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Gioppatto S, Prado PS, Elias MAL, de Carvalho VH, Paiva CRDC, Alexim GDA, Reis RTB, Nogueira ACC, de Sousa Munhoz Soares AA, Nadruz W, de Carvalho LSF, Sposito AC. The Clinical and Economic Impact of Delayed Reperfusion Therapy: Real-World Evidence. Arq Bras Cardiol 2024; 121:e20230650. [PMID: 38747748 PMCID: PMC11081405 DOI: 10.36660/abc.20230650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/22/2024] [Accepted: 02/01/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Early reperfusion therapy is acknowledged as the most effective approach for reducing case fatality rates in patients with ST-segment elevation myocardial infarction (STEMI). OBJECTIVE Estimate the clinical and economic consequences of delaying reperfusion in patients with STEMI. METHODS This retrospective cohort study evaluated mortality rates and the total expenses incurred by delaying reperfusion therapy among 2622 individuals with STEMI. Costs of in-hospital care and lost productivity due to death or disability were estimated from the perspective of the Brazilian Unified Health System indexed in international dollars (Int$) adjusted by purchase power parity. A p < 0.05 was considered statistically significant. RESULTS Each additional hour of delay in reperfusion therapy was associated with a 6.2% increase (95% CI: 0.3% to 11.8%, p = 0.032) in the risk of in-hospital mortality. The overall expenses were 45% higher among individuals who received treatment after 9 hours compared to those who were treated within the first 3 hours, primarily driven by in-hospital costs (p = 0.005). A multivariate linear regression model indicated that for every 3-hour delay in thrombolysis, there was an increase in in-hospital costs of Int$497 ± 286 (p = 0.003). CONCLUSIONS The findings of our study offer further evidence that emphasizes the crucial role of prompt reperfusion therapy in saving lives and preserving public health resources. These results underscore the urgent need for implementing a network to manage STEMI cases.
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Affiliation(s)
- Silvio Gioppatto
- Universidade Estadual de CampinasDepartamento de CardiologiaCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp) - Departamento de Cardiologia, Campinas, SP – Brasil
| | - Paulo Sousa Prado
- Universidade de BrasíliaBrasíliaDFBrasilUniversidade de Brasília, Brasília, DF – Brasil
| | | | | | | | - Gustavo de Almeida Alexim
- Hospital de Base do Distrito FederalBrasíliaDFBrasilHospital de Base do Distrito Federal, Brasília, DF – Brasil
| | | | - Ana Claudia Cavalcante Nogueira
- Universidade de BrasíliaBrasíliaDFBrasilUniversidade de Brasília, Brasília, DF – Brasil
- Hospital de Base do Distrito FederalBrasíliaDFBrasilHospital de Base do Distrito Federal, Brasília, DF – Brasil
- Instituto Aramari ApoBrasíliaDFBrasilInstituto Aramari Apo, Brasília, DF – Brasil
| | | | - Wilson Nadruz
- Universidade Estadual de CampinasDepartamento de CardiologiaCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp) - Departamento de Cardiologia, Campinas, SP – Brasil
| | - Luiz Sergio F. de Carvalho
- Universidade Estadual de CampinasDepartamento de CardiologiaCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp) - Departamento de Cardiologia, Campinas, SP – Brasil
| | - Andrei C. Sposito
- Universidade Estadual de CampinasDepartamento de CardiologiaCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp) - Departamento de Cardiologia, Campinas, SP – Brasil
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French WJ, Gunderson M, Travis D, Bieniarz M, Zegre‐Hemsey J, Goyal A, Jacobs AK. Emergency Interhospital Transfer of Patients With ST‐Segment–Elevation Myocardial Infarction: Call 9‐1‐1—The American Heart Association Mission: Lifeline Program. J Am Heart Assoc 2022; 11:e026700. [DOI: 10.1161/jaha.122.026700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT: The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction. Every minute of delay in treatment adversely affects 1‐year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3‐step process of an interhospital “Call 9‐1‐1” protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming patient with ST‐segment–elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9‐1‐1 process in a system of care that involves all stakeholders.
