were selected for presentation at the conference. The innovations were presented to ED leaders, researchers, and policymakers. Innovations were organized into three groups: physical plant changes, technological innovations, and process/flow changes.

CONCLUSION

The results of the work of a learning collaborative focused on ED intake are summarized here as a qualitative review of new intake strategies. Early iterations of these new and unpublished innovations, occurring mostly in non-academic settings, are presented.

Effect of emergency department in-hospital tele-electrocardiographic triage and interventional cardiologist activation of the infarct team on door-to-balloon times in ST-segment-elevation acute myocardial infarction

Current guidelines recommend that >75% of patients with ST-elevation myocardial infarction (STEMI) receive primary percutaneous coronary intervention (PPCI) within 90 minutes. The goal has been hardly achievable, so we conducted a 2-year before-and-after study to determine the impact of emergency department (ED) tele-electrocardiographic (tele-ECG) triage and interventional cardiologist activation of the infarct team at door-to-balloon time (D2BT) and the proportion of patients undergoing PPCI within 90 minutes since arrival. In total 105 consecutive patients with acute STEMI (mean age 62 ± 13 years, 82% men) were studied, 54 before and 51 after the change in protocol. The 51patients in the tele-ECG group underwent tele-electrocardiography at the ED and electrocardiograms were transmitted to a third-generation mobile telephone of an on-call interventional cardiologist within 10 minutes of ED arrival. The infarct team was activated and PPCI was performed by the interventional cardiologist. Fifty-four patients with acute STEMI who underwent PPCI in the year before implementation of tele-electrocardiography served as control subjects. Median D2BT of the tele-ECG group was 86 minutes, significantly shorter than the median time of 125 minutes of the control group (p <0.0001). The proportion of patients who achieved a D2BT <90 minutes increased from 44% in the control group to 76% in the tele-ECG group (p = 0.0001). In conclusion, implementation of ED tele-ECG triage and interventional cardiologist activation of the infarct team can significantly shorten D2BT and result in a larger proportion of patients achieving guideline recommendations.

Hospital-based strategies contributing to percutaneous coronary intervention time reduction in the patient with ST-segment elevation myocardiaI infarction: a review of the "system-of-care" approach

A myriad of hospital-wide initiatives have been implemented with the goal of decreasing door-to-balloon time. Much of the evidence behind the common strategies used is unknown; multiple strategies have been suggested in the reduction to the use of this important time-sensitive intervention. Among 8 primary strategies, 2 have substantial evidence to support their implementation in the attempt to reduce door-to-balloon time in ST-segment elevation myocardial infarction (STEMI), including emergency physician activation of the cardiac catheterization laboratory and prehospital activation of the STEMI alert process. Two strategies have moderate evidence to support their use, including real-time data feedback to team members and team-based approach to STEMI management. The remaining 4 strategies have no quantitative evidence to support their use, including single call to a central paging system, expecting the cardiac catheterization laboratory personnel to arrive within 20 minutes of activation, attending cardiologist on site (within the hospital), and senior management commitment to the project. Although all the STEMI systems of care reviewed are associated with a decreased in time to treatment, only a few have sufficient quantitative evidence to support their implementation. To be effective, the movement to decrease time to treatment of STEMI at any hospital must be composed of an institutional response that includes multiple disciplines. Success also requires active participation from nurses, members of the catheterization team, and hospital leadership.

Six Sigma process utilization in reducing door-to-balloon time at a single academic tertiary care center

BACKGROUND

Rapid reperfusion in patients with ST-elevation myocardial infarction (STEMI) is associated with lower mortality. Reduction in door-to-balloon (D2B) time for percutaneous coronary intervention requires multidisciplinary cooperation, process analysis, and quality improvement methodology.

METHODS

Six Sigma methodology was used to reduce D2B times in STEMI patients presenting to a tertiary care center. Specific steps in STEMI care were determined, time goals were established, and processes were changed to reduce each step's duration. Outcomes were tracked, and timely feedback was given to providers.

RESULTS

After process analysis and implementation of improvements, mean D2B times decreased from 128 to 90 minutes. Improvement has been sustained; as of June 2010, the mean D2B was 56 minutes, with 100% of patients meeting the 90-minute window for the year.

