Reducing Door-to-Balloon Times: The Transfer Factor
In a metropolitan system for STEMI management, paramedic referral for PCI resulted in earlier treatment than did ED referral.
Recent articles have focused attention on strategies to reduce door-to-balloon times for patients with ST-segment-elevation MI (STEMI) who undergo percutaneous coronary intervention. Patients who require interhospital transfer for PCI are the most susceptible to long delays; thus, regionalization strategies may increase the number of patients who can undergo primary PCI but may also lengthen the time to treatment.
The city of Ottawa implemented an integrated metropolitan-area approach in which all patients with STEMI are referred to a single cardiac care center for primary PCI. From May 2005 through April 2006, 344 patients with STEMI were referred to the regional center: 135 directly from the field by paramedics and 209 from hospital emergency departments. About half the patients transferred from EDs arrived at the ED by self-transport.
Patients who were referred directly from the field had a median door-to-balloon time of 69 minutes, compared with 123 minutes for those arriving through interhospital transfer. Of the patients referred directly, about 80% had door-to-balloon times of <90 minutes, compared with about 12% of the interhospital transfer patients. The median time from the onset of symptoms to first balloon inflation was 158 minutes for field-referred patients and 230 minutes for the interhospital transfer patients. In-hospital mortality was 3.0% for patients who were directly referred to the PCI center and 5.7% for patients who were transferred (P=0.30).
Comment: This paper joins a series of excellent reports of pioneering strategies to speed STEMI treatment within a context of regionalized care. The results demonstrate the value of direct referral to a PCI-capable center; however, more than half the patients in this study presented to hospitals without PCI capability, indicating that it is still important to develop systems that speed interhospital transfer or allow the use of fibrinolytic therapy when long delays are expected.
Published in Journal Watch Cardiology January 16, 2008
Le May MR et al. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2008 Jan 17; 358:231.
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