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Affiliation(s)
- William J. French
- Geffen School of Medicine at UCLA, Cardiac Catheterization Laboratory, Harbor‐UCLA Medical Center Torrance CA
| | - Mic Gunderson
- Center for Systems Improvement, Cambridge Consulting Group; Emergency Health Services University of Maryland Baltimore County MD
| | - David Travis
- EMS Programs Hillsborough Community College Tampa FL
| | - Mark Bieniarz
- New Mexico Heart Institute Lovelace Medical Center Albuquerque NM
| | - Jessica Zegre‐Hemsey
- School of Nursing; Department of Emergency Medicine The University of North Carolina at Chapel Hill NC
| | - Abhinav Goyal
- Emory Heart and Vascular Center, Emory Healthcare; Medicine (Cardiology) Emory School of Medicine; Emory Rollins School of Public Health Atlanta GA
| | - Alice K. Jacobs
- Department of Medicine Boston University School of Medicine and Boston Medical Center Boston MA
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Panchavati S, Lam C, Zelin NS, Pellegrini E, Barnes G, Hoffman J, Garikipati A, Calvert J, Mao Q, Das R. Retrospective validation of a machine learning clinical decision support tool for myocardial infarction risk stratification. Healthc Technol Lett 2021; 8:139-147. [PMID: 34938570 PMCID: PMC8667565 DOI: 10.1049/htl2.12017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/26/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022] Open
Abstract
Diagnosis and appropriate intervention for myocardial infarction (MI) are time-sensitive but rely on clinical measures that can be progressive and initially inconclusive, underscoring the need for an accurate and early predictor of MI to support diagnostic and clinical management decisions. The objective of this study was to develop a machine learning algorithm (MLA) to predict MI diagnosis based on electronic health record data (EHR) readily available during Emergency Department assessment. An MLA was developed using retrospective patient data. The MLA used patient data as they became available in the first 3 h of care to predict MI diagnosis (defined by International Classification of Diseases, 10th revision code) at any time during the encounter. The MLA obtained an area under the receiver operating characteristic curve of 0.87, sensitivity of 87% and specificity of 70%, outperforming the comparator scoring systems TIMI and GRACE on all metrics. An MLA can synthesize complex EHR data to serve as a clinically relevant risk stratification tool for MI.
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Affiliation(s)
| | - Carson Lam
- Division of Data ScienceDascena, Inc.HoustonTexasUSA
| | | | | | - Gina Barnes
- Division of Data ScienceDascena, Inc.HoustonTexasUSA
| | - Jana Hoffman
- Division of Data ScienceDascena, Inc.HoustonTexasUSA
| | | | - Jacob Calvert
- Division of Data ScienceDascena, Inc.HoustonTexasUSA
| | - Qingqing Mao
- Division of Data ScienceDascena, Inc.HoustonTexasUSA
| | - Ritankar Das
- Division of Data ScienceDascena, Inc.HoustonTexasUSA
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Myers V, Nolan B. Delays to Initiate Interfacility Transfer for Patients Transported by a Critical Care Transport Organization. Air Med J 2021; 40:436-440. [PMID: 34794785 DOI: 10.1016/j.amj.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The time to initiate an interfacility transfer is an important and understudied cause of delay to definitive management. This study identifies characteristics associated with delays to initiate interfacility transfer of critically ill patients. METHODS We performed a retrospective cohort study of adult patients who underwent interfacility transfer by a provincial critical care transport organization over a 3-year period. The primary outcome was the time to initiate interfacility transfer. Quantile regression explored the impact of patient, environmental, and institutional characteristics. RESULTS In total 11,231 patients were included. Cardiac (+1.45 hours), gastrointestinal (+3.28 hours), respiratory (+4.90 hours), or sepsis (+3.03 hours) reasons for transfer; vasopressor requirements (+2.31 hours); and evening time (+3.67 hours) were associated with longer times to initiate interfacility transfer at the 90th quantile. Neurologic (-1.45 hours), obstetric (-1.56 hours), or trauma (-3.14 hours) reasons for transfer; Glasgow Coma Scale < 8 (-0.98 hours); blood transfusion requirement (-1.47 hours); and smaller sending sites were associated with shorter times to initiate transfer. CONCLUSION The time to initiate interfacility transfer represents a modifiable delay in a patient's transport journey. This study highlights important patient, environmental, and institutional characteristics associated with increased time to initiate transfer. Collaboration between transport organizations and hospitals in developing regional bypass criteria and prearranged transfer agreements may help facilitate timely patient transfer.
