D2B Time Research Articles

Abstract TMP9: Hospitals' Performance on Timely Reperfusion in Stroke and Myocardial Infarction is not Correlated

Introduction: Timely reperfusion is performed less optimally in acute ischemic stroke (AIS) than in acute myocardial infarction (AMI). The degree to which hospital performance is correlated on emergent AMI and AIS care is unknown. Hypothesis: There would be a positive correlation between hospital performance on door-to-balloon time (D2B) for AMI and door-to-needle time (DTN) for AIS; and hospital performance on D2B would predict DTN even after controlling for patient and hospital differences. Methods: Prospective study of all hospitals participating in both Get With The Guidelines (GWTG)-Stroke and -Coronary Artery Disease from 2006-09 and treating ≥10 patients. We compared hospital-level DTN and D2B before and after risk adjustment using Spearman’s rank correlation coefficients and hierarchical linear regression modeling. We also correlated hospitals’ DTN and D2B data from 2013-14 using GWTG (DTN) and Hospital Compare (D2B). Results: There were 43 hospitals contributing data (1976 AIS and 59,823 AMI patients). Hospitals’ DTN times for AIS did not correlate with their D2B times for AMI (median DTN 85 min [IQR 77-99] vs. median D2B 72 min [IQR 62-81]; ρ=-0.09; p=0.55). There was no correlation between hospitals’ proportion of eligible patients treated within target time windows for AIS and AMI (median DTN<60 minutes: 21% [IQR 11-30]; median D2B<90 minutes: 68% [IQR 62-79]; ρ=-0.14; p=0.36). The lack of correlation between hospitals’ DTN and D2B times persisted after risk adjustment. From 2013-14, hospitals’ DTN performance in GWTG was not correlated with D2B performance in Hospital Compare (N=546 hospitals; see figure). Conclusions: We found no correlation between hospitals’ observed or risk-adjusted DTN and D2B times. Opportunities exist to improve hospitals’ performance of time-critical care processes for AIS and AMI in a coordinated rather than condition-specific manner.

ST-Segment Elevation Myocardial Infarction: Door to Balloon Time Improvement Project.

BackgroundThe purpose of this quality improvement project was to evaluate prospectively the causes of delay for patients with acute ST-segment elevation myocardial infarction (STEMI) requiring primary percutaneous coronary intervention (PCI) upon arrival at the emergency department (ED) and implement recommendations to reduce delays and analyze the impact of recommendations to reduce the door-to-balloon (D2B) time in a newly established cardiac center (King Faisal Cardiac Center (KFCC)). Primary PCI has developed as an effective treatment strategy for acute STEMI, the survival rate and patient outcome are however dependent on the time to treatment. The international benchmark for all programs dealing with acute coronary syndrome patients suffering from STEMI has been established as 90 minutes or less from the time the patient arrives at the hospital to the opening of the affected vessel in the cardiac catheterization laboratory “door-to-balloon time” or D2B. In KFCC during the year 2014, the STEMI, D2B time of ≤ 90 minutes was achieved in 25%.MethodsWe conducted a single center prospective data collection for consecutive patients presenting with STEMI within 24 hours of the onset of chest pain between January 2015 and December 2015. The boundaries of the process began when the patient entered the emergency department and ended when the balloon was inflated during the PCI. Certain well-defined metrics were chosen to drive the change and identify the defect.ResultsA total of 37 patients presented with STEMI. The number of patients who achieved the target D2B time ≤ 90 minutes was 20 (54%). Nine patients (24.4%) had D2B time between 91 and 120 minutes and eight patients (21.6%) beyond 120 minutes. The delays were due to late identifications of patients with chest pain as well as in obtaining ECG, activation and transport to the catheterization laboratory.ConclusionThere was a measurable improvement up to 54%. Several factors have contributed to the delays in achieving the goal standard of above 90%; these include late identifications of patients with STEMI, delays in obtaining the ECG, activation of the catheterization laboratory and delay of patients’ transportation.

Coordinated Digital-Assisted Program Improved Door-to-Balloon Time for Acute Chest Pain Patients.

