Understanding timely STEMI treatment performance: A 3‐year retrospective cohort study using diagnosis‐to‐balloon‐time and care subintervals

Abstract

Objective: From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-toballoon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG. Methods: This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified doorto-balloon-time and diagnosis-to-balloon-time with its care subintervals. Results: Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-toballoon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Fallacy of Median Door‐to‐ECG Time: Hidden Opportunities for STEMI Screening Improvement

“…Our prior work has highlighted a cohort of patients whose diagnostic ECGs are acquired prior to ED arrival (ie, at another facility or via EMS). 24 More than half of ED patients with STEMI at these PCI centers were excluded because their screening ECG was acquired prior to ED arrival. This highlights the success of efforts to reduce the time to diagnosis in the STEMI care pathway, often referred to as the chain of survival.…”

“… 21 , 22 , 23 As a result, it is difficult to understand the timeliness of ED‐specific STEMI screening and diagnosis using these data. 23 , 24 , 25 Furthermore, many risk factors for STEMI diagnosis delay have been documented in the literature. 3 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 However, the degree to which these characteristics vary among those with timely versus untimely care is not well characterized in the undifferentiated population of ED‐diagnosed patients with STEMI.…”

Influence of time‐to‐diagnosis on time‐to‐percutaneous coronary intervention for emergency department ST‐elevation myocardial infarction patients: Time‐to‐electrocardiogram matters

“…However, the personnel responsible for each step in the sequence may vary depending on the setting a patient is in at the time of diagnosis (referring facility ED, prehospital EMS care, or a PCI‐center ED). 13 Within this PCI‐center ED cohort, the difference in D2E between the timely and untimely groups is 13 min. This suggests that within a PCI‐center ED, care unfolds more consistently between the groups after cath‐lab activation.…”

“… 21 , 22 However, little cross‐facility work has been performed to optimize the same care intervals for ED‐diagnosed STEMI patients. 13 Prior work has illustrated that the process sequence of screening to STEMI diagnosis, to cath‐lab activation, and movement to treatment is highly consistent across patients. However, the personnel responsible for each step in the sequence may vary depending on the setting a patient is in at the time of diagnosis (referring facility ED, prehospital EMS care, or a PCI‐center ED).…”

“…Patients who are diagnosed in a PCI center ED de novo have been found to have shorter E2B times than patients identified by emergency medical services (EMS) or those transferred from other hospitals for a higher level of STEMI care through the ED. 13 The association between D2E and E2B in this sub‐population—whose early identification is contingent on established screening processes 7 —has not been well examined. Additionally, we lack information on which care intervals within the ED are the best targets for practice change.…”