CONCLUSION

Six Sigma methodology and immediate provider feedback result in significant reductions in D2B times. The lessons learned may be extrapolated to other primary percutaneous coronary intervention centers.

Data feedback reduces door-to-balloon time in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Current guidelines recommend a goal of door-to-balloon (D2B) time < 90 min for patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). We aim to prospectively determine the effect of data feedback on D2B time and its seven individual components in primary PCI. From December 7, 2007, to June 2, 2009, 116 consecutive patients with STEMI who received PCI within 12 h of symptom onset were enrolled, including 56 patients before and 60 patients after the implementation of data feedback on July 28, 2008. The proportion of patients treated within 90 min increased from 26.8 to 55.0% (p = 0.002). On multivariable analyses, data feedback (OR 5.3, p = 0.003), known coronary artery disease (OR 5.6, p = 0.043), regular hours presentation (OR 3.3, p = 0.048), and arrival by transfer (OR 14.0, p = 0.003) were independent predictors of a D2B time less than 90 min. Median D2B time decreased from 112 min before data feedback to 87 min after data feedback (p < 0.001). The most significant decrease occurred in median door-to-ECG (11 vs. 3 min, p < 0.001), consult-to-cardiologist (5 vs. 3 min, p < 0.001), and puncture-to-balloon (21 vs. 17 min, p = 0.004) time. Data feedback to the emergency department and catheterization laboratory staff decreases D2B time in primary PCI. This simple approach may be the best first step to decrease D2B time in hospitals that are still striving to achieve the goal of D2B time < 90 min.

Accelerated management of patients with ST-segment elevation myocardial infarction in the ED

PURPOSES

The objective of this study was to evaluate improvement opportunities in the emergency department for timely ST-segment elevation myocardial infarction management and evaluated the new process flow.

BASIC PROCEDURES

In a prospective study, we compared time from door to cath laboratory before and after implementation of a new ST-segment elevation myocardial infarction (STEMI) protocol. The new protocol included a blend of strategies to reduce door to cath laboratory time.

MAIN FINDINGS

We included 55 patients. After implementing a new STEMI protocol, we included 54 patients. Time to cath laboratory was 21 (interquartile range, 9-40) minutes before and 10 (interquartile range 5-25) minutes after initiation of the new protocol (P = .02). A door to cath laboratory time less than 15 minutes was reached in 36% of our patients in phase 1 and in 61% in phase 2 (odds ratio; 0.36, 95% confidence interval, 0.16-0.81; P = .01).

PRINCIPAL CONCLUSION

Simple changes in organizational strategies resulted in a significantly faster care for patients with acute uncomplicated STEMI.

Impact of 24-hr in-hospital interventional cardiology team on timeliness of reperfusion for ST-segment elevation myocardial infarction

OBJECTIVE

We studied the effect of 24 hr a day, 7 days a week interventional cardiology staff on door-to-balloon (D2B) time and mortality in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Any delay in PPCI in acute STEMI is associated with higher mortality and, therefore, time to treatment should be as short as possible. Despite the use of several strategies, goal D2B time of <90 min remains elusive.

METHODS

The study examined 790 consecutive STEMI patients treated with PPCI as the reperfusion therapy of choice. Patients were grouped into a pre-24 x 7 and post-24 x 7 cohort to study the impact of the new protocol on D2B time and major adverse cardiovascular events (MACE) and mortality.

RESULTS

Median D2B time decreased from 99 min in the pre-24 x 7 group to 55 min in the post-24 x 7 group (P = 0.001) and was not influenced by time of day or day of week. Adjusted for patient and clinical characteristics, the pre-24 x 7 group had increased in-hospital cardiovascular mortality (odds ratio 1.94, 95% confidence interval 0.95-3.94; P = 0.048) and MACE (odds ratio 1.66, 95% confidence interval 1.10-2.49; P = 0.009) compared with the post-24 x 7 group. Prolonged D2B time was also associated with higher 1-year overall mortality in the pre-24 x 7 group compared with the post-24 x 7 group (12.8% vs. 8.1%; hazard ratio 1.17, 95% confidence interval 1.04-2.66; P = 0.044).

