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Tseng LM, Chuang CY, Chua SK, Tseng VS. Identification of Coronary Culprit Lesion in ST Elevation Myocardial Infarction by Using Deep Learning. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2022; 11:70-79. [PMID: 36654772 PMCID: PMC9842227 DOI: 10.1109/jtehm.2022.3227204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/08/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Early revascularization of the occluded coronary artery in patients with ST elevation myocardial infarction (STEMI) has been demonstrated to decrease mortality and morbidity. Currently, physicians rely on features of electrocardiograms (ECGs) to identify the most likely location of coronary arteries related to an infarct. We sought to predict these culprit arteries more accurately by using deep learning. METHODS A deep learning model with a convolutional neural network (CNN) that incorporated ECG signals was trained on 384 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) at a medical center. The performances of various signal preprocessing methods (short-time Fourier transform [STFT] and continuous wavelet transform [CWT]) with different lengths of input ECG signals were compared. The sensitivity and specificity for predicting each infarct-related artery and the overall accuracy were evaluated. RESULTS ECG signal preprocessing with STFT achieved fair overall prediction accuracy (79.3%). The sensitivity and specificity for predicting the left anterior descending artery (LAD) as the culprit vessel were 85.7% and 88.4%, respectively. The sensitivity and specificity for predicting the left circumflex artery (LCX) were 37% and 99%, respectively, and the sensitivity and specificity for predicting the right coronary artery (RCA) were 88.4% and 82.4%, respectively. Using CWT (Morlet wavelet) for signal preprocessing resulted in better overall accuracy (83.7%) compared with STFT preprocessing. The sensitivity and specificity were 93.46% and 80.39% for LAD, 56% and 99.7% for LCX, and 85.9% and 92.9% for RCA, respectively. CONCLUSION Our study demonstrated that deep learning with a CNN could facilitate the identification of the culprit coronary artery in patients with STEMI. Preprocessing ECG signals with CWT was demonstrated to be superior to doing so with STFT.
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Affiliation(s)
- Li-Ming Tseng
- Department of Emergency MedicineShin Kong Wu Ho-Su Memorial Hospital Taipei 11101 Taiwan
- Department of Computer ScienceNational Yang Ming Chiao Tung University Hsinchu 30010 Taiwan
- School of Medicine, College of MedicineFu Jen Catholic University New Taipei 24205 Taiwan
| | - Cheng-Yen Chuang
- Division of CardiologyDepartment of Internal MedicineShin Kong Wu Ho-Su Memorial Hospital Taipei 11101 Taiwan
| | - Su-Kiat Chua
- Division of CardiologyDepartment of Internal MedicineShin Kong Wu Ho-Su Memorial Hospital Taipei 11101 Taiwan
- School of Medicine, College of MedicineFu Jen Catholic University New Taipei 24205 Taiwan
| | - Vincent S Tseng
- Department of Computer ScienceNational Yang Ming Chiao Tung University Hsinchu 30010 Taiwan
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Wang YC, Chen KW, Tsai BY, Wu MY, Hsieh PH, Wei JT, Shih ESC, Shiao YT, Hwang MJ, Chang KC. Implementation of an All-Day Artificial Intelligence-Based Triage System to Accelerate Door-to-Balloon Times. Mayo Clin Proc 2022; 97:2291-2303. [PMID: 36336511 DOI: 10.1016/j.mayocp.2022.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/18/2022] [Accepted: 05/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To implement an all-day artificial intelligence (AI)-based system to facilitate chest pain triage in the emergency department. METHODS The AI-based triage system encompasses an AI model combining a convolutional neural network and long short-term memory to detect ST-elevation myocardial infarction (STEMI) on electrocardiography (ECG) and a clinical risk score (ASAP) to prioritize patients for ECG examination. The AI model was developed on 2907 twelve-lead ECGs: 882 STEMI and 2025 non-STEMI ECGs. RESULTS Between November 1, 2019, and October 31, 2020, we enrolled 154 consecutive patients with STEMI: 68 during the AI-based triage period and 86 during the conventional triage period. The mean ± SD door-to-balloon (D2B) time was significantly shortened from 64.5±35.3 minutes to 53.2±12.7 minutes (P=.007), with 98.5% vs 87.2% (P=.009) of D2B times being less than 90 minutes in the AI group vs the conventional group. Among patients with an ASAP score of 3 or higher, the median door-to-ECG time decreased from 30 minutes (interquartile range [IQR], 7-59 minutes) to 6 minutes (IQR, 4-30 minutes) (P<.001). The overall performances of the AI model in identifying STEMI from 21,035 ECGs assessed by accuracy, precision, recall, area under the receiver operating characteristic curve, F1 score, and specificity were 0.997, 0.802, 0.977, 0.999, 0.881, and 0.998, respectively. CONCLUSION Implementation of an all-day AI-based triage system significantly reduced the D2B time, with a corresponding increase in the percentage of D2B times less than 90 minutes in the emergency department. This system may help minimize preventable delays in D2B times for patients with STEMI undergoing primary percutaneous coronary intervention.