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Affiliation(s)
- Victoria Myers
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Brodie Nolan
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Emergency Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Ornge, Toronto, Ontario, Canada
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Lieng MK, Marcin JP, Dayal P, Tancredi DJ, Swanson MB, Haynes SC, Romano PS, Sigal IS, Rosenthal JL. Emergency Department Pediatric Readiness and Potentially Avoidable Transfers. J Pediatr 2021; 236:229-237.e5. [PMID: 34000284 PMCID: PMC8830940 DOI: 10.1016/j.jpeds.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components. STUDY DESIGN This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates. RESULTS After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan. CONCLUSIONS Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.
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Affiliation(s)
- Monica K Lieng
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA.
| | - James P Marcin
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Parul Dayal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Morgan B Swanson
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Sarah C Haynes
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Patrick S Romano
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Ilana S Sigal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Jennifer L Rosenthal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
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Howell D, Li T, De Bono J, Berkowitz J. Reduction in Interfacility Transfer Response Time after Implementation of an AutoLaunch Protocol. PREHOSP EMERG CARE 2021; 26:739-745. [PMID: 34251976 DOI: 10.1080/10903127.2021.1954271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Interfacility transfers (IFTs) are an essential component of healthcare systems to allow movement of patients between facilities. It is essential to limit any delays in patients receiving the care they require at the receiving facility. The primary objective of this study was to assess whether IFT response time was reduced after implementation of an AutoLaunch protocol, in which an ambulance is dispatched to the sending facility prior to acceptance of the patient by the receiving facility. The secondary objective was to describe the frequency and amount of time ambulances had to stage outside the sending facility in situations where the ambulance arrived prior to the patient being accepted by the receiving facility. Methods: This was a retrospective pre-post analysis of patients undergoing IFT for services not available at the sending facility between October 1, 2018 and September 30, 2019, with the AutoLaunch protocol being implemented on March 25, 2019. IFT response time was defined as the time the transfer request was initially made to the time the ambulance arrived at the sending facility. Dispatch call logs and transport records were analyzed before and after implementation of the AutoLaunch protocol to assess for a difference in IFT response time as well as frequency and amount of time ambulances had to stage. Results: Of 1,881 IFTs analyzed, 885 (47.0%) were completed under the traditional protocol and 996 (53.0%) were completed under the AutoLaunch protocol. The median IFT response time under the traditional protocol was 27.5 minutes (interquartile range (IQR): 17.9, 43.3), compared with 19.9 minutes (IQR: 12.8, 28.2) under the AutoLaunch protocol (p < 0.01), representing a 27.6% reduction in response time, or 7.6 minutes saved. Of the 996 AutoLaunch transfers, there were 215 incidents (21.6%) in which the IFT ambulance had to stage, and the median staging time was 10.1 minutes (IQR: 4.9, 24.2). Conclusions: Implementation of our AutoLaunch protocol resulted in a significant reduction in ambulance response time for interfacility transfers. Further studies are needed to assess whether the reduction in response time is associated with improved patient outcomes for certain conditions.
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Govea A, Lipinksi J, Patel MP. Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI. Interv Cardiol Clin 2021; 10:293-306. [PMID: 34053616 DOI: 10.1016/j.iccl.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.
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Affiliation(s)
- Alayn Govea
- Division of Cardiovascular Medicine, UC San Diego, San Diego, CA, USA; UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA
| | - Jerry Lipinksi
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Department of Internal Medicine, UC San Diego, San Diego, CA, USA
| | - Mitul P Patel
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Division of Cardiovascular Medicine, UC San Diego Cardiovascular Institute, San Diego, CA, USA.