CONCLUSIONS

Round-the-clock, in-hospital interventional cardiology team consistently and significantly reduces D2B time, in-hospital cardiovascular mortality, MACE, and 1-year mortality in patients with STEMI.

Quality of care for acute myocardial infarction in 58 U.S. emergency departments

OBJECTIVES

The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance.

METHODS

The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.

RESULTS

The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, -1.5; 95% confidence interval [CI] = -2.4 to -0.5) and southern EDs (beta-coefficient, -5.2; 95% CI = -9.6 to -0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7).

CONCLUSIONS

Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes.

Impact of a statewide ST-segment-elevation myocardial infarction regionalization program on treatment times for women, minorities, and the elderly

BACKGROUND

Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age.

METHODS AND RESULTS

STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients.

CONCLUSIONS

A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

Prevalence, etiology and outcome of catheterization laboratory false alarms in patients with suspected ST-elevation myocardial infarction

INTRODUCTION AND OBJECTIVES

To investigate the prevalence, causes and outcome of catheterization laboratory false alarms (CLFAs) in a regional primary angioplasty network.

METHODS

A prospective registry of 1,662 patients referred for primary angioplasty between January 2003 and August 2008 was reviewed to identify CLFAs (i.e. when no culprit coronary lesion could be found).

RESULTS

No culprit coronary lesion could be identified in 120 patients (7.2%; 95% confidence interval [CI], 5.9-8.5%). Of these, 104 (6.3%, 95% CI, 5.1-7.4%) had a discharge diagnosis other than ST-elevation myocardial infarction, 91 (5.5%; 95% CI, 4.3-6.6%) had no significant coronary disease, and 64 (3.8%; 95% CI, 2.9-4.8%) tested negative for cardiac biomarkers. The most frequent alternative diagnoses were: previous Q-wave myocardial infarction (18 cases), nonspecific ST-segment abnormalities (11), pericarditis (10) and transient apical dyskinesia (10). The 30-day mortality rate was similar in patients with and without culprit lesions (5.8% vs. 5.8%; P=.99). The prevalence of CLFAs was slightly higher in patients not previously evaluated by a cardiologist and referred from emergency departments in hospitals without catheterization laboratories than in those referred by cardiologists from emergency departments at hospitals with such facilities (9.5% vs. 6.1%; P=.02; odds ratio=1.64; 95% CI, 1.08-2.5). The prevalence of CLFAs was not significantly higher in patients referred by physicians with out-of-hospital emergency medical services (7.2%; P=.51; odds ratio=1.37; 95% CI, 0.79-2.37).

CONCLUSIONS

The prevalence of CLFAs was 7.2%, with the criterion of no culprit coronary lesion. Our findings suggest that different patterns of referral to catheterization laboratories could account for small variations in the prevalence of CLFAs.

Prevalence, etiology and outcome of catheterization laboratory false alarms in patients with suspected ST-elevation myocardial infarction

INTRODUCTION AND OBJECTIVES

To investigate the prevalence, causes and outcome of catheterization laboratory false alarms (CLFAs) in a regional primary angioplasty network.

METHODS

A prospective registry of 1,662 patients referred for primary angioplasty between January 2003 and August 2008 was reviewed to identify CLFAs (i.e. when no culprit coronary lesion could be found).

RESULTS

No culprit coronary lesion could be identified in 120 patients (7.2%; 95% confidence interval [CI], 5.9-8.5%). Of these, 104 (6.3%, 95% CI, 5.1-7.4%) had a discharge diagnosis other than ST-elevation myocardial infarction, 91 (5.5%; 95% CI, 4.3-6.6%) had no significant coronary disease, and 64 (3.8%; 95% CI, 2.9-4.8%) tested negative for cardiac biomarkers. The most frequent alternative diagnoses were: previous Q-wave myocardial infarction (18 cases), nonspecific ST-segment abnormalities (11), pericarditis (10) and transient apical dyskinesia (10). The 30-day mortality rate was similar in patients with and without culprit lesions (5.8% vs. 5.8%; P=.99). The prevalence of CLFAs was slightly higher in patients not previously evaluated by a cardiologist and referred from emergency departments in hospitals without catheterization laboratories than in those referred by cardiologists from emergency departments at hospitals with such facilities (9.5% vs. 6.1%; P=.02; odds ratio=1.64; 95% CI, 1.08-2.5). The prevalence of CLFAs was not significantly higher in patients referred by physicians with out-of-hospital emergency medical services (7.2%; P=.51; odds ratio=1.37; 95% CI, 0.79-2.37).

