Fewer than 10% of cases meet the recommended 30-minute limit between a STEMI patient’s presentation to an emergency department and his or her discharge for transfer to a facility that can perform percutaneous coronary intervention, according to a report in the Nov. 28 issue of Archives of Internal Medicine.
"In the first national assessment of performance in this critical phase of treatment, we find that median times are more than double the 30 minutes recommended by many experts, with DIDO [door-in to door-out] times exceeding 1 hour for more than half of patients," said Jeph Herrin, Ph.D., of the cardiovascular medicine section at Yale University, New Haven, Conn., and his associates.
In addition, DIDO times vary markedly by patient characteristics such as age, sex, and race, and by hospital factors including geographic location.
"Our findings suggest that many patients may have benefitted from fibrinolytic therapy at the transferring hospital rather than from transfer for primary PCI," they noted.
Dr. Herrin and his colleagues examined DIDO times for patients with ST-elevation myocardial infarction (STEMI) across the United States, because "very little is known about how frequently this goal is met nationally." To do so, they used data collected by the Centers for Medicare and Medicaid Services (CMS), which requires that hospitals report the information for all patients in order to receive reimbursement for those eligible for Medicare or Medicaid. (The CMS is developing a new performance measure for DIDO times.)
After excluding hospitals that reported fewer than 5 PCI-transfer patients during the study year (2009), the investigators included 13,776 patients who presented to 1,034 hospitals with STEMI and were transferred to another hospital for PCI. The median DIDO time was 64 minutes (range, 43-104 minutes).
Only 9.7% of patients were discharged for transfer within 30 minutes, and a full 31% were not discharged for transfer until 90 minutes had passed, the investigators said (Arch. Intern. Med. 2011;171:1879-86).
Nationally, only 13 hospitals (1.3%) had median DIDO times of 30 minutes or less. Times were significantly longer if hospitals had fewer than 100 or more than 150 beds; were government owned; were rural; had fewer than 10 such cases per year; or were located in the Mountain, West South Central, or Midatlantic regions of the country.
Hospitals that transfer many such patients are more likely to have systems in place to facilitate the transfers. Rural hospitals may be hindered by lack of transportation to the PCI-capable facility, including long wait times for helicopters, said Dr. Herrin, who is also at the Health Research and Educational Trust, Chicago, and his colleagues.
Dr. Harlan M. Krumholz
Patient factors also were found to be associated with DIDO time. The time for women was a mean of 8.9 minutes longer than for men, the time for African Americans was a median of 9.1 minutes longer than for whites, and the time for young adults (aged 18-35 years) and the elderly (over age 75) was more than 16 minutes longer than for patients aged 46-55 years.
In contrast, DIDO time did not vary according to time of arrival at the emergency department, most likely because even EDs at smaller hospitals are staffed at a similar level around the clock.
Overall, although there may have been many "legitimate" patient-centered reasons for delays in DIDO times, "most patients are transferred after twice the recommended time," the researchers said. "Improvement efforts should focus on understanding and reducing this delay."
This study was supported by the CMS and the National Heart, Lung, and Blood Institute. The corresponding author, Dr. Harlan M. Krumholz of Yale University, reported ties to United Healthcare and Medtronic.