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(Circulation. 2007;116:67-76.)
© 2007 American Heart Association, Inc.

Interventional Cardiology

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

Umesh N. Khot, MD; Michele L. Johnson, RN; Curtis Ramsey, MS; Monica B. Khot, MD; Randall Todd, MD; Saeed R. Shaikh, MD; William J. Berg, MD

From the Indiana Heart Physicians, Indianapolis (U.N.K., M.B.K., S.R.S., W.J.B.); St. Francis Hospital and Health Centers, Beech Grove (M.L.J.); Curtis Ramsey and Associates, Indianapolis (C.S.); and Emergency Physicians of Indianapolis, Beech Grove (R.T.), Ind.

Correspondence to Umesh N. Khot, MD, Indiana Heart Physicians/St. Francis Heart Center, 5330 E Stop 11 Rd, Indianapolis, IN 46237. E-mail khot{at}cvresearch.net

Received November 20, 2006; accepted April 20, 2007.

Background— Consensus guidelines and hospital quality-of-care programs recommend that ST-elevation myocardial infarction patients achieve a door-to-balloon time of 90 minutes. However, there are limited prospective data on specific measures to significantly reduce door-to-balloon time.

Methods and Results— We prospectively determined the impact on median door-to-balloon time of a protocol mandating (1) emergency department physician activation of the catheterization laboratory and (2) immediate transfer of the patient to an immediately available catheterization laboratory by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected door-to-balloon time for 60 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention within 24 hours of presentation from October 1, 2004, through August 31, 2005, and compared this group with 86 consecutive ST-elevation myocardial infarction patients from September 1, 2005, through June 26, 2006, after protocol implementation. Median door-to-balloon time decreased overall (113.5 versus 75.5 minutes; P<0.0001), during regular hours (83.5 versus 64.5 minutes; P=0.005), during off-hours (123.5 versus 77.5 minutes; P<0.0001), and with transfer from an outside affiliated emergency department (147 versus 85 minutes; P=0.0006). Treatment within 90 minutes increased from 28% to 71% (P<0.0001). Mean infarct size decreased (peak creatinine kinase, 2623±3329 versus 1517±1556 IU/L; P=0.0089), as did hospital length of stay (5±7 versus 3±2 days; P=0.0097) and total hospital costs per admission ($26 826±29 497 versus $18 280±8943; P=0.0125).

Conclusions— Emergency department physician activation of the catheterization laboratory and immediate transfer of the patient to an immediately available catheterization laboratory reduce door-to-balloon time, leading to a reduction in myocardial infarct size, hospital length of stay, and total hospital costs.

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