Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction

Abstract

Objectives Most U.S. hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion and referring EDs are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs. Methods We retrospectively analyzed a secondary dataset used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), time periods that comprised DIDO (door-to-EKG, EKG-to-PCI activation, and PCI activation-to-exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval). Results We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (IQR 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was comprised of: door-to-EKG 5 minutes (IQR 2,11), EKG-to-PCI activation 18 minutes (IQR 7,37), and PCI activation-to-exit 44 minutes (IQR 34,56). DIDO accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability=1.37) of these intervals. Conclusions In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision-making and transportation coordination following PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.

Association of Emergency Department Length of Stay and Crowding for Patients with ST-Elevation Myocardial Infarction

“… 3 Further heightening the importance of the role of the ED and its timeliness is that most patients with STEMI initially present to U.S. EDs. 4 Not only are transfers from U.S. EDs increasing in frequency for patients with STEMI, 5 but the time spent at transferring EDs is longer and more variable than either the transportation or pPCI center phases. Considering the role of the emergency care system is to rapidly identify, coordinate and treat time-sensitive emergency conditions like STEMI, the timeliness and performance of the ED for patients with STEMI is central to high-quality care.…”

The Paradoxical Impact of Insurance Status on Interfacility Transfer Times and Outcomes in Patients with ST-Elevation Myocardial Infarction

“…The review of literature shows that uninsured STEMI patients present conflicting data. [7][8][9][10][11] For the most part, uninsured patients are transferred out and discharged more readily from the receiving facilities, possibly due to the potential financial impact. In patients where time critical diagnosis (TCD) is encountered, guidelines dictate transfer to a facility where optimal management is available.…”

“…Herrin et al discovered a small but statistically significant delay in door-to-balloon time for Medicaid and uninsured STEMI patients versus the privately insured, [7] while Ward et al from found that uninsured STEMI patients are more likely to be transferred but it is unclear if this is based on non-availability of PCI or purely due to lack of insurance. [8] In our study, we sought to determine the impact of insurance status on inter-facility transfer times and length of stay for STEMI patients.…”

Association Between Hospital Practices and Door-in-door-out Time in ST-segment Elevation Myocardial Infarction

“…Second, the list of system practices may be incomplete. Third, additional factors not captured in our survey - such as collaborative relationships between EMS agencies, STEMI referral hospitals, and STEMI receiving centers 13,14 and decision-making processes at the STEMI referral hospital 15 – may influence DIDO and first-DTB times. Finally, our sample size may have been insufficient to detect a more subtle relationship between system practices and DIDO and FIRST-DTB times.…”