Emergency care for patients with chest pain can be a challenge in remote areas. Digital communication technology has the potential to improve outcomes by allowing early diagnosis and faster treatment. The aim of the present study was to investigate whether implementation of a coordinated digital-assisted program (CDAP) for Chinese hospitals can reduce the door-to-balloon (D2B) time for percutaneous coronary intervention (PCI) in acute chest pain patients in China. From March to December 2011, 609 patients (CDAP group) requiring an emergency response for acute chest pain were evaluated using this CDAP. The results were compared in terms of time interval reduction (including D2B) and economic indices with those of 528 patients (non-CDAP group) previously treated by conventional protocols after admission. We screened 154 and 127 eligible patients under PCI in the CDAP and non-CDAP groups, respectively. PCI patients achieved a D2B time < 90 minutes using CDAP (82.5 versus 26.0%, P < 0.001). CDAP reduced D2B time under PCI and reduced hospitalization lengths and costs (all P < 0.001).

Abstract 16857: Design and Implementation of a Prehospital Electrocardiogram Remote Transmission and Data Recording App for Acute Myocardial Infarction Based on WeChat in China

Introduction: There were evidences showing prehospital electrocardiogram (ECG) remote transmission could reduce door-to-balloon (D2B) time in ST-segment elevation myocardial infarction (STEMI) care. There is spacious room for improvement due to low ratio of tele-ECG transmission usage in China. Meanwhile, the collection of prehospital clinical data, especially key time points during emergency care is not sufficient. The existing systems for ECG transmission require unique hardware leading to poor cost-benefits. We designed a mobile app to solve these problems based on WeChat, the most popular messaging communication app in China, which can transmit clear images of high quality and has a monthly-active-user of 549 million. Hypothesis: We assessed the hypothesis that such an app could solve the problems above in China. Methods: Firstly, we included 192 PCI hospitals together with their global positioning system (GPS) coordinates and telephone numbers into the database throughout China. Once an ECG image is sent through the app, ECG image, transmission time and sender’s GPS coordinates will be automatically recorded onto the server; the app will reply with a multimedia message listing nearby PCI hospitals, which can be contacted by clicking the specific link easily. At the same time, the on-call physician in the PCI hospital will receive a short message containing the ECG. Furthermore, an automatically generated electronic form evaluating prehospital treatment delay is also provided, in which the key time points can be recorded by clicking. Results: We performed a field test for a STEMI case, it took 20 seconds sending ECG and feedback message was received in 2 seconds, the responding physician in the PCI hospital stated ECG image was clear enough to interpret and all key time points were traceable. A pilot study is being conducted in a regional network including 4 PCI hospitals and 13 non-PCI hospitals in Tianjin. Conclusions: In conclusion, this is a low cost novel digital system integrated with daily communication service app on prehospital emergency care for STEMI to solve the problems of prehospital ECG remote transmission and prehospital clinical data recording in China. The effect on D2B time and outcomes requires further study.

Evolution of the interventional reperfusion strategy and reperfusion times in acute ST-segment elevation myocardial infarction

In patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), the recommended times (first medical contact-to-balloon (M2B) < 120 min or < 90 min, and door-to-balloon (D2B) < 45 min) are reached in less than 50% of patients. To compare the interventional reperfusion strategy and reperfusion times between two series of consecutive STEMI patients referred for pPCI within 12 hours of symptom onset, in 2007 and 2012. Retrospective study of 182 patients, 87 admitted from January 2007 to March 2008 (period 1), and 95 admitted from January to December 2012 (period 2). The procedural characteristics and the different times between onset of pain and mechanical reperfusion were gathered and compared by non-parametric tests. Radial access, thrombo aspiration, and drug eluting stents were more frequent, and cardiogenic shock was less common during period 2, compared with the period 1. The median time from first medical contact and balloon (M2B) decreased by 26% (135 min, quartiles [113–183] in 2007 versus 100 [76–137] in 2012, P < 0.001), in relation to the reduction in both pre-hospital times and time in the catheterization laboratory (D2B 51 [44–65] and 44 min [37–55], respectively, P < 0.01). The D2B and M2B times significantly decreased in our centre between 2007 and 2012, and reached the recommended values in > 60% of the cases. This may be explained by better coordination between emergency medical units and interventional cardiologists, and by the presence of two paramedics in the cath lab for 24/24 7/7 pPCI since 2010 in France, in accordance with recent national regulation.