CONCLUSIONS

The prevalence of CLFAs was 7.2%, with the criterion of no culprit coronary lesion. Our findings suggest that different patterns of referral to catheterization laboratories could account for small variations in the prevalence of CLFAs.

Time of admission, quality of PCI care, and outcome of patients with ST-elevation myocardial infarction

OBJECTIVE

Our study aimed to analyse the hospital mortality of patients admitted in- and off-regular working hours with ST-elevation myocardial infarction (STEMI) within the special logistical setting of the urban area of the city of Berlin.

BACKGROUND

There is a debate whether patients with acute myocardial infarction admitted to hospital outside regular working hours experience higher mortality rates than those admitted within regular working hours.

METHODS

This study analyses data from the Berlin Myocardial Infarction Registry and comprises 2,131 patients with STEMI and treated with percutaneous coronary intervention (PCI) in 2004-2007. Data of patients admitted during in- and off-regular working hours were compared.

RESULTS

There was significant difference in door-to-balloon time (median in-hours: 79 min; median off-hours: 90 min, p < 0.001) and in hospital mortality (in-hours: 4.3%; off-hours: 6.8%, p = 0.020) between STEMI patients admitted in- and off-hours for treatment with PCI. After adjustment, admission off-hours remained an independent predictor for in-hospital death for patients (OR = 2.50; 95% CI 1.38-4.56). In patients with primary care from physician-escorted Emergency Medical Services (EMS), door-to-balloon time was reduced by 10 min for in-hours as well as off-hours patients. The difference in hospital mortality between off-hour and in-hour admission was reduced to a non-significant OR = 1.61 (95% CI 0.79-3.27).

CONCLUSIONS

In conclusion, patients admitted off-hours experienced longer door-to-balloon times and higher hospital mortality than did those admitted in-hours. The differences observed between patients admitted in-hours and off-hours were reduced through physician-escorted EMS reflecting the influence of optimized STEMI care.

Fibrinolysis versus primary percutaneous intervention in ST-elevation myocardial infarction with long interhospital transfer distances

BACKGROUND

Current guidelines recommend rapid initiation of reperfusion therapy for ST-elevation myocardial infarction (STEMI), with short-distance transfer for primary percutaneous coronary intervention (pPCI) preferred over fibrinolysis in non-pPCI-capable hospitals. Comparative outcomes in patients with longer transfer times are unclear.

HYPOTHESIS

We designed this study to assess whether administering fibrinolytics prior to initiating longer-distance interhospital transfer in patients with STEMI leads to a delay in transfer or worse outcomes compared with transfer for pPCI.

METHODS

We analyzed 259 STEMI patients transferred to a receiving pPCI-capable center in eastern North Carolina. The patients were divided into 2 groups, with 43 (16.6%) transferred for pPCI and the remaining 216 (83.4%) transferred following fibrinolysis. The primary endpoint was door-to-door time. We also compared stroke, death, significant bleeding, and combined outcomes between the 2 groups.

RESULTS

The median door-to-door time was similar for pPCI and fibrinolysis patients (135 vs 128 minutes; P = 0.71). Median door-to-balloon time among pPCI patients was 182 minutes from the point of arrival at the referral hospital and 49 minutes from arrival at the receiving pPCI center. Median door-to-needle time in the fibrinolysis patients was 30 minutes, with rescue PCI eventually performed in 81 (37.5%) patients. In-hospital mortality was higher in patients with pPCI (9.3%) compared with fibrinolysis patients (1.9%; P = 0.03). Combined incidence of stroke, significant bleeding, and death was 14% in pPCI patients compared with 7% in fibrinolysis patients (P = 0.13).

