Door‐to‐balloon times are reduced in ST‐elevation myocardial infarction by emergency physician activation of the cardiac catheterisation laboratory and immediate patient transfer

Abstract

Objectives: To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door‐to‐balloon (DTB) times for patients with suspected ST‐elevation myocardial infarction (STEMI). Design, setting and participants: A quasi‐experimental before‐and‐after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary‐care hospital, Western Australia. Main outcomes measures: Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door‐to‐activation time, activation‐to‐balloon time and false‐positive activations of the CCL. Results: Two hundred and thirty‐four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door‐to‐activation time from 28 to 15 minutes (P = 0.002) and median activation‐to‐balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38). Conclusion: ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

Optimising acute care and secondary prevention for patients with acute coronary syndrome

“…This transfer is most efficient if done direct from the emergency department, and requires an undertaking from the ambulance service that these patients are a priority, and a similar commitment from the receiving PCI‐capable hospital to provide emergency access to the cath lab. Hospitals with PCI services can shorten times to reperfusion through the application of simple local practices, including emergency department activation of the cath lab, emergency department bypass when the diagnosis has been made in the field, and routine feedback of outcomes to all those involved in provision of this service 6 , 7 …”

Performance of Reperfusion Therapy and Hospital Mortality in ST-Elevation Myocardial Infarction Patients with Non-Chest Pain Complaints

“…We may reduce the differences in door-to-balloon time between males and females by enhancing reperfusion therapy for patients with non-chest pain presentation. Over the last decade, the hospital process facilitating emergent PCI for STEMI patients has been improved, achieving a shorter door-to-balloon time for all patients 22,23,24,25,26,27. Recently, trials with a focus on high risk patients with delayed PCI reported that triage process changes, triage staff education, and a feedback system could improve the door-to-ECG time and door-to-balloon time of STEMI patients presenting non-chest pain 12,13…”

Do we need cardiac arrest centres in Australia?

“…More recently, most states in Australia have adopted prehospital, EMS 12‐lead electrocardiography (ECG) programmes in which patients with ST elevation on initial field ECG are transported directly to hospitals capable of emergency coronary intervention with field transmission of ECG and notification to cardiac team prior to patient arrival. Such programmes have been shown to reduce significantly door‐to‐balloon time, which is associated with improved patient outcomes . The system of care for STEMI patients requires further development with regard to integration of non‐metropolitan patients, data collection and monitoring systems but may provide a framework for the integration of patients with OHCA.…”

“…Such programmes have been shown to reduce significantly door-to-balloon time, which is associated with improved patient outcomes. 22,23 The system of care for STEMI patients requires further development with regard to integration of nonmetropolitan patients, data collection and monitoring systems but may provide a framework for the integration of patients with OHCA.…”