Interhospital transfer due to failed prehospital diagnosis for primary percutaneous coronary intervention: an observational study on incidence, predictors, and clinical impact

Abstract

Background: For patients with ST-elevation myocardial infarction (STEMI), guidelines recommend prehospital triage and direct referral to a percutaneous coronary intervention (PCI)-capable centre in order to minimize ischemic time. However, few have studied failed prehospital diagnosis. We assessed the incidence, predictors, and clinical impact of interhospital transfer for primary PCI after initial referral to a non-PCI-capable centre due to a failed prehospital STEMI diagnosis. Methods: We studied 846 consecutive STEMI patients undergoing primary PCI between January 2008 and January 2010. Results: We found that 609 patients (72%) were directly admitted through prehospital triage and 127 patients (15%) required interhospital transfer after failed prehospital diagnosis. Median first medical contact to treatment time was 88 min in the prehospital diagnosis group and 155 min in the interhospital transfer group (p<0.001). In the interhospital transfer group, the first available electrocardiogram was diagnostic for STEMI in 77% of cases. Predictors of interhospital transfer were female gender, diabetes, prior myocardial infarction, and greater event location to PCI-capable centre distance. Interhospital transfer independently accounted for a 47% increase in ischemic time (95% CI 33 to 63%; p<0.001). One-year mortality was higher in the interhospital transfer group (10 vs. 5.3%; p=0.030). Conclusions: Despite an often-diagnostic electrocardiogram, interhospital transfer after failed prehospital diagnosis occurred in 15% of STEMI patients undergoing primary PCI. Interhospital transfer was a major predictor of ischemic time and 1-year mortality was significantly higher. Continuing efforts to optimize prehospital triage are warranted, especially among patients at higher risk of failed prehospital diagnosis.

Influence of gender on delays and early mortality in ST-segment elevation myocardial infarction: Insight from the first French Metaregistry, 2005–2012 patient-level pooled analysis

“…The present study included only STEMI patients presenting in an emergency department with PCI facilities or else managed by MICU; cases involving interhospital transfer were excluded, to minimize bias. Thus the results do not show longer system delay for women, as previously reported, especially in terms of lower priority for MICU management 24 and higher rates of overlooked pre-hospital STEMI diagnosis 37 . The recent Swiss study observed, in of 4723 patients presented with acute MI, discrimination of elderly patients and females in the provision of pPCI 38 .…”

Information handoff and outcomes of critically ill patients transferred between hospitals

“…These diagnoses constitute only a fraction of indications for inter-hospital transfers. Despite established practices, delays are frequent and often related to unnecessary testing, uncertain diagnoses, and imperfect adherence to guidelines[12, 23–26]. …”

Role and timing of coronary intervention in non-ST-elevation myocardial infarction

“…Certainly, a short time to first medical contact is desirable to facilitate expeditious diagnosis and early pharmacological therapy and to treat possible life-threatening complications such as arrhythmia or cardiogenic shock. Second, while 12-lead ECG-based prehospital triage has shown to contribute to early diagnosis and treatment in STEMI patients [73,74], this is not the case in NSTEMI patients who also require (in-hospital) cardiac biomarker assessment for diagnosis [75]. Finally, whereas delay to reperfusion should be as short as possible to optimize outcome in STEMI patients [76], the relation between delay to reperfusion and outcome in NSTEMI is more complex.…”