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Affiliation(s)
- Yu-Chen Wang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan; Division of Cardiovascular Medicine, Asia University Hospital, Taichung, Taiwan; Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung, Taiwan
| | - Ke-Wei Chen
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Being-Yuah Tsai
- AI Center for Medical Diagnosis, China Medical University Hospital, Taichung, Taiwan
| | - Mei-Yao Wu
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung, Taiwan
| | | | - Jung-Ting Wei
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Edward S C Shih
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Yi-Tzone Shiao
- Center of Institutional Research and Development, Asia University, Taichung, Taiwan
| | - Ming-Jing Hwang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
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Kim D, Hwang JE, Cho Y, Cho HW, Lee W, Lee JH, Oh IY, Baek S, Lee E, Kim J. A Retrospective Clinical Evaluation of an Artificial Intelligence Screening Method for Early Detection of STEMI in the Emergency Department. J Korean Med Sci 2022; 37:e81. [PMID: 35289140 PMCID: PMC8921208 DOI: 10.3346/jkms.2022.37.e81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Rapid revascularization is the key to better patient outcomes in ST-elevation myocardial infarction (STEMI). Direct activation of cardiac catheterization laboratory (CCL) using artificial intelligence (AI) interpretation of initial electrocardiography (ECG) might help reduce door-to-balloon (D2B) time. To prove that this approach is feasible and beneficial, we assessed the non-inferiority of such a process over conventional evaluation and estimated its clinical benefits, including a reduction in D2B time, medical cost, and 1-year mortality. METHODS This is a single-center retrospective study of emergency department (ED) patients suspected of having STEMI from January 2021 to June 2021. Quantitative ECG (QCG™), a comprehensive cardiovascular evaluation system, was used for screening. The non-inferiority of the AI-driven CCL activation over joint clinical evaluation by emergency physicians and cardiologists was tested using a 5% non-inferiority margin. RESULTS Eighty patients (STEMI, 54 patients [67.5%]) were analyzed. The area under the curve of QCG score was 0.947. Binned at 50 (binary QCG), the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 98.1% (95% confidence interval [CI], 94.6%, 100.0%), 76.9% (95% CI, 60.7%, 93.1%), 89.8% (95% CI, 82.1%, 97.5%) and 95.2% (95% CI, 86.1%, 100.0%), respectively. The difference in sensitivity and specificity between binary QCG and the joint clinical decision was 3.7% (95% CI, -3.5%, 10.9%) and 19.2% (95% CI, -4.7%, 43.1%), respectively, confirming the non-inferiority. The estimated median reduction in D2B time, evaluation cost, and the relative risk of 1-year mortality were 11.0 minutes (interquartile range [IQR], 7.3-20.0 minutes), 26,902.2 KRW (22.78 USD) per STEMI patient, and 12.39% (IQR, 7.51-22.54%), respectively. CONCLUSION AI-assisted CCL activation using initial ECG is feasible. If such a policy is implemented, it would be reasonable to expect some reduction in D2B time, medical cost, and 1-year mortality.