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8
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What is the real impact of on-site percutaneous coronary intervention? A propensity score matched analysis of patients admitted with Acute Coronary Syndrome. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.repce.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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9
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Ward MJ, Vogus TJ, Muñoz D, Collins SP, Moser K, Jenkins CA, Liu D, Kripalani S. Examining the Timeliness of ST-elevation Myocardial Infarction Transfers. West J Emerg Med 2021; 22:319-325. [PMID: 33856318 PMCID: PMC7972365 DOI: 10.5811/westjem.2020.8.47770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI. Methods We conducted a retrospective analysis of interfacility transfers from emergency departments (ED) to a single percutaneous coronary intervention center between 2011–2014. We included emergency department (ED) patients transferred to the percutaneous coronary intervention center and excluded scene transfers and those given fibrinolytics. We calculated descriptive statistics and used multivariable linear regression to model the association of variables with ED time intervals (arrival to electrocardiogram [ECG], ECG-to-EMS activation, and ECG-to-STEMI alert) adjusting for patient age, gender, mode of arrival, weekday hour presentation, facility transfers in the past year, and transferring facility distance. Results We identified 159 patients who met inclusion criteria. Subjects were a mean of 59 years old (standard deviation 13), 22% female, and 93% White; 59% arrived by private vehicle, and 24% presented after weekday hours. EDs transferred a median of 9 STEMIs (interquartile range [IQR] 3, 15) in the past year and a median of 65 miles (IQR 35, 90) from the percutaneous coronary intervention center. Median ED length of stay was 65 minutes (IQR 51, 85). Among component intervals, arrival to ECG was 6%, ECG-to-EMS activation 32%, and ECG-to-STEMI alert was 49% of overall ED length of stay. Only 18% of transfers had EMS activation earlier than STEMI alert. ECG-to-EMS activation was shorter in EDs achieving length of stay ≤60 minutes compared to those >60 minutes (12 vs 31 minutes, P<0.001). Multivariable modeling showed that after-hours presentation was associated with longer ECG-to-EMS activation (adjusted relative risk [RR] 1.05, P<0.001). Female gender (adjusted RR 0.81, P<0.001), prior facility transfers (adjusted RR 0.84, P<0.001), and initial ambulance presentation (adjusted RR 0.93, P = 0.02) were associated with shorter ECG-to-EMS activation. Conclusion In STEMI transfers, faster EMS activation was more likely to achieve a shorter ED length of stay than a rapid, percutaneous coronary intervention center STEMI alert. Large-scale quality improvement efforts such as the American Heart Association’s Mission Lifeline that were designed to regionalize STEMI have improved the timeliness of reperfusion, but major gaps, particularly in interfacility transfers, remain. While the transferring EDs are recognized as the primary source of delay during interfacility STEMI transfers, the contributions to delays at transferring EDs remain poorly understood.
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Affiliation(s)
- Michael J Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee.,VA Tennessee Valley Healthcare System, Department of Emergency Medicine, Murfreesboro, Tennessee
| | - Timothy J Vogus
- Vanderbilt University, Owen Graduate School of Management, Nashville, Tennessee
| | - Daniel Muñoz
- Vanderbilt University School of Medicine, Division of Cardiology, Nashville, Tennessee
| | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee.,VA Tennessee Valley Healthcare System, Department of Emergency Medicine, Murfreesboro, Tennessee
| | - Kelly Moser
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Cathy A Jenkins
- Vanderbilt University School of Medicine, Department of Biostatistics, Nashville, Tennessee
| | - Dandan Liu
- Vanderbilt University School of Medicine, Department of Biostatistics, Nashville, Tennessee
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Center for Clinical Quality and Implementation Research, Nashville, Tennessee
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Miranda H, Sousa C, Santos H, Almeida I, Chin J, Almeida S, Tavares J. What is the real impact of on-site percutaneous coronary intervention? A propensity score analysis of patients admitted with acute coronary syndrome. Rev Port Cardiol 2021; 40:169-188. [PMID: 33518393 DOI: 10.1016/j.repc.2020.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/03/2020] [Accepted: 06/17/2020] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION In an era in which coronary heart disease is one of the leading causes of death worldwide, several studies report the persistence of obstacles to accessing revascularization, and percutaneous coronary intervention in particular, which may be associated with worse outcomes. OBJECTIVES To compare cardiovascular outcomes in patients admitted to hospitals with and without on-site percutaneous coronary intervention (PCI) capabilities. MATERIAL AND METHODS A retrospective study based on the National Registry of Acute Coronary Syndromes (ACS) - with data collection from 2010 to 2018. Division of the patients into two groups: with and without ST-elevation. Two subgroups were subsequently created according to the presence/absence of on-site PCI. A propensity score was performed to standardize the results. Patients without information about hospital admission (with/without PCI) were excluded. RESULTS 6008 patients were included after exclusion criteria and propensity score were applied. We found that patients admitted for ACS with ST-elevation (STE-ACS) had more episodes of sustained ventricular tachycardia (OR 2.14; CI (1.26-3.61); p=0.004) in hospitals without on-site PCI. Regarding ACS without ST elevation (NSTE-ACS), there were more cases of congestive heart failure (OR 0.79; CI (0.65-0.98)) in hospitals with on-site PCI. CONCLUSION The incidence of a greater number of major adverse events in hospitalizations without on-site PCI, particularly in the case of STE-ACS, is a consequence of the delay before revascularization. National and local strategies must be established to reduce the negative impact of the absence of on-site PCI and the resulting time before revascularization.
