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How Timely Is PCI During Off Hours?

Not timely enough to meet guideline standards in 74% of admissions for ST-segment-elevation MI

Door-to-balloon times for percutaneous coronary intervention (PCI) are longer at night and on weekends than during regular working hours. To understand those delays better, researchers analyzed 1999–2002 data from 421 U.S. hospitals on 102,086 patients with ST-segment-elevation MI (STEMI) who had been enrolled in the National Registry of Myocardial Infarction: 68,439 patients received fibrinolytic therapy, and 33,647 underwent PCI. Most fibrinolysis (68%) and PCI (54%) patients were treated during off hours (weekdays 5 PM to 7 AM or on weekends).

The mean door-to-drug time was slightly, though significantly, longer during off hours than regular hours (34 vs. 33 minutes). The difference in mean door-to-balloon time between off hours and regular hours was much greater (116 vs. 95 minutes), due to delays between completion of ECG registration and arrival at the catheterization laboratory (70 vs. 49 minutes). The guideline-recommended 90-minute door-to-balloon time was achieved in significantly fewer patients during off hours than during regular hours (25.7% vs. 47.0%), and prolonged door-to-balloon times (>120 minutes) were significantly more common during off hours (41.5% vs. 27.7%). Off-hours delays were consistent across hospital categories (including hospital type, volume, and location). Finally, in analyses adjusted for potentially confounding patient variables, the in-hospital mortality rate was significantly higher among patients who presented during off hours than among those who presented during regular hours (odds ratio, 1.07; 95% CI, 1.01–1.14).

Comment: Off-hours presentation by STEMI patients remains common, and guideline-recommended door-to-balloon times are being met during off hours in only about a quarter of cases. Such delays worsen patients’ chances for survival. Potential solutions for institutions that provide PCI during off hours include 24-hour staffing of catheterization laboratories, cross-training of noncardiac cath lab staff, and transferring patients to regional centers with dedicated 24-hour facilities.

— Beat J. Meyer, MD

Published in Journal Watch Cardiology September 16, 2005

Citation(s):

Magid DJ et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA 2005 Aug 17; 294:803-12.

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