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Affiliation(s)
- Dongsung Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Youngjin Cho
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Hyoung-Won Cho
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Wonjae Lee
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Hyun Lee
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Il-Young Oh
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sumin Baek
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eunkyoung Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Big Data Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Big Data Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Tsukui T, Sakakura K, Taniguchi Y, Yamamoto K, Seguchi M, Jinnouchi H, Wada H, Fujita H. Factors associated with poor clinical outcomes of ST-elevation myocardial infarction in patients with door-to-balloon time <90 minutes. PLoS One 2020; 15:e0241251. [PMID: 33091051 PMCID: PMC7580980 DOI: 10.1371/journal.pone.0241251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/11/2020] [Indexed: 12/22/2022] Open
Abstract
Background Recent guidelines for ST-elevation myocardial infarction (STEMI) recommended the door-to-balloon time (DTBT) <90 minutes. However, some patients could have poor clinical outcomes in spite of DTBT <90 minutes, which suggest the importance of therapeutic targets except DTBT. The purpose of this study was to find factors associated with poor clinical outcomes in STEMI patients with DTBT <90 minutes. Methods This retrospective study included 383 STEMI patients with DTBT <90 minutes. The primary endpoint was the major adverse cardiac events (MACE) defined as the composite of all-cause death, acute myocardial infarction, and acute heart failure requiring hospitalization. Result The median follow-up duration was 281 days, and the cumulative incidence of MACE was 16.2%. In the multivariate Cox hazard model, low body mass index (< 20 kg/m2) (vs. >20 kg/m2: HR 2.80, 95% CI 1.39–5.64, p = 0.004), history of previous myocardial infarction (HR 2.39, 95% CI 1.06–5.37, p = 0.04), and Killip class 3 or 4 (vs. Killip class 1 or 2: HR 2.39, 95% CI 1.30–4.40, p = 0.005) were significantly associated with MACE. In another multivariate Cox hazard model, flow worsening during percutaneous coronary intervention (PCI) (HR 3.24, 95% CI 1.79–5.86, p<0.001) and use of mechanical support (HR 3.15, 95% CI 1.71–5.79, p<0.001) were significantly associated with MACE, whereas radial approach (HR 0.54, 95% CI 0.32–0.92, p = 0.02) was inversely associated with MACE. Conclusion Low body mass index, Killip class 3/4, history of previous myocardial infarction, use of mechanical support, and flow worsening were significantly associated with MACE, whereas radial-access was inversely associated with MACE. It is important to avoid flow worsening during primary PCI even when appropriate DTBT was achieved.
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Affiliation(s)
- Takunori Tsukui
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- * E-mail:
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Utilization of a multidisciplinary emergency department sepsis huddle to reduce time to antibiotics and improve SEP-1 compliance. Am J Emerg Med 2020; 38:2400-2404. [PMID: 33041123 DOI: 10.1016/j.ajem.2020.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 11/20/2022] Open
Abstract
Sepsis is a significant public health crisis in the United States, contributing to 50% of inpatient hospital deaths. Given its dramatic health effects and implications in the setting of new CMS care guidelines, ED leaders have renewed focus on appropriate and timely sepsis care, including timely administration of antibiotics in patients at risk for sepsis. Modeling the success of multidisciplinary bedside huddles in improving compliance with appropriate care in other healthcare settings, a Sepsis Huddle was implemented in a large, academic ED, with the goal of driving compliance with standardized sepsis care as described in the CMS SEP-1 measure. A retrospective cohort analysis was performed, with the primary finding that utilization of the Sepsis Huddle resulted in antibiotics being administered on average 41 min sooner than when the Sepsis Huddle was not performed. Given that literature suggests that early administration of appropriate antibiotic therapy is a major driver of mortality reduction in patients with sepsis, this study represents a proof of concept that utilization of a Sepsis Huddle may serve to improve outcomes among ED patients at risk for sepsis.
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Yoshioka Y, Teshima R, Gamo M, Yoneda R, Matsunaga N, Takada T, Fukuta Y, Kishi K. A physician-staffed ground emergency medical service does not significantly shorten door-to-balloon time in patients with STEMI: an observational study in a single emergency center in Japan. Acute Med Surg 2020; 7:e542. [PMID: 32685177 PMCID: PMC7362674 DOI: 10.1002/ams2.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 11/08/2022] Open
Abstract
Aim Current guidelines recommend a door‐to‐balloon time (DTBT) of <90 min for reperfusion treatment of patients with ST‐segment elevation myocardial infarction (STEMI). A physician‐staffed ground emergency medical service (GEMS) using a rapid response car (RRC) system was implemented at our hospital in April 2015. The medical team, including a physician and nurse, is dispatched to assess the patient and expedite the start of treatment by emergency physicians and cardiologists after arrival at the hospital. The study aimed to determine whether the RRC system shortened the DTBT. Methods This retrospective observational study was carried out in a tertiary emergency center in Japan. Those STEMI patients with primary percutaneous intervention between January 2016 and December 2018 were evaluated. The DTBTs of patients transported by the RRC system, the emergency medical service (EMS), and transferred from other hospitals after STEMI diagnosis (TRANS group) were compared. Results A total of 121 patients were included, 33 in the RCC, 20 in the EMS, and 68 in the TRANS groups. The median DTBT was 51 min (interquartile range [IQR], 43–67) in the RRC, 61 min (IQR, 52–85) in the EMS, and 59 min (IQR, 48–72) in the TRANS groups (P = 0.13). The DTBT was not significantly shorter in the RRC than in the other groups. Conclusion An RRC physician‐staffed GEMS did not significantly shorten the DTBT of patients with STEMI compared with other transport systems.