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Affiliation(s)
- Hugo Miranda
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas.
| | - Catarina Sousa
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Faculdade de Medicina, Universidade de Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas
| | - Hélder Santos
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas
| | - Inês Almeida
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas
| | - Joana Chin
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas
| | - Samuel Almeida
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas
| | - João Tavares
- Serviço de Cardiologia do Centro Hospitalar Barreiro-Montijo, Lisboa, Portugal; Centro Nacional de Colheita de Dados em Cardiologia, Sociedade Portuguesa de Cardiologia, Coimbra, Portugal; Investigadores do Registo Nacional de Síndromes Coronárias Agudas
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Scheving WL, Froehler M, Hart K, McNaughton CD, Ward MJ. Inter-facility transfer for patients with acute large vessel occlusion stroke receiving mechanical thrombectomy. Am J Emerg Med 2021; 39:132-136. [PMID: 33039216 PMCID: PMC7736132 DOI: 10.1016/j.ajem.2020.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/29/2020] [Accepted: 09/16/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the preferred treatment for large vessel occlusion (LVO) ischemic stroke, and neurological outcome improves with earlier treatment. Patients with LVO frequently require inter-facility transfer to access MT but delays at transferring EDs may worsen neurological outcomes. METHODS We conducted a retrospective observational study to evaluate the association of time spent and transferring EDs with 90-day neurological outcomes among patients who were transferred from an outside ED to the Comprehensive Stroke Center and received MT. Time intervals at transferring EDs were examined descriptively, and multivariable logistic regression modeling was used to examine the association of time spent in the ED with 90-day neurologic outcome (modified Rankin Scale; good ≤2, poor ≥3). RESULTS Among 111 patients transferred to a stroke center for MT between 2013 and 2017, the time between CT scan and the stroke center transfer request was 44 (IQR 27,65) minutes, or 47% of transferring ED total duration. Duration at the transferring ED was not significantly associated with 90-day outcome. Only NIH Stroke Scale at the time of arrival to the stroke center was associated with good 90-day neurological outcome (aOR 0.84, 95%CI 0.77, 0.92, p < 0.0001). CONCLUSIONS Among LVO patients transferred for MT, the total time spent at transferring EDs was not associated with 90-day neurologic outcome in patients with LVO. As therapies and their associated effectiveness improves over time, future investigations should further characterize the time between CT and transfer request to identify targets for process improvement and clinical outcomes.
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Affiliation(s)
- William L Scheving
- University of California at Los Angeles School of Medicine, Department of Emergency Medicine, Los Angeles, CA, USA.
| | - Michael Froehler
- Vanderbilt University Medical Center, Department of Neurology, Nashville, TN, USA.
| | - Kimberly Hart
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN, USA.
| | - Candace D McNaughton
- Vanderbilt University Medical Center, Department of Emergency Medicine. Geriatric Research Education and Clinical Centers (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Michael J Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine. VA Tennessee Valley Healthcare System, 1313 21st Ave. S. Nashville, TN 37232, USA.
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Breaking down walls: a qualitative evaluation of perceived emergency department delays for patients transferred with ST-elevation myocardial infarction. BMC Emerg Med 2020; 20:60. [PMID: 32762657 PMCID: PMC7409424 DOI: 10.1186/s12873-020-00355-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/27/2020] [Indexed: 11/10/2022] Open
Abstract
Background Despite regionalization efforts, delays at transferring hospitals for patients transferred with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) persist. These delays primarily occur in the emergency department (ED), and are associated with increased mortality. We sought to use qualitative methods to understand staff and clinician perceptions underlying these delays. Methods We conducted semi-structured interviews at 3 EDs that routinely transfer STEMI patients to identify staff perceptions of delays and potential interventions. Interviews were recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build and refine a list of themes and subthemes, and identify supporting quotes. Results We interviewed 43 ED staff (staff, nurses, and physicians) and identified 3 major themes influencing inter-facility transfers of STEMI patients: 1) Processes, 2) Communication; and 3) Resources. Standardized processes (i.e., protocols) reduce uncertainty and can mobilize resources. Use of performance benchmarks can motivate staff but are frequently focused on internal, not inter-organizational performance. Direct use ofcommunication between ORGANIZATIONS can process uncertainty and expedite care. Record sharing and regular post-transfer communication could provide opportunities to discuss and learn from delays and increase professional satisfaction. Finally, characteristics of resources that enhanced their capacity, clarity, experience, and reliability were identified as contributing to timely transfers. Conclusions Processes, communication, and resources were identified as modifying inter-facility transfer timeliness. Potential quality improvement strategies include ongoing updates of protocols within and between organizations to account for changes, enhanced post-transfer feedback between organizations, shared medical records, and designated roles for coordination.
