Causes of Delay and Associated Mortality in Patients Transferred With ST-Segment–Elevation Myocardial Infarction

Abstract

Background-Regional ST-segment-elevation myocardial infarction systems are being developed to improve timely access to primary percutaneous coronary intervention (PCI). System delays may diminish the mortality benefit achieved with primary PCI in ST-segment-elevation myocardial infarction patients, but the specific reasons for and clinical impact of delays in patients transferred for PCI are unknown. Methods and Results-This was a prospective, observational study of 2034 patients transferred for primary PCI at a single center as part of a regional ST-segment-elevation myocardial infarction system from March 2003 to December 2009. Despite long-distance transfers, 30.4% of patients (nϭ613) were treated in Յ90 minutes and 65.7% (nϭ1324) were treated in Յ120 minutes. Delays occurred most frequently at the referral hospital (64.0%, nϭ1298), followed by the PCI center (15.7%, nϭ317) and transport (12.6%, nϭ255). For the referral hospital, the most common reasons for delay were awaiting transport (26.4%, nϭ535) and emergency department delays (14.3%, nϭ289). Diagnostic dilemmas (median, 95.5 minutes; 25th and 75th percentiles, 72-127 minutes) and nondiagnostic initial ECGs (81 minutes; 64 -110.5 minutes) led to delays of the greatest magnitude. Delays caused by cardiac arrest and/or cardiogenic shock had the highest in-hospital mortality (30.6%), in contrast with nondiagnostic initial ECGs, which, despite long treatment delays, did not affect mortality (0%). Significant variation in both the magnitude and clinical impact of delays also occurred during the transport and PCI center segments. Key Words: delays Ⅲ delivery of health care Ⅲ myocardial infarction Ⅲ angioplasty, balloon, coronary T imely reperfusion is the cornerstone of treatment in patients with ST-segment-elevation myocardial infarction (STEMI). Improving door-to-needle time for fibrinolytic therapy and door-to-balloon time for primary percutaneous coronary intervention (PCI) has been shown to decrease mortality in a linear fashion. [1][2][3] PCI is the preferred method of reperfusion if it can be performed in a timely manner at high-volume centers. 4 -7 Yet, only 25% of US hospitals have PCI capability. Both the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) guidelines currently recommend a door-to-balloon time of Յ90 minutes for primary PCI, although the ECS guidelines extend this to Ͻ120 minutes for transferred patients. 5,6 Clinical Perspective on p 1644 Conclusions-TreatmentThe mortality benefit achieved with primary PCI in STEMI patients is diminished by treatment delays. 8,9 It is therefore imperative to develop strategies that both increase access to primary PCI and improve door-to-balloon times. 10 -13 The ACC launched the D2B Alliance 14 to improve time to treatment in PCI hospitals, and the AHA established Mission: Lifeline 15 to develop STEMI systems of care that will improve timely access to PCI. The Joint Commission includes door-to-balloon times as a core quality assuran...

Regional “Call 911” Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST‐Segment–Elevation Myocardial Infarction

“…Given the retrospective nature of the study and the limitations of the data registry, reasons for individual patient‐related and system‐related delays are unknown. The reason for the delay may be more important than the length of delay in regard to patient outcomes 4. Finally, LA County is primarily urban‐suburban, and therefore these results may not be generalizable to rural areas, where transport times are longer.…”

“…Although potential solutions have been proposed,25 prior experience has shown that improving DIDO is difficult, and delay in obtaining transport is a significant contributor. Miedema et al4 evaluated reasons for delay within each time interval. At the referral facility, the most common reason for delay was awaiting transport, affecting 26% of patients and representing 40% of all delays.…”

“…National estimates for the proportion of patients with IFT receiving PPCI within 120 minutes vary widely and range from 16% to 65% 11, 12, 13. The ability to minimize time at the transferring hospital has been demonstrated to be particularly challenging and delay in door‐in‐door‐out (DIDO) is associated with increased mortality 4, 14…”

Evaluation of Emergency Interhospital Patient Transfers from Province of Mardin to Out-of-Province Hospitals in a Year

“…Besides, delays in referrals are sometimes experienced. In the study above, the authors reported that delays in referral were seen more frequently in referring hospitals (64%) and then in PCI centers (15.7%) and during transfer (12.6%), respectively (19). In another study, considering the direct admissions to a PCI center, the door-balloon time was found to be longer in transferred STEMI patients (20).…”

“…It is pointed out that it takes a maximum of 120 minutes to transfer patients from health centers without this capacity or facility to ones with the capacity of PCI, and it is suggested that even patients receiving fibrinolytic therapy be transferred to health centers with a PCI facility within the first 24 hours (18). Miedema et al (19) investigated delays in transfers and related mortality rates for transferred STEMI patients in their study of 2034 diseases, and they found that for patients with door-balloon contact after 120 minutes, the in-hospital mortality rate was higher compared to patients with door-balloon contact before 120 minutes. Accordingly, the transfer of AMI patients seems to be a medicolegal obligation for the province of Mardin.…”