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Affiliation(s)
- Yuki Yoshioka
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Ryota Teshima
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Mina Gamo
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Ryuhei Yoneda
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Naoki Matsunaga
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Tadaaki Takada
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Yasushi Fukuta
- Department of Emergency and Critical Care Medicine Tokushima Red Cross Hospital Komatsushima City Japan
| | - Koichi Kishi
- Department of Cardiology Tokushima Red Cross Hospital Komatsushima City Japan
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Wood T, Azin A, Quereshy FA. Effect of time to operation on outcomes in adults who underwent emergency general surgery procedure. J Surg Res 2018; 228:118-126. [PMID: 29907200 DOI: 10.1016/j.jss.2018.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/30/2017] [Accepted: 02/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients who undergo an emergency procedure have an increase in postoperative morbidity and mortality. Emergency procedures constitute 14.2% of all general surgery procedures and account for 53.5% of deaths. Among this population, time to surgery from arrival to the emergency department (ED) has not been evaluated as an independent risk factor for morbidity and mortality. MATERIAL AND METHODS Patients who underwent an emergency general surgery procedure from 2013 to 2015 were identified using a local American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Outcomes of interest included 30-d mortality, all morbidity, and severe morbidity. Multivariate analyses were conducted using a logistic regression model using clinically relevant covariates to determine predictors of the outcome measures. RESULTS A total of 974 patients were included in the final analysis. The prolonged median time from ED presentation to OR was predictive of all morbidity (14.3 h versus 13.3 h, P = 0.009) and severe morbidity (13.3 h versus 14.4 h, P = 0.063) on univariate analysis. Time from ED presentation to OR was not predictive of mortality (13.5 h versus 13.6 h, P = 0.474). Multivariate analysis demonstrated an adjusted increased odd of morbidity of 2.3 (95% CI: 1.01-5.24) for priority level A cases within the fourth quartile compared to that of the first quartile of time (P = 0.048). CONCLUSIONS This study corroborates with known data that morbidity and mortality increases in patients who are older, have multiple comorbidities, and higher ASA class. Furthermore, the time from ED arrival to the OR is associated with an overall increase in morbidity.
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Affiliation(s)
- Trevor Wood
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Arash Azin
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Fayez A Quereshy
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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Koh JQ, Tong DC, Sriamareswaran R, Yeap A, Yip B, Wu S, Perera P, Menon S, Noaman SA, Layland J. In-hospital ‘CODE STEMI’ improves door-to-balloon time in patients undergoing primary percutaneous coronary intervention. Emerg Med Australas 2017; 30:222-227. [DOI: 10.1111/1742-6723.12855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/14/2017] [Accepted: 07/25/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Ji Quan Koh
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
- Department of Medicine; Monash University; Melbourne Victoria Australia
| | - David C Tong
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
| | | | - Allysha Yeap
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
| | - Bryan Yip
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
| | - Sam Wu
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
| | - Padeepa Perera
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
| | - Shyaman Menon
- Department of Emergency; Peninsula Health; Melbourne Victoria Australia
| | - Saad Al Noaman
- Department of Emergency; Peninsula Health; Melbourne Victoria Australia
| | - Jamie Layland
- Department of Cardiology; Peninsula Health; Melbourne Victoria Australia
- Department of Medicine; Monash University; Melbourne Victoria Australia
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Chaou CH, Chiu TF, Yen AMF, Ng CJ, Chen HH. Analyzing Factors Affecting Emergency Department Length of Stay-Using a Competing Risk-accelerated Failure Time Model. Medicine (Baltimore) 2016; 95:e3263. [PMID: 27057879 PMCID: PMC4998795 DOI: 10.1097/md.0000000000003263] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Emergency department (ED) length of stay (LOS) is associated with ED crowding and related complications. Previous studies either analyzed single patient disposition groups or combined different endpoints as a whole. The aim of this study is to evaluate different effects of relevant factors affecting ED LOS among different patient disposition groups.This is a retrospective electronic data analysis. The ED LOS and relevant covariates of all patients between January 2013 and December 2013 were collected. A competing risk accelerated failure time model was used to compute endpoint type-specific time ratios (TRs) for ED LOS.A total of 149,472 patients was included for analysis with an overall medium ED LOS of 2.15 [interquartile range (IQR) = 6.51] hours. The medium LOS for discharged, admission, and mortality patients was 1.46 (IQR = 2.07), 11.3 (IQR = 33.2), and 7.53 (IQR = 28.0) hours, respectively. In multivariate analysis, age (TR = 1.012, P < 0.0001], higher acuity (triage level I vs level V, TR = 2.371, P < 0.0001), pediatric nontrauma (compared with adult nontrauma, TR = 3.084, P < 0.0001), transferred patients (TR = 2.712, P < 0.0001), and day shift arrival (compared with night shift, TR = 1.451, P < 0.0001) were associated with prolonged ED LOS in the discharged patient group. However, opposite results were noted for higher acuity (triage level I vs level V, TR = 0.532, P < 0.0001), pediatric nontrauma (TR = 0.375, P < 0.0001), transferred patients (TR = 0.852, P < 0.0001), and day shift arrival (TR = 0.88, P < 0.0001) in the admission patient group.Common influential factors such as age, patient entity, triage acuity level, or arrival time may have varying effects on different disposition groups of patients. These findings and the suggested model could be used for EDs to develop individually tailored approaches to minimize ED LOS and further improve ED crowding status.