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Clot S, Rocher T, Morvan C, Cardine M, Lotfi M, Turk J, Usseglio P, Descotes-Genon V, Vanzetto G, Savary D, Debaty G, Belle L. Door-in to door-out times in acute ST-segment elevation myocardial infarction in emergency departments of non-interventional hospitals: A cohort study. Medicine (Baltimore) 2020; 99:e20434. [PMID: 32501989 PMCID: PMC7306318 DOI: 10.1097/md.0000000000020434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In France, one in eight patients with acute ST-segment elevation myocardial infarction (STEMI) is admitted direct to an emergency department (ED) in a hospital without percutaneous coronary intervention (PCI) facilities. Guidelines recommend transfer to a PCI center, with a door-in to door-out (DI-DO) time of ≤30 min. We report DI-DO times and identify the main factors affecting them.RESURCOR is a French Northern Alps registry of patients with STEMI of <12 h duration. We focused on patients admitted direct, without prehospital medical care, to EDs in 19 non-PCI centers from 2012 to 2014. We divided DI-DO time into diagnostic time (ED admission to call for transfer) and logistical time (call for transfer to ED discharge).Among 2007 patients, 240 were admitted direct to EDs in non-PCI centers; 57.9% were treated with primary angioplasty and 32.9% received thrombolysis. Median (interquartile range) DI-DO time was 92.5 (67-143) min, with a diagnostic time of 41 (23-74) min and a logistical time of 47.5 (32-69) min. Five patients (2.1%) had a DI-DO time ≤30 min. Five variables were independently associated with a shorter DI-DO time: local transfer (mobile intensive care unit [MICU] team available at referring ED) (P = .017) or transfer by air ambulance (P = .004); shorter distance from referring ED to PCI center (P < .001); shorter time from symptom onset to ED admission (P = .002); thrombolysis (P = .006); and extended myocardial infarction (P = .007).In view of longer-than-recommended DI-DO times, efforts are required to promote urgent local transfer and use of thrombolysis.
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Affiliation(s)
- Sandrine Clot
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | - Thomas Rocher
- Emergency Department and Emergency Medical Service, Annecy Hospital, Annecy
| | - Claire Morvan
- Biostatistician, RENAU (Reseau Nord Alpin des Urgences), Annecy
| | - Mathieu Cardine
- Emergency Department and Emergency Medical Service, Grenoble University Hospital, Grenoble
| | | | - Julien Turk
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | - Pascal Usseglio
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | | | - Gerald Vanzetto
- Department of Cardiology, Grenoble University Hospital, Grenoble, France
| | - Dominique Savary
- Emergency Department and Emergency Medical Service, Annecy Hospital, Annecy
| | - Guillaume Debaty
- Emergency Department and Emergency Medical Service, Grenoble University Hospital, Grenoble
| | - Loic Belle
- Department of Cardiology, Annecy Hospital, Annecy
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Timeliness of Care for Injured Patients Initially Seen at Freestanding Emergency Departments: A Pilot Quality Improvement Project. Qual Manag Health Care 2020; 29:95-99. [PMID: 32224793 DOI: 10.1097/qmh.0000000000000252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of freestanding emergency departments (FSEDs) on timeliness of care for trauma patients is not well understood. This quality improvement project had 2 objectives: (1) to determine whether significant delays in definitive care existed among trauma patients initially seen at FSEDs compared with those initially seen at other outlying sites prior to transfer to a level I trauma center; and (2) to determine the feasibility of identifying differences in time-to-definitive care and emergency department length of stay (ED LOS) based on initial treatment location. METHODS Trauma registry data from January 1, 2017, through December 31, 2017, from a verified level I trauma center were analyzed by location of initial presentation. Appropriate statistical tests are used to make comparisons across transport groups. RESULTS Patients initially seen at non-FSEDs experienced ED LOS that were, on average, 24.5 minutes greater than patients seen initially at FSEDs, although the difference was not statistically significant (P = .3112). Several challenges were identified in the feasibility analysis that will inform the design for a larger study including large quantities of missing time stamp data and potential selection bias. Prospective solutions were identified. CONCLUSION This project found that there were not significant differences in ED LOS for injured patients presenting initially to FSEDs or other non-FSED facilities, suggesting that timeliness of care was similar across location types.
