Finally, the current analysis is not without a sliver of good news.
The researchers observed that overall DTB time has further improved for transferred patients with STEMI, with about one in five patients treated within a DTB time of less than 90 minutes. The proportion of patients with a DIDO time of 30 minutes or less also showed improvement over time, with median DIDO times falling from 90 minutes in January 2007 to 58 minutes in March 2010.
The authors noted that the proportion of STEMI patients that required interhospital transfer for primary PCI was very likely underestimated, because reperfusion is known to be underutilized in routine practice.
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Source Elsevier Global Medical News
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EMS Efficiencies Key in Rural Areas
The most important modifiable predictor of outcome in ST-elevation myocardial infarction is time to treatment with reperfusion therapy. Primary percutaneous coronary intervention is preferred over fibrinolytic therapy as a reperfusion strategy when the delay in time to treatment is short and the patient presents to a high-volume, well-equipped center with expert interventional cardiologists. However, most hospitals do not have PCI capability. Their options are to transfer patients quickly for primary PCI or give the patient fibrinolytic therapy and keep the patient or transfer for urgent or delayed PCI.
Patients transferred from STEMI referral hospitals to STEMI receiving hospitals for primary PCI have substantial delays that prolong total myocardial ischemia time and increase complication and mortality rates. DIDO time of less than 30 minutes is a new performance measure meant to reduce system delays in interhospital transfer for primary PCI by referral hospitals, similar to the use of door-to-balloon times to reduce in-hospital system delays in receiving hospitals.
In this report from the ACTION Registry-GWTG, the authors emphasize that the median DIDO time was 68 minutes and only 11% of patients were within 30 minutes. However, the good news is that median DIDO times decreased from 90 minutes in January 2007 to 58 minutes in March 2010. Moreover, although only 19% achieved first door-to-balloon time within the 90 minutes, the U.S. target, 50% were within the 2- hour European target.
Unfortunately, the rural referral hospital does not have control of limited emergency transport services or geographic challenges that prolong transfer times. Therefore, this quality metric will probably have more utility in urban and suburban referral hospitals for walk-in patients where shorter interhospital transfer times are possible.
A better primary PCI strategy for these communities, however, is early triage by emergency medical services, rapid diagnosis with prehospital electrocardiography, destination protocols that bypass hospitals without PCI capability, and prehospital activation of the cardiac catheterization laboratory.
ERIC BATES, M.D., is professor of internal medicine at the University of Michigan Health System in Ann Arbor. He also chairs Mission: Lifeline Science Task Force and co-chairs the Mission: Lifeline program in Michigan. He has no relevant disclosures.