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Affiliation(s)
- Chung-Hsien Chaou
- From the Department of Emergency Medicine (C-HC, T-FC, C-JN), Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan; Institute of Epidemiology and Preventive Medicine (C-HC, H-HC), College of Public Health, National Taiwan University, Taipei, Taiwan; and School of Oral Hygiene (AM-FY), College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
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Brown RA, Varma C, Connolly DL, Ahmad R, Shantsila E, Lip GYH. Simultaneous computerised activation of the primary percutaneous coronary intervention pathway reduces out-of-hours door-to-balloon time but not mortality. Int J Cardiol 2015; 186:226-30. [PMID: 25828121 DOI: 10.1016/j.ijcard.2015.03.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 03/05/2015] [Accepted: 03/16/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND In 2009 activation of out of hours (OOH) primary percutaneous coronary intervention (PPCI) in our institution changed from separate telephone calls to a simultaneous computerised alert. We assessed the impact of this protocol change on door-to-balloon (DTB) time, in hospital and 1 year mortality. METHODS Retrospective survey of our Myocardial Ischaemia National Audit Project (MINAP) database. OOH patients were categorized--pre- (Group 1) and post- (Group 2) introduction of the computerised alert protocol. RESULTS OOH PPCI was performed for 793 patients (mean age 61, 73.4% male)--295 in Group 1 and 498 in Group 2. Median DTB times were 92 min (interquartile range [IQR] 75-111) for Group 1 and 76 min (IQR 64-97) for Group 2 (p < 0.0001). Forty-eight percent achieved DTB in ≤ 90 min in Group 1 compared to 70% in Group 2 (p < 0.0001). Computerised alert was associated with a shorter DTB time on multivariate analysis (beta coefficient -0.09, p = 0.03 for linear regression and OR 2.8, 95% CI 1.6-5.0, p < 0.0001 for logistic regression). In hospital mortality was 4.1% in Group 1 and 5% in Group 2 (p = 0.60). All-cause mortality at 1 year was 6.1% in Group 1 and 9.9% in Group 2 (p = 0.09). CONCLUSIONS Simultaneous computerised activation for OOH PPCI reduced DTB times, increased the number of patients achieving target DTB times but did not affect mortality.
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Affiliation(s)
- R A Brown
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - C Varma
- Cardiology Department at Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham and Sandwell Hospital, West Bromwich, United Kingdom
| | - D L Connolly
- Cardiology Department at Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham and Sandwell Hospital, West Bromwich, United Kingdom
| | - R Ahmad
- Cardiology Department at Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham and Sandwell Hospital, West Bromwich, United Kingdom
| | - E Shantsila
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Cardiology Department at Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham and Sandwell Hospital, West Bromwich, United Kingdom
| | - G Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Cardiology Department at Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham and Sandwell Hospital, West Bromwich, United Kingdom.
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Martin L, Murphy M, Scanlon A, Clark D, Farouque O. The impact on long term health outcomes for STEMI patients during a period of process change to reduce door to balloon time. Eur J Cardiovasc Nurs 2015; 15:e37-44. [PMID: 25784283 DOI: 10.1177/1474515115577294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 02/22/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend a 'door to balloon time' (DTBT) within 90 minutes. It is unclear whether strategies to reduce DTBT translate to improved longer-term health outcomes for STEMI patients. AIMS This study sought to determine whether implemented strategies to improve timely management of STEMI reduced DTBT and impacted upon health outcomes such as length of stay, unplanned readmission and 12-month mortality. Predictors of timely management for STEMI were also examined. METHODS A five-year review was undertaken on primary percutaneous coronary intervention for STEMI in one tertiary hospital. Comparisons were made between process change groups and DTBT. Logistic regression identified predictors of timely management. RESULTS 470 STEMI patients underwent immediate primary percutaneous coronary intervention. Process change improved the median DTBT (109 min vs. 72 min, p<0.001) with no significant effect on length of stay (p=0.83), unplanned cardiac readmissions (p=0.68) or 12-month mortality (9.0% vs. 8.6%, p=0.64). Those receiving timely treatment (i.e. DTBT< 90 min) were younger (p<0.05), male (p<0.03), presented via ambulance (p<0.004), during business hours (p<0.0001) and had a lower Thrombolysis In Myocardial Infarction score (p<0.006). Timely treatment was associated with lower 12-month mortality (3.7% vs. 15.7%, p<0.0001) and increased uptake of inpatient cardiac rehabilitation (p<0.005), with length of stay and unplanned readmission similar between groups (p=NS). CONCLUSIONS Process changes improved DTBT but had no effect on length of stay, readmission rate or 12-month mortality. Yet, timely management was critical to 12-month outcomes. Further studies are required to explore the barriers to timely treatment.