Évolution de la prise en charge interventionnelle et des délais de reperfusion à la phase aiguë de l’infarctus du myocarde avec sus-décalage du segment ST

BackgroundIn patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), the recommended times (first medical contact-to-balloon (M2B) <120 or <90min, and door-to-balloon (D2B) <45min) are reached in less than 50% of patients. PurposeTo compare the interventional reperfusion strategy and reperfusion times between two series of consecutive STEMI patients referred for pPCI within 12hours of symptom onset, in 2007 and 2012. MethodsRetrospective study of 182 patients, 87 admitted from January 2007 to March 2008 (period 1), and 95 admitted from January to December 2012 (period 2). The procedural characteristics and the different times between onset of pain and mechanical reperfusion were gathered and compared by non-parametric tests. ResultsRadial access, thromboaspiration, and drug eluting stents were more frequent, and cardiogenic shock was less common during period 2, compared with the period 1. The median time from first medical contact to balloon (M2B) decreased by 26% (135min, [quartiles: 113–183] in 2007 versus 100 [76–137] in 2012, P<0.001), in relation to the reduction in both prehospital times and time in the catheterization laboratory (D2B: 51 [44–65] and 44min [37–55], respectively, P<0.01). ConclusionsThe D2B and M2B times significantly decreased in our centre between 2007 and 2012, and reached the recommended values in >60% of the cases. This may be explained by better coordination between emergency medical units and interventional cardiologists, and by the presence of two paramedics in the catheterization laboratory for 24/24 7/7 pPCI since 2010 in France, in accordance with recent national regulation.

SUSTAINABILITY OF “PHYSICIAN-LESS” AUTOMATED PRE-HOSPITAL STEMI DIAGNOSIS AND CATHETERIZATION LABORATORY ACTIVATION TO ENSURE DOOR-TO-BALLOON TIMES: UPDATE AT 5 YEARS

Primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI) is the revascularization method of choice provided that it can be achieved rapidly. Since 2010, we have adopted an automated system of pre-hospital CCL STEMI diagnosis at first medical contact and pre-hospital cardiac catheterization laboratory (CCL) activation without real-time physician oversight. This system was previously reported to significantly reduce door-to balloon (D2B) times at our center. Herein, we present our updated results at 5 years in order to report on the stability of the algorithm’s performance over time. Pre-hospital ECG’s were performed for all patients with a complaint of chest pain or shortness of breath. An electrographic diagnosis of STEMI (Zoll Medical Corporation) automatically resulted in CCL activation and direct transfer without prior physician interpretation of the ECG. Patient demographics, landmark time-points, treatments, and outcomes were abstracted for all consecutive pre-hospital CCL activations from February 2010 to January 2015. D2B was defined conventionally as the time from arrival at the hospital to first intracoronary device activation and contact-to-balloon (C2B) was defined as the time from first medical contact in the field to device activation. Over the study period, we identified 489 pre-hospital CCL activations for STEMI. In the first 253 activations analyzed, (full results will be presented at congress), 71% were male with a mean age of 65±14 years. 60% had high blood pressure, 58% dyslipidemia, 17% were known diabetics, and 21% had a history of known or suspected coronary disease. A total of 213 (84%) patients had a final diagnosis of STEMI. Of these, 207 (97%) underwent an attempt at PCI with a success rate of 97%. Median (IQR) D2B for this cohort was 46 minutes (35.75 - 56.0 min). The recommended D2B of <90 minutes was achieved in 99% of patients. Median (IQR) C2B was 75.5 minutes (67.0 - 87 min). The present series confirms that a high rate of target D2B times is achievable with a “physician-less” system of pre-hospital CCL activation. Furthermore, the present results demonstrate that such superior results appear sustained 5 years after protocol implementation.

Time-to-reperfusion in STEMI undergoing interhospital transfer using smartphone and WhatsApp messenger

ObjectiveThe objective of this study is to assess the efficacy of WhatsApp application as a communication method among the emergency physician (EP) in a rural hospital without percutaneous coronary intervention (PCI) capability and the interventional cardiologist at a tertiary PCI center. BackgroundCurrent guidelines recommend that patients with ST-segment elevation myocardial infarction (STEMI) receive primary PCI within 90minutes. This door-to-balloon (D2B) time has been difficult to achieve in rural STEMI. Methods and resultsWe evaluated 108 patients with STEMI in a rural hospital with emergency department but without PCI capability to determine the impact of WhatsApp triage and activation of the cardiac catheterization laboratory on D2B time. The images were obtained from cases of suspected STEMI using the smartphones by the EP and were sent to the interventional cardiologist via the WhatsApp application (group 1, n=53). The control group included concurrently treated patients with STEMI during the same period but not receiving triage (group 2, n=55). The D2B time was significantly shorter in the intervention group (109±31 vs 130±46minutes, P<.001) with significant reduction in false STEMI rate as well. ConclusionThis study demonstrates that use of WhatsApp triage with activation of the cardiac catheterization laboratory was associated with shorter D2B time and results in a greater proportion of patients achieving guideline recommendations. The method is cheap, quick, and easy to operate.

