Achieving Sustainable First Door-to-Balloon Times of 90 Minutes for Regional Transfer ST-Segment Elevation Myocardial Infarction

Wilson, B. Hadley; Humphrey, Angela; Cedarholm, John C.; Downey, William; Haber, Robert; Kowalchuk, Glen J.; Rinaldi, Michael; Miller, Dorothea; Sarafin, Jennifer L.; Garvey, J. Lee

doi:10.1016/j.jcin.2013.05.018

Cited by 21 publications

(10 citation statements)

References 22 publications

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“…Although state, regional, provincial, and national analyses have provided clear strategies to improve the transfer STEMI process, 7,8,13,16,27 our national analyses confirm that STEMI volume of the referring hospital may be related to achievement of timely first door-to-device times. 8,17 Furthermore, our findings emphasize that one of the most powerful predictors of a first door-to-device time ≤120 minutes is the volume of STEMI patients treated at the PCI center.…”

Section: Race Region and Volumementioning

confidence: 68%

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

Dauerman

Bates

Kontos

et al. 2015

Circ: Cardiovascular Interventions

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Multiple strategies have been used to improve the safety and efficacy of regional primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) programs. [1][2][3] Strategies that may improve first medical contact to device times include prehospital cardiac catheterization laboratory activation and bypass of non-PCI-capable hospitals or emergency departments. 4,5 Although rerouting patients directly to PCI centers may eliminate potential delays associated with transfer of STEMI patients for primary PCI, 5 ≈50% of patients with STEMI do not arrive to an emergency department via ambulance.6 Thus, regional systems of care face the ongoing challenge of determining best practices for timely transfer of patients from STEMI referring centers to STEMI PCI hospitals.Although significant progress has been made in achieving short ischemic time intervals for patients presenting directly to PCI centers, transfer STEMI time intervals remain a challenge.7,8 Both European and US STEMI guidelines recommend first medical contact to device time of ≤120 minutes for the transfer STEMI population 9,10 : STEMI referring facilities unable to achieve this 2-hour interval should consider fibrinolytic therapy as the primary reperfusion strategy.11 Timely first door-to-device intervals have been achieved for transfer patients in selected regional programs.12,13 However, recentBackground-Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process. Methods and Results-We studied 14 518 patients transferred from non-PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times >60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤120 minutes was achieved in 65% of patients (n=9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥75% of transfer STEMI patients with ≤120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals' rural location and longer estimated transfer time were identifi...

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Section: Race Region and Volumementioning

confidence: 68%

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

Dauerman

Bates

Kontos

et al. 2015

Circ: Cardiovascular Interventions

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“…In this study, the D2-to-B time with on-call activation was 80 minutes for the non-PREPARE groups and 74 minutes for the PREPARE group, similar to the average time of 76 minutes required for PCI at the STEMI-receiving hospital in South Korea. 6 Wilson et al 28 reported a 60% to 90% improvement in performance within 120 minutes of D1-to-B time following a regionalization strategy at the hospitals within a radius of 80 km of the Carolina Medical Center. In their study, the D2-to-B time target in the referred hospital was 30 minutes and the performance was increased from 72.3% to 93.4% after the protocol was applied.…”

Section: Discussionmentioning

confidence: 99%

Effect of percutaneous coronary intervention team prenotification based on real time electrocardiogram transmission in interhospital transfer of ST elevation myocardial infarction patients: pilot trial of Preparing Revascularization Effort before Patients’ Arrival via Regionalization Engagement protocol