CONCLUSIONS

In settings with longer transfer distances, administering fibrinolytics prior to transfer to a pPCI-capable center did not cause any significant delay in transfer or worse outcomes.

A STEMI code protocol improves door-to-balloon time on weekdays and weekends

Primary percutaneous coronary intervention (PCI) has emerged as the standard of care for the management of ST-elevation myocardial infarctions (STEMI). Only 32% of patients with STEMI receive this procedure within the recommended 90 min for door-to-balloon time (DTB). We reviewed all STEMI cases that presented to our institution before and after the implementation of a STEMI Code protocol. Before the STEMI Code protocol, 27.1% of weekday cases and 6.3% of weekend cases were performed within 90 min. After the STEMI Code protocol, there was a threefold increase in the number of patients who received PCI within 90 min (p<.0001). A STEMI Code protocol dramatically improves DTB and equalizes disparities between weekday and weekend care.

Achieving routine sub 30 minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access

BACKGROUND

In primary angioplasty (primary percutaneous coronary intervention [PPCI]) for acute myocardial infarction, institutional logistical delays can increase door-to-balloon times, resulting in increased mortality.

METHODS

We moved from a thrombolysis (TL) service to 24/7 PPCI for direct access and interhospital transfer in April 2004. Using autonomous ambulance diagnosis with open access to the myocardial infarction center catheter laboratory, we compared reperfusion times and clinical outcomes for the final 2 years of TL with the first 3 years of PPCI.

RESULTS

Comparison was made between TL (2002-2004, n = 185) and PPCI (2004-2007, n = 704); all times are medians in minutes (interquartile range): for TL, symptom to needle 153 (85-225), call to needle 58 (49-73), first professional contact (FPC) to needle 47 (39-63), door to needle 18 (12-30) (mortality: 7.6% at 30 days, 9.2% at 1 year); for interhospital transfer PPCI (n = 227), symptom to balloon 226 (175-350), call to balloon 135 (117-188), FPC to balloon 121 (102-166), first door-to-balloon 100 (80-142) (mortality: 7.0% at 30 days, 12.3% at 1 year); for direct-access PPCI (n = 477), symptom to balloon 142 (101-238), call to balloon 79 (70-93), FPC to balloon 69 (59-82), door to balloon 20 (16-29) (mortality: 4.6% at 30 days, 8.6% at 1 year). There was no difference between direct-access PPCI and TL times for symptom to needle/balloon. Direct-access PPCI was significantly quicker for the group than in-hospital thrombolysis for door to needle/balloon times due to the lack of any long wait patients (P < .001).

CONCLUSIONS

Interhospital transfer remains slow even with rapid institutional door-to-balloon times. With autonomous ambulance diagnosis and open access direct to the catheter laboratory, a median door-to-balloon time of <30 minutes day and night was achieved, and >95% of patients were reperfused within 1 hour.

Sustaining Improvement in Door-to-Balloon Time Over 4 Years

Background— American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) <90 minutes for nontransferred patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention. Systems of care to achieve and sustain this DTB performance over several years have not been previously reported.

Methods and Results— The Mayo Clinic STEMI protocol was implemented in April 2004 and included activation of the cardiac catheterization laboratory by the emergency medicine physician; a single call system to activate the catheterization laboratory; catheterization laboratory staff arrival within 20 to 30 minutes of activation; and real-time performance feedback within 24 to 48 hours. Data were collected on nontransferred STEMI patients. The preimplementation group (June 2002 to March 2004) comprised 96 patients with a median DTB of 97 (interquartile range, 82, 130) minutes, and 40% had a DTB <90 minutes. The postimplementation group (May 2004 to March 2008) comprised 322 patients with a median DTB of 67 (interquartile range, 55, 82) minutes, and 81% had a DTB <90 minutes. Postimplementation DTB was significantly shorter than preimplementation DTB ( P <0.001). In the 4-year follow-up after protocol implementation, the DTB performance remained stable over time ( P =0.41).

Conclusions— The Mayo Clinic STEMI protocol implemented strategies to reduce DTB for nontransferred patients with STEMI. DTB was significantly reduced, and the results were sustained over the 4-year follow-up period. Our experience demonstrates the effectiveness and durability of process changes targeting timeliness of primary percutaneous coronary intervention.

