Transfer of Patients with ST-Elevation Myocardial Infarction for Primary Percutaneous Coronary Intervention: A Province-Wide Evaluation of "Door-in to Door-Out" Delays at the First Hospital
Background—Inter-hospital transfer of patients with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PPCI) is associated with longer delays to reperfusion, related partly to turnaround ('door-in' to 'door-out', DIDO) time at the initial hospital. As part of a systematic, province-wide evaluation of STEMI care, we examined DIDO times and associations with patient, hospital and process-of-care factors.
Methods and Results—We performed medical chart review for STEMI patients transferred for PPCI during a 6-month period (October 1, 2008 - March 31, 2009), and linked these data to ambulance service databases. Two core laboratory cardiologists reviewed presenting ECGs to identify left bundle branch block (LBBB) and, in absence of LBBB, "definite STEMI" (according to both) or an "ambiguous" reading. Median DIDO time was 51 minutes (25th - 75th percentile: 35 - 82); 14.1% of the 988 patients had a timely DIDO interval (≤30 minutes as guideline-recommended). The "data-to-decision" delay was the major contributor to DIDO time. Female sex, more comorbidities, longer symptom duration, arrival by means other than ambulance, arrival at a hospital not exclusively transferring for PPCI, arrival at a low STEMI volume center and an ambiguous ECG were independently associated with longer DIDO time. When turnaround was timely, 70% of patients received timely PPCI (door-to-device ≤90 minutes), versus 14% if not (p<0.0001).
Conclusions—Benchmark DIDO times for STEMI patients transferred for PPCI were rarely achieved. Interventions aimed at facilitating the transfer decision, particularly when faced with 'difficult-to-interpret' ECGs, are likely to have the best impact on reducing delay to reperfusion.
- Received October 24, 2013.
- Revision received March 10, 2014.
- Accepted April 4, 2014.