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Affiliation(s)
- Lorelle Martin
- LaTrobe University School of Nursing, Melbourne, Australia Department of Cardiology, Austin Health, Heidelberg, Australia
| | - Maria Murphy
- LaTrobe University School of Nursing, Melbourne, Australia Department of Cardiology, Austin Health, Heidelberg, Australia
| | - Andrew Scanlon
- LaTrobe University School of Nursing, Melbourne, Australia
| | - David Clark
- LaTrobe University School of Nursing, Melbourne, Australia
| | - Omar Farouque
- LaTrobe University School of Nursing, Melbourne, Australia
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Huitema AA, Zhu T, Alemayehu M, Lavi S. Diagnostic accuracy of ST-segment elevation myocardial infarction by various healthcare providers. Int J Cardiol 2014; 177:825-9. [PMID: 25465827 DOI: 10.1016/j.ijcard.2014.11.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aimed to compare the accuracy of ECG interpretation for diagnosis of STEMI by different groups of healthcare professionals involved in the STEMI program at our institution. METHODS We selected 21 ECGs from patients with typical symptoms of MI that were diagnosed with STEMI, and 10 ECGs of STEMI mimics. STEMI mimic ECGs were repeated in the package with a story of typical and atypical chest pain. ECGs were interpreted to diagnose STEMI and identify need for initiation of the cardiac catheterization lab (CCL). Participants identified confidence in STEMI recognition, and average number of ECGs read per week. RESULTS A total of 64 participants completed the study package. Cardiologists were more likely to provide correct interpretation compared to other groups. False positive diagnoses were more likely made by paramedics when compared to cardiologists (p < 0.01). There was a positive correlation between increased exposure to ECGs and accurate STEMI diagnosis (r = 0.482, p < 0.001). A threshold of ≥ 20 ECGs read per week showed a statistically significant improvement in accuracy (p < 0.001). Self-reported confidence correlated positively with accuracy (r = 0.402, p =< 0.001). Changing the ECG narrative of the STEMI mimic ECGs had a significant effect on interpretation between groups (p = 0.043). CONCLUSIONS Our study showed that healthcare profession and number of ECGs reviewed per week are predictive of the accuracy of ECG interpretation of STEMI. Cardiologists are the most accurate diagnosticians, and are the least likely to falsely activate the CCL. Weekly exposure of ≥ 20 ECGs may improve diagnostic accuracy regardless of underlying experience.
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Affiliation(s)
- Ashlay A Huitema
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Tina Zhu
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | | | - Shahar Lavi
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
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Min MK, Ryu JH, Kim YI, Park MR, Park YM, Park SW, Yeom SR, Han SK, Kim YW. Does cardiac catheterization laboratory activation by electrocardiography machine auto-interpretation reduce door-to-balloon time? Am J Emerg Med 2014; 32:1305-10. [DOI: 10.1016/j.ajem.2014.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/24/2014] [Accepted: 07/26/2014] [Indexed: 11/30/2022] Open
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Roswell RO, Greet B, Parikh P, Mignatti A, Freese J, Lobach I, Guo Y, Keller N, Radford M, Bangalore S. From door-to-balloon time to contact-to-device time: predictors of achieving target times in patients with ST-elevation myocardial infarction. Clin Cardiol 2014; 37:389-94. [PMID: 24700343 DOI: 10.1002/clc.22278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/02/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The 2013 American College of Cardiology Foundation/American Heart Association ST-segment elevation myocardial infarction (STEMI) guidelines have shifted focus from door-to-balloon (D2B) time to the time from first medical contact to device activation (contact-to-device time [C2D] ). HYPOTHESIS This study investigates the impact of prehospital wireless electrocardiogram transmission (PHT) on reperfusion times to assess the impact of the new guidelines. METHODS From January 2009 to December 2012, data were collected on STEMI patients who received percutaneous coronary interventions; 245 patients were included for analysis. The primary outcome was median C2D time in the PHT group and the secondary outcome was D2B time. RESULTS Prehospital wireless electrocardiogram transmission was associated with reduced C2D times vs no PHT: 80 minutes (interquartile range [IQR], 64-94) vs 96 minutes (IQR, 79-118), respectively, P < 0.0001. The median D2B time was lower in the PHT group vs the no-PHT group: 45 minutes (IQR, 34-56) vs 63 minutes (IQR, 49-81), respectively, P < 0.0001. Multivariate analysis showed PHT to be the strongest predictor of a C2D time of <90 minutes (odds ratio: 3.73, 95% confidence interval: 1.65-8.39, P = 0.002). Female sex was negatively predictive of achieving a C2D time <90 minutes (odds ratio: 0.23, 95% confidence interval: 0.07-0.73, P = 0.01). CONCLUSIONS In STEMI patients, PHT was associated with significantly reduced C2D and D2B times and was an independent predictor of achieving a target C2D time. As centers adapt to the new guidelines emphasizing C2D time, targeting a shorter D2B time (<50 minutes) is ideal to achieve a C2D time of <90 minutes.