Financial impact of reducing door-to-balloon time in ST-elevation myocardial infarction: a single hospital experience

BACKGROUND

The impact of reducing door-to-balloon time on hospital revenues, costs, and net income is unknown.

METHODS

We prospectively determined the impact on hospital finances of (1) emergency department physician activation of the catheterization lab and (2) immediate transfer of the patient to an immediately available catheterization lab by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected financial data for 52 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention from October 1, 2004-August 31, 2005 and compared this group to 80 consecutive ST-elevation myocardial infarction patients from September 1, 2005-June 26, 2006 after protocol implementation.

RESULTS

Per hospital admission, insurance payments (hospital revenue) decreased ($35,043 +/- $36,670 vs. $25,329 +/- $16,185, P = 0.039) along with total hospital costs ($28,082 +/- $31,453 vs. $18,195 +/- $9,242, P = 0.009). Hospital net income per admission was unchanged ($6962 vs. $7134, P = 0.95) as the drop in hospital revenue equaled the drop in costs. For every $1000 reduction in total hospital costs, insurance payments (hospital revenue) dropped $1077 for private payers and $1199 for Medicare/Medicaid. A decrease in hospital charges ($70,430 +/- $74,033 vs. $53,514 +/- $23,378, P = 0.059), diagnosis related group relative weight (3.7479 +/- 2.6731 vs. 2.9729 +/- 0.8545, P = 0.017) and outlier payments with hospital revenue>$100,000 (7.7% vs. 0%, P = 0.022) all contributed to decreasing ST-elevation myocardial infarction hospitalization revenue. One-year post-discharge financial follow-up revealed similar results: Insurance payments: $49,959 +/- $53,741 vs. $35,937 +/- $23,125, P = 0.044; Total hospital costs: $39,974 +/- $37,434 vs. $26,778 +/- $15,561, P = 0.007; Net Income: $9984 vs. $9159, P = 0.855.

CONCLUSION

All of the financial benefits of reducing door-to-balloon time in ST-elevation myocardial infarction go to payers both during initial hospitalization and after one-year follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT00800163.

Incidence and prognosis of non-Q-wave vs. Q-wave myocardial infarction following catheter-based reperfusion therapy

BACKGROUND

The clinical importance of classifying myocardial infarction (MI) into non-Q-wave (NQWMI) vs. Q-wave (QWMI) subsets is controversial and might depend on the therapeutic reperfusion strategy employed. The prognostic implications of NQWMI development following primary percutaneous coronary intervention (PCI) have not been reported.

AIM

To examine the incidence, determinants and prognostic implications of NQWMI vs. QWMI development following primary PCI.

DESIGN

The ACSIS Registry, a 2-month nationwide survey conducted biennially, prospectively collects data from all MI admissions in Israel.

METHODS

Outcomes were compared among patients managed by primary PCI who subsequently developed NQWMI vs. QWMI. Independent predictors of Q-wave development and 1-year mortality were determined by multivariate stepwise logistic regression analysis and Cox proportional hazard model, respectively.

RESULTS

Of 4537 MI patients with ST-segment elevation on admission, 1230 (27%) were treated with primary PCI. A discharge diagnosis of NQWMI was made in 259 (21.1%) patients. The baseline features and PCI strategies employed were similar among NQWMI vs. QWMI patients, though peak creatine kinase levels were higher (median 795 U/l vs. 1681 U/l, P = 0.0001) and severe left ventricular ejection fraction (LVEF) impairment (<40%) more frequent (22.6% vs. 43.9%, P < 0.0001), in the latter group. Mortality at 1-year was significantly lower in NQWMI vs. QWMI patients (3.9% vs. 10.8%, P log-rank = 0.001). By Cox proportional hazard analysis, NQWMI vs. QWMI was an independent predictor of freedom from 1-year mortality [HR = 0.34 (95% CI: 0.15-0.79), P = 0.01].

DISCUSSION

The diagnosis of NQWMI after primary PCI is associated with an excellent prognosis independent of established prognosticators, including LVEF.