Impact of Prolonged Door-to-Balloon Times on the Diastolic Function in Acute ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

Emerging evidence indicates that diastolic left ventricular (LV) function is a powerful outcome predictor after acute ST-elevation myocardial infarction (STEMI). We hypothesized that shorter door-to-balloon (D2B) times with early restoration of coronary perfusion may preserve diastolic LV function in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). This study enrolled 340 consecutive STEMI patients who underwent PPCI with D2B times of < 90 min in 232 patients and D2B times ≥ 90 min in 108 patients, who all received subsequent echocardiographic examination within 48 hours of hospitalization. Although the LV ejection fraction was similar (50.92% vs. 51.66%, p = 0.573), the proportion of E/E' ratio > 15 was greater in patients with D2B times ≥ 90 min compared to those with D2B times < 90 min (44.4% vs. 30.6%, p = 0.013). Logistic regression analysis revealed that D2B time ≥ 90 min [odds ratio (OR): 1.82, 95% confidence interval (Cl): 1.04-3.17, p = 0.035] was an independent predictor for LV diastolic dysfunction. The effect was more prominent in patients ≥ 65 years of age (OR: 2.77, 95% CI: 1.09-7.00, p = 0.032), in whom the fraction of LV diastolic dysfunction increased proportionally with prolonged D2B times. Prolonged D2B time of greater than 90 min predicted LV diastolic dysfunction, particularly in aged subjects. D2B times shortening is important to preserve diastolic heart function after PPCI. Acute myocardial infarction; Diastolic dysfunction; Door-to-balloon time; Primary percutaneous coronary intervention.

Impact of Cardiac Cath Lab Organization on Process and Outcome Quality: A Case Study

Quality improvement must balance two conflicting objectives: process conformance and process re-engineering. Healthcare facility organization structure may favor one approach over the other. We examined whether cardiac cath labs that are open [permitting operators to work at other sites] or closed achieve faster door-to-balloon times [D2B] and lower in-hospital mortality. We used retrospective secondary data from the Massachusetts Department of Public Health on all 30,903 cath lab visits involving a percutaneous coronary intervention [PCI] in 4/1/03-12/31/04. Patient-level models were estimated for in-hospital mortality in all patients, and for D2B time in ST-segment elevation myocardial infarction [STEMI] patients, accounting for patient risk, hospital and operator PCI procedural volume.The parameters of interest were the effects of a lab’s closed status or the by the mean number of labs where an open lab’s operators worked across. In unadjusted analyses, the patients of closed labs had lower in-hospital mortality (1.0% vs. 1.7%, PPatients of closed and less open cath labs in Massachusetts were less likely to receive timely PCI, but not more or less likely to die in hospital. Hospital and operator PCI experience was inconsistently associated with D2B times. This case study’s findings support a broader search for the success factors of PCI quality beyond experience or site processes towards aspects of a lab’s organization and staffing pattern.

Reassessing After-Hour Arrival Patterns and Outcomes in ST-Elevation Myocardial Infarction.

IntroductionDifferences in after-hours capability or performance of ST-elevation myocardial infarction (STEMI) centers has the potential to impact outcomes of patients presenting outside of regular hours.MethodsUsing a prospective observational study, we analyzed all 1,247 non-transfer STEMI patients treated in 15 percutaneous coronary intervention (PCI) facilities in Dallas, Texas, during a 24-month period (2010–2012). Controlling for confounding factors through a variety of statistical techniques, we explored differences in door-to-balloon (D2B) and in-hospital mortality for those presenting on weekends vs. weekdays and business vs. after hours.ResultsPatients who arrived at the hospital on weekends had larger D2B times compared to weekdays (75 vs. 65 minutes; KW=48.9; p<0.001). Patients who arrived after-hours had median D2B times >16 minutes longer than those who arrived during business hours and a higher likelihood of mortality (OR 2.23, CI [1.15–4.32], p<0.05).ConclusionWeekends and after-hour PCI coverage is still associated with adverse D2B outcomes and in-hospital mortality, even in major urban settings. Disparities remain in after-hour STEMI treatment.

