The relationship between off-hours admissions for primary percutaneous coronary intervention, door-to-balloon time and mortality for patients with ST-elevation myocardial infarction in England: a registry-based prospective national cohort study

Abstract

BackgroundThe degree to which elevated mortality associated with weekend or night-time hospital admissions reflects poorer quality of care (‘off-hours effect’) is a contentious issue. We examined if off-hours admissions for primary percutaneous coronary intervention (PPCI) were associated with higher adjusted mortality and estimated the extent to which potential differences in door-to-balloon (DTB) times—a key indicator of care quality for ST elevation myocardial infarction (STEMI) patients—could explain this association.MethodsNationwide registry-based prospective observational study using Myocardial Ischemia National Audit Project data in England. We examined how off-hours admissions and DTB times were associated with our primary outcome measure, 30-day mortality, using hierarchical logistic regression models that adjusted for STEMI patient risk factors. In-hospital mortality was assessed as a secondary outcome.ResultsFrom 76 648 records of patients undergoing PPCI between January 2007 and December 2012, we included 42 677 admissions in our analysis. Fifty-six per cent of admissions for PPCI occurred during off-hours. PPCI admissions during off-hours were associated with a higher likelihood of adjusted 30-day mortality (OR 1.13; 95% CI 1.01 to 1.25). The median DTB time was longer for off-hours admissions (45 min; IQR 30–68) than regular hours (38 min; IQR 27–58; p<0.001). After adjusting for DTB time, the difference in adjusted 30-day mortality between regular and off-hours admissions for PPCI was attenuated and no longer statistically significant (OR 1.08; CI 0.97 to 1.20).ConclusionHigher adjusted mortality associated with off-hours admissions for PPCI could be partly explained by differences in DTB times. Further investigations to understand the off-hours effect should focus on conditions likely to be sensitive to the rapid availability of services, where timeliness of care is a significant determinant of outcomes.

Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy

“…In the cardiac literature, admission to a hospital for myocardial infarction over the weekend and during evenings is associated with significantly greater odds of 30-day mortality. 23 In our situation, while one could reasonably hypothesize that extended stays in the hospital following elective lumbar laminectomy would reduce the risk of some complications occurring in the postdischarge setting, it could also increase the risk of other complications, such as nosocomial infection. While further research is needed to evaluate the long-term consequences of prolonged LOS, our study finds no evidence to support the notion that patients fare better from a prolonged LOS while they remain in the hospital.…”

Improved door-to-balloon time for primary percutaneous coronary intervention for patients conveyed via emergency ambulance service

“…This is in agreement with a large prospective observational study in England, which showed that after-hours admission was associated with a longer DTB time. 16 Our findings are unique as we were able to break down the components of DTB time to see which aspect was impacted. Based on our findings, we recommend that departments looking to improve after-hours DTB times focus on the processes after CVL lab activation such as movement of patients to the CVL as well as the call-back process for on-call CVL personnel.…”

“…For the predictors, we included factors that have been reported to be associated with DTB time, including age, sex, presentation during working hours, and ambulance usage. 15,16 Secondary outcomes include door-to-ECG time, door-to-activation time, activationto-lab time and lab-to-balloon time.…”

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

“…Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues, 26 showing that the increased mortality for out-of-hours admissions with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying the specific care process on which interventions should be targeted. To improve clinical practice, we Editorial need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.…”