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Affiliation(s)
- Robert O Roswell
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
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Yu ZX, Shen X, Ma YT, Yang YN, Ma X, Xie X. An analysis of the door-to-balloon time in STEMI patients in an underdeveloped area of China: a single-centre analysis. Emerg Med J 2013; 31:e35-9. [PMID: 23978376 DOI: 10.1136/emermed-2012-201707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Zi-Xiang Yu
- First Department of Coronary Heart Disease, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi, Xinjiang, China
| | - Xin Shen
- First Department of Coronary Heart Disease, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi, Xinjiang, China
| | - Yi-Tong Ma
- First Department of Coronary Heart Disease, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi, Xinjiang, China
| | - Yi-Ning Yang
- First Department of Coronary Heart Disease, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi, Xinjiang, China
| | - Xiang Ma
- First Department of Coronary Heart Disease, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi, Xinjiang, China
| | - Xiang Xie
- First Department of Coronary Heart Disease, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi, Xinjiang, China
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Kuo FY, Huang WC, Chiou KR, Mar GY, Cheng CC, Chung CC, Tsai HL, Jiang CH, Wann SR, Lin SL, Liu CP. The effect of failure mode and effect analysis on reducing percutaneous coronary intervention hospital door-to-balloon time and mortality in ST segment elevation myocardial infarction. BMJ Qual Saf 2013; 22:626-38. [PMID: 23457371 DOI: 10.1136/bmjqs-2012-001288] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Door-to-balloon (D2B) time is an important factor in the outcome of ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. We aimed to use failure mode and effect analysis to reduce the D2B time for patients with STEMI and to improve clinical outcomes. METHODS There were three stages in this study. In Stage 0, data collected from 2005-2006 was used to identify failures in the process, and during Stage 2 (2007) and Stage 3 (2008) the efficacy of intrahospital and interhospital strategies to reduce the D2B time were evaluated. This study enrolled 385 patients; 86 from 2005-2006; 80 in 2007; and 219 in 2008. RESULTS By making improvements in these steps, the median D2B time was reduced from 146 min to 32 min for all patients. The proportion of patients with a D2B time of <90 min significantly increased from Stage 0 to Stage 1 and from Stage 1 to Stage 2, for all patients as well as for the non-transferred and transferred subgroups of patients (all p values <0.0001). For non-transferred patients, only reinfarction-free survival showed significant difference among the three stages (p=0.0225), and for transferred patients, only overall survival showed significant difference among the three stages (p=0.0322). Cox's proportional hazards regression analysis showed Stage 2 was associated with a lower risk of reinfarction and mortality compared with Stage 0. CONCLUSIONS This study found that failure mode and effect analysis is a powerful method for identifying weaknesses in D2B processes and evaluating strategies to reduce the D2B time.
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Affiliation(s)
- Feng-Yu Kuo
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.