The Utility of Prehospital ECG Transmission in a Large EMS System

Background. Prehospital identification of STEMI and activation of the catheterization lab can improve door-to-balloon (D2B) times but may lead to decreased specificity and unnecessary resource utilization. The purpose of this study was to examine the effect of electrocardiogram (ECG) transmission on false-positive (FP) cath lab activations and time to reperfusion. Methods. This is a retrospective cohort from a registry in a large metropolitan area with regionalized cardiac care and emergency medical services (EMS) with ECG transmission capabilities. Thirty-four designated STEMI receiving centers (SRC) contribute to this registry, from which patients with a prehospital ECG software interpretation of myocardial infarction (MI) indicated by ****Acute MI****, or manufacturer equivalent, were identified between April 2011 and September 2013. Frequency of FP field activations (defined as not resulting in emergent percutaneous coronary intervention [PCI] or referral for CABG during hospital admission) for patients with ECG transmission received by the SRC was compared to a reference group without successful ECG transmission. FP field activations were compared to the baseline frequency of FP ED activations. We hypothesized that successful transmission would reduce FP field activation to ED activation levels. Door-to-balloon and first medical contact-to-balloon (FMC2B) times were compared. The protocol for field cath lab activation varied by institution. Results. There were 7,768 patients presenting with a prehospital ECG indicating MI. The ECG was received by the SRC for 2,156 patients (28%). Regardless of transmission, the cath lab was activated 77% of the time; this activation occurred from the field in 73% and 74% of the activations in the transmission and reference group, respectively. The overall proportion of FP activation was 57%. Among field activations, successful ECG transmission reduced the FP activation rate compared to without ECG transmission, 55% vs. 61% (RD = −6%, 95%CI −9, −3%). This led to an overall system reduction in FP activations of 5% (95%CI 2, 8%). ECG transmission had no effect on D2B and FMC2B time. Conclusion. Prehospital ECG transmission is associated with a small reduction in false-positive field activations for STEMI and had no effect on time to reperfusion in this cohort. Key words: emergency medical services; myocardial infarction; myocardial reperfusion; electrocardiography

Shorter Door-to-Balloon Time in ST-Elevation Myocardial Infarction Saves Insurance Payments: A Single Hospital Experience in Taiwan.

The relationship between quality of care and cost of medical services is a popular topic. In this study, we examined whether a reduced door-to-balloon (D2B) time led to cost savings, benefitted insurance payers, and improved patient outcomes. We retrospectively enrolled consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI) and received primary percutaneous coronary intervention (PCI) between Feb. 1, 2007, and Jul. 31, 2009, at a tertiary hospital in Taiwan. The patient data were collected by chart review. We utilized claims data from the hospital financial system as the proxy for insurance payer costs. We only included the claims data, regardless of whether patients were inpatients or outpatients, associated with the first three cardiovascular related ICD-9 codes. Multivariable logistic regression was used to examine the relationships between the D2B time, in-hospital mortality and one-year cardiovascular readmission. We utilized a multivariable linear regression to test the relationships between the D2B time, hospitalization cost and one-year cardiovascular-related cost. The D2B time did not influence the in-hospital mortality rate, but a D2B time greater than 90 min increased the probability of one-year cardiovascular readmission (p = 0.018). The D2B time did not increase the index hospitalization cost, but patients with a D2B time above 90 min had 14.6% higher one-year cardiovascular- related costs. Our study shows that the D2B time in patients with STEMI could impact the one-year cardiovascular readmission and one-year cardiovascular-related health cost. These results suggest that the pursuit of high-quality care not only leads to better outcomes, but also reduces costs. Acute myocardial infarction; Cost; Door-to-balloon time; Insurance payer; Quality.

Why Decreased D2B Time Has Lowered Mortality in Individuals but Not at the Population Level

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation myocardial infarction (STEMI), but time delays before the procedure hamper clinical outcomes. Although door-to-balloon time (D2B time) is predictive of in-hospital mortality, recent declines in average D2B time have not been associated with reduced mortality at the population level. Researchers in the U.S. retrospectively investigated this paradoxical finding by simultaneously assessing components of …

The impact of processes of care on myocardial infarct size in patients with ST-segment elevation myocardial infarction: observations from the CRISP-AMI trial.