et al. 2020

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Objective Prompt reperfusion is important for patients with ST elevation myocardial infarction (STEMI). However, patients often require interhospital transfer for percutaneous coronary intervention (PCI) because not all hospitals can provide. The purpose of this study is to reduce the PCI delay using a regionalization protocol in patients with STEMI following transfer from another hospital lacking PCI facility. Methods We established a revascularization protocol designated as Preparing Revascularization Effort before Patients' Arrival via Regionalization Engagement (PREPARE) for the STEMI patients transferred from an outside regional hospital. The protocol included immediate referral acceptance by an emergency physician, real-time electrocardiogram sharing via mobile phone and early activation of the PCI team. We analyzed the differences between the PREPARE and the non-PREPARE groups. Results In the PREPARE group, the median time from the first hospital visit to the ballooning procedure via PCI at the receiving facility (D1-to-B time) was 111.0 (interquartile range 97.0-130.0) minutes, which was significantly shorter than in the non-PREPARE group 134.0 (interquartile range 115.0-182.0) minutes. The proportion of D1-to-B time within 120 minutes was 30.4% in the group and 60.0% in the PREPARE group, which represents a significant difference (P = 0.004). Multivariate logistic regression analysis revealed that patient transfer via PREPARE protocol (odds ratio, 3.399; 95% confidence interval, 1.150-10.050, P = 0.027) was related to adequate D1-to-B time. No statistically significant differences were found in the hospital length of stay or major adverse cardiac events within 4 weeks. Conclusion The PREPARE protocol is an effective strategy to reduce the time to revascularization of the transferred STEMI patients.

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“…In elderly STEMI patients symptom-to-contact time might be underestimated due to atypical symptoms [ 27 ] and higher comorbidity might also negatively affect success of PCI [ 28 ]. Apart from this, albeit our system-related delay in patients presenting to non-PCI capable hospitals could be further reduced as has been demonstrated in other STEMI networks, a longer system related delay in patients presenting to non-PCI capable hospitals will always persist due to inter-hospital transfer logistics [ 29 , 30 ]. Accordingly, in order to further reduce the total ischemic time burden in STEMI patients community campaigns are needed to increase the rate of EMS presentation as the fastest reperfusion pathway and to increase the awareness of signs of myocardial infarction so that patients seek medical attention earlier.…”

Section: Discussionmentioning

confidence: 99%

Impact of the Type of First Medical Contact within a Guideline-Conform ST-Elevation Myocardial Infarction Network: A Prospective Observational Registry Study

et al. 2016

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AimsThe impact of type of first medical contact (FMC) in the setting of a guideline conform metropolitan ST-elevation myocardial infarction (STEMI) network providing obligatory primary percutaneous coronary intervention (PCI) is unclear.Methods and Results3,312 patients were prospectively included between 2006 and 2012 into a registry accompanying the “Cologne Infarction Model” STEMI network, with 68.4% primarily presenting to emergency medical service (EMS), 17.6% to non-PCI-capable hospitals, and 14.0% to PCI-capable hospitals. Median contact-to-balloon time differed significantly by FMC with 89 minutes (IQR 72–115) for EMS, 107 minutes (IQR 85–148) for non-PCI- and 65 minutes (IQR 48–91) for PCI-capable hospitals (p < 0.001). TIMI-flow grade III and in-hospital mortality were 75.7% and 10.4% in EMS, 70.3% and 8.6% in non-PCI capable hospital and 84.4% and 5.6% in PCI-capable hospital presenters, respectively (p both < 0.01). The association of FMC with in-hospital mortality was not significant after adjustment for baseline characteristics, but risk of TIMI-flow grade < III remained significantly increased in patients presenting to non-PCI capable hospitals.ConclusionDespite differences in treatment delay by type of FMC in-hospital mortality did not differ significantly. The increased risk of TIMI-flow grade < III in patients presenting to non PCI-capable hospitals needs further study.

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Achieving Sustainable First Door-to-Balloon Times of 90 Minutes for Regional Transfer ST-Segment Elevation Myocardial Infarction

Abstract: A system-wide network program can achieve sustained (over 4 years) 1st D2B times of <90 min.

Cited by 21 publications

References 22 publications

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

Impact of the Type of First Medical Contact within a Guideline-Conform ST-Elevation Myocardial Infarction Network: A Prospective Observational Registry Study

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