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Beller JP, Hawkins RB, Mehaffey JH, Chancellor WZ, Fonner CE, Speir AM, Quader MA, Rich JB, Yarboro LT, Teman NR, Ailawadi G. Impact of transfer status on real-world outcomes in nonelective cardiac surgery. J Thorac Cardiovasc Surg 2020; 159:540-550. [PMID: 30878161 PMCID: PMC6689463 DOI: 10.1016/j.jtcvs.2018.12.107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 12/07/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Transfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department. METHODS All patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center. RESULTS A total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P < .01) and equivalent postoperative morbidity (15.6% vs 15.3% P = .63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P < .01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90). CONCLUSIONS Transfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup.
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Affiliation(s)
- Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | | | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Va
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
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Clark G, Corey K, Hutchison T, Lalonde T, Dunn J. Assessing Lift-Off Times for a Hospital-Based Helicopter Transport Program. Air Med J 2019; 38:183-187. [PMID: 31122584 DOI: 10.1016/j.amj.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/02/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hospital-based helicopter transport programs must define and track their own lift-off times (LOTs). The goal of this quality improvement study was to evaluate LOTs, identify factors influencing LOTs, and implement changes to improve LOTs without compromising safety. METHODS A retrospective evaluation of 248 flights during 2016 was completed using recorded times from our dispatch center. Actual LOTs were compared with policy LOT goals. Tasks for flight departure were identified, timed, and sorted into those that should not be pressured and those amenable to process change. RESULTS Five tasks were identified as being amenable to process change. The average LOT for scene calls was 10.56 minutes (range, 1-22 minutes) and met our 10-minute policy goal 59% of the time. The average LOT for interfacility flights was 13.2 minutes (range, 4-76 minutes) and met the policy goal of 15 minutes 76.5% of the time. CONCLUSION We identified tasks amenable to safe process change to decrease LOTs. The data supported LOT policy change to a single LOT goal of 13 minutes for all flights. This change represents an acceptable goal for all LOTs without compromising safety to our patients and teams.
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Affiliation(s)
| | | | | | | | - Julie Dunn
- UCHealth Trauma Research/Acute Care Surgery
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Nanda A, Urban A, Duong V, Heckle M, Ibebuogu UN, Reed G, Jefferies J, Khouzam RN. The Paradoxical Impact of Insurance Status on Interfacility Transfer Times and Outcomes in Patients with ST-Elevation Myocardial Infarction. Curr Probl Cardiol 2019; 46:100414. [PMID: 31003755 DOI: 10.1016/j.cpcardiol.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/09/2019] [Indexed: 11/24/2022]
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Cahuzac C, Ta TH, Henaoui A, Laborne FX, Briole N, Porche M, Lamhaut L, Sapir D, Andrianjafy H. Évaluation du délai DIDO ( door in-door out) des syndromes coronariens aigus dans les hôpitaux sans cardiologie interventionnelle du réseau RESSIF. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectifs : Le délai door in-door out (DIDO) représente la durée de séjour au service d’urgence (SU) des patients pris en charge pour un syndrome coronarien aigu ST+ (SCAST+), avant transfert en centre de cardiologie interventionnelle (CCI). Le DIDO ne devrait pas dépasser 30 minutes. Notre objectif était d’évaluer le DIDO dans le réseau des urgences Sud Île-de-France (RESSIF).
Matériel et méthodes : Étude épidémiologique, rétrospective, multicentrique comparant le DIDO entre 2014 et 2015 (période 1), puis en 2016 (période 2) dans deux hôpitaux sans CCI, l’hôpital de Longjumeau et l’hôpital d’Arpajon. En 2016 était appliqué dans notre protocole régional SCAST+ le « réflexe électro-oculotéléphonique » (REOT), avec l’objectif de diminuer le DIDO : dès l’électrocardiogramme qualifiant (ECGq), avant tout traitement ou obtention du CCI de transfert, le médecin urgentiste appelle le service d’aide médicale à l’urgence (SAMU) pour l’envoi immédiat d’un service mobile d’urgence et de réanimation (SMUR) secondaire.