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Ong MEH, Wong ASL, Seet CM, Teo SG, Lim BL, Ong PJL, Lai SM, Ong SH, Lee FCY, Chan KP, Anantharaman V, Chua TSJ, Pek PP, Li H. Nationwide Improvement of Door-to-Balloon Times in Patients With Acute ST-Segment Elevation Myocardial Infarction Requiring Primary Percutaneous Coronary Intervention With Out-of-Hospital 12-Lead ECG Recording and Transmission. Ann Emerg Med 2013; 61:339-47. [DOI: 10.1016/j.annemergmed.2012.08.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 07/25/2012] [Accepted: 08/06/2012] [Indexed: 10/27/2022]
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Cost reductions associated with a quality improvement initiative for patients with ST-elevation myocardial infarction. Jt Comm J Qual Patient Saf 2013; 39:16-21. [PMID: 23367648 DOI: 10.1016/s1553-7250(13)39004-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention. Int J Cardiol 2012; 157:8-23. [DOI: 10.1016/j.ijcard.2011.06.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 03/17/2011] [Accepted: 06/06/2011] [Indexed: 11/22/2022]
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20
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Wang YC, Lo PH, Chang SS, Lin JJ, Wang HJ, Chang CP, Hsieh LC, Chen YP, Chen WK, Chen CH, Chang KC, Hung JS. Reduced door-to-balloon times in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Int J Clin Pract 2012; 66:69-76. [PMID: 22171906 DOI: 10.1111/j.1742-1241.2011.02775.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity, particularly when door-to-balloon (D2B) time is < 90 min. We sought to minimize preventable delays by instituting an on-site cardiology team-based approach in the emergency department (ED). METHODS The on-site group comprised 146 consecutive patients with STEMI undergoing primary PCI after implementation of the on-site strategy. This new patient care model was compared with the conventional care administered before instituting the on-site cardiology team-based strategy in ED, which included 90 patients (interim group) receiving primary PCI at a catheterization room in the same building as the ED, and 147 patients (pre-on-site group) undergoing primary PCI at a catheterization room two blocks away from the ED. RESULTS Median D2B time decreased from 107 min in the pre-on-site group to 72 min in the interim group, and to 47 min in the on-site group, respectively (p < 0.001). The percentage of D2B times < 90 min increased from 34% to 78% and 96%, respectively among the three groups (p < 0.001). Hospitalization costs were significantly reduced in the on-site and interim vs. pre-on-site groups ($5944, $5999, and $6581, respectively; p = 0.008). In-hospital mortality did not differ significantly among the three groups (4.8%, 2.2%, and 6.1%, respectively; p = 0.387). CONCLUSIONS Institution of an on-site cardiology team-based approach in the ED significantly reduces D2B time in STEMI patients eligible for primary PCI.
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Affiliation(s)
- Y-C Wang
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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Levis JT, Mercer MP, Thanassi M, Lin J. Factors Contributing to Door-to-Balloon Times of ≤90 Minutes in 97% of Patients with ST-Elevation Myocardial Infarction: Our One-Year Experience with a Heart Alert Protocol. Perm J 2011. [PMID: 20844699 DOI: 10.7812/tpp/10-027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
CONTEXT Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) can significantly reduce mortality and morbidity, although its effectiveness may be limited by delays in delivery. In March 2008, our hospital implemented a Heart Alert protocol to rapidly identify and treat patients with STEMI presenting to our Emergency Department (ED) with PCI, using strategies previously described to reduce door-to-balloon times. Before the Heart Alert protocol start date, patients with STEMI presenting to our ED were treated with thrombolysis. OBJECTIVE We evaluated data from patients with STEMI after one year of use of our Heart Alert protocol to determine protocol success on the basis of the percentage of patients for whom the recommended door-to-balloon times of ≤90 minutes were met. We examined factors involved in implementation of the protocol that contributed to these results. DESIGN We conducted a retrospective data and chart review for patients in the ED with STEMI who underwent PCI after a Heart Alert protocol activation between March 17, 2008, and March 17, 2009. RESULTS During the study period, our staff met the recommended door-to-balloon time of ≤90 minutes (mean door-to-balloon time, 57.3 ± 17.6 minutes) for 70 of 72 patients (97%) presenting to our ED with STEMI. Sixty-five of the 72 patients (90.3%) survived to hospital discharge. CONCLUSION Initiation of a Heart Alert protocol at our hospital resulted in achievement of door-to-balloon times of ≤90 minutes for 97% of patients with STEMI. This achievement was obtained through careful preparation, training, and interdepartmental collaboration and occurred despite immediate conversion from a previous thrombolytic protocol.
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Data feedback reduces door-to-balloon time in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Heart Vessels 2010; 26:25-30. [PMID: 20978899 DOI: 10.1007/s00380-010-0030-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 01/29/2010] [Indexed: 10/18/2022]
Abstract
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.
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Tilling L, Clapp B. Changing strategies for managing acute myocardial infarctions. Int J Clin Pract 2009; 63:1670-2. [PMID: 19930326 DOI: 10.1111/j.1742-1241.2009.02208.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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