Résultats : Entre les deux périodes, le délai DIDO médian n’a pas été modifié significativement (–16 min [4–42] ; p = 0,06). Le délai entre ECGq et appel du SAMU n’était pas significativement différent avant et après application du REOT (15 [8–34] vs 9 min [6–26] ; p = 0,12). Le DIDO était supérieur ou égal à 30 min en période 1, contre 6 % en période 2 (p = 0,11).
Conclusion : Le DIDO du RESSIF n’a pas été significativement modifié. Il n’y a pas eu d’impact significatif du REOT sur le DIDO, mais notre étude manque de puissance. Le REOT pourrait être évalué plus largement dans les SU. Un réseau de soins impliquant les SAMU, SMUR, SU et CCI avec protocoles partagés est essentiel pour le pronostic des SCAST+.
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Association Between Hospital Practices and Door-in-door-out Time in ST-segment Elevation Myocardial Infarction. Crit Pathw Cardiol 2017; 15:165-168. [PMID: 27846009 DOI: 10.1097/hpc.0000000000000093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current guidelines suggest a "door-in-door-out" (DIDO) time of 30 minutes or shorter for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a STEMI referral hospital and are transferred to a STEMI-receiving center for primary percutaneous coronary intervention. Experts previously identified 18 system practices as critical for reducing DIDO times. The objective of this study was to describe how frequently these critical practices are used and to determine whether their use was associated with shorter DIDO times. METHODS We surveyed 18 STEMI referral hospitals for 4 STEMI-receiving centers regarding their use of these 18 practices. The median number used was 14 practices (interquartile range 12-15). We then evaluated their association with DIDO times in all patients (n = 93) transferred from these STEMI referral hospitals to the 4 STEMI-receiving centers for primary percutaneous coronary intervention. RESULTS In univariate linear regression analyses, system-wide quality improvement programs with leaders in the emergency medical services agencies and STEMI referral hospitals were associated with shorter DIDO times (P < 0.001 for all). Overall use of system practices was not associated with DIDO times (P = 0.143). The majority (76%, 95% confidence interval: 66%-85%) of DIDO times did not meet the 30-minute goal. CONCLUSIONS These findings highlight the difficulty in achieving the 30-minute DIDO goal and the need for continued focus on strategies for reducing DIDO time, including system-wide quality improvement programs.
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Ward MJ, Baker O, Schuur JD. Association of Emergency Department Length of Stay and Crowding for Patients with ST-Elevation Myocardial Infarction. West J Emerg Med 2015; 16:1067-72. [PMID: 26759656 PMCID: PMC4703176 DOI: 10.5811/westjem.2015.8.27908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/14/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction With the majority of U.S. hospitals not having primary percutaneous coronary intervention (pPCI) capabilities, the time spent at transferring emergency departments (EDs) is predictive of clinical outcomes for patients with ST-elevation myocardial infarction (STEMI). Compounding the challenges of delivering timely emergency care are the known delays caused by ED crowding. However, the association of ED crowding with timeliness for patients with STEMI is unknown. We sought to examine the relationship between ED crowding and time spent at transferring EDs for patients with STEMI. Methods We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The outcome was time spent at a transferring ED (i.e., door-in-door-out [DIDO]), was CMS measure OP-3b for hospitals with ≥10 acute myocardial infarction (AMI) cases requiring transfer (i.e., STEMI) annually: Time to Transfer an AMI Patient for Acute Coronary Intervention. We used four CMS ED timeliness measures as surrogate measures of ED crowding: admitted length of stay (LOS), discharged LOS, boarding time, and waiting time. We analyzed bivariate associations between DIDO and ED timeliness measures. We used a linear multivariable regression to evaluate the contribution of hospital characteristics (academic, trauma, rural, ED volume) to DIDO. Results Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure. These facilities were primarily non-academic (99.0%), non-trauma centers (65.4%), and in urban locations (68.5%). Median DIDO was 54.0 minutes (IQR 42.0,68.0). Increased DIDO time was associated with longer admitted LOS and boarding times. After adjusting for hospital characteristics, a one-minute increase in ED LOS at transferring facilities was associated with DIDO (coefficient, 0.084 [95% CI [0.049,0.119]]; p<0.001). This translates into a five-minute increase in DIDO for every one-hour increase in ED LOS for admitted patients. Conclusion Among patients with STEMI presenting to U.S. EDs, we found that ED crowding has a small but operationally insignificant effect on time spent at the transferring ED.
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Affiliation(s)
- Michael J Ward
- Vanderbilt University, Department of Emergency Medicine, Nashville, Tennessee
| | - Olesya Baker
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
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