Primary percutaneous coronary intervention (PCI) is the most common method of reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) in the United States. The intersection between processes of care and performance measures such as door-to-balloon (D2B) times and clinical trials evaluating novel therapies for STEMI has not been fully investigated. Processes of STEMI care, incorporating clinical trial enrollment and randomization, in patients undergoing reperfusion with primary PCI in the Counterpulsation Reduces Infarct Size Pre-Percutaneous Coronary Intervention Acute Myocardial Infarction trial (CRISP-AMI) will conform to current standards of care. Patients enrolled in CRISP-AMI were included in the current analysis. Processes of care during reperfusion were recorded prospectively and compared between groups. A total of 337 patients with anterior STEMI without cardiogenic shock were randomized in CRISP-AMI. Complete processes-of-care data were available for 303 patients (89.9%). In this cohort, 68.0% of patients underwent reperfusion within 90 minutes of hospital contact, and the median D2B time was 71 minutes. Time from hospital contact to informed consent was significantly different across different regions (North America, 45 minutes; India, 35 minutes; Europe, 20 minutes). In CRISP-AMI, reperfusion was accomplished in a timely fashion while incorporating informed consent and randomization among patients with anterior myocardial infarction. Further study of patients' comprehension and preferences during the informed-consent process in STEMI patients is warranted so that innovative drugs and devices can be safely and ethically tested.

Abstract 15193: The Impact of Age and Gender on Door to Balloon Time in Patients with ST Elevation Myocardial Infarction

Introduction: Shortening door-to-balloon (D2B) time is important to improve outcomes in patients suffering ST elevated acute myocardial infarction (STEMI). Age and gender are associated with poor outcomes in previous reports, however the impact of differences in age and gender on D2B time is still unclear. Objective: To determine the association of age and gender with D2B time in patients suffering STEMI. Methods: The Yokohama cardiovascular workshop registry is a prospective multicenter cohort in an urban area of Japan. 1261 consecutive STEMI patients during May 2010 to May 2013 were enrolled for the present analysis. Patients were divided into four groups according to age (&gt;75years old) and gender; elderly female (n=146), young female (n=125), elderly male (n=206) and young male (n=783). Results: D2B time was longer in female gender (93.2 vs. 85.5 min, p&lt;0.01) and in the elderly (92.3 vs. 85.1, p&lt;0.001). Among the four groups described above, D2B time was the longest in elderly female patients and followed by young female patients (p=0.002). Elderly female patients also had the lowest proportion of Killip class I, the longest time interval from hospital arrival to achieve TIMI flow grade 2/3, the worst final TIMI flow grade and the highest in-hospital mortality. The percentage of patients in achieving D2B time &lt;90min was the lowest in elderly male (p&lt;0.001, odds ratio 0.54) followed by elderly female (p=0.009, odds ratio 0.61). Conclusions: Both female gender and higher age were associated with longer D2B time in patients with STEMI. Further effort should be made to shorten the D2B time, especially in the elderly and women, for the improvement of clinical outcomes.

Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study

Recent reductions in average door-to-balloon (D2B) times have not been associated with decreases in mortality at the population level. We investigated this seemingly paradoxical finding by assessing components of this association at the individual and population levels simultaneously. We postulated that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently decreased mortality in individual patients with shorter D2B times. This was a retrospective study of ST-elevation myocardial infarction (STEMI) patients who underwent pPCI between Jan 1, 2005, and Dec 31, 2011, in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. We looked for catheterisation laboratory visits associated with STEMI. We excluded patients not undergoing pPCI, transfer patients for pPCI, patients with D2B times less than 15 min or more than 3 h, and patients at hospitals that did not consistently report data across the study period. We assessed in-hospital mortality in the entire cohort and 6-month mortality in elderly patients aged 65 years or older matched to data from the Centers for Medicare and Medicaid Services. We built multilevel models to assess the relation between D2B time and in-hospital and 6-month mortality, including both individual and population-level components of this association after adjusting for patient and procedural factors. 423 hospitals reported data on 150,116 procedures with a 55% increase in the number of patients undergoing pPCI at these facilities over time, as well as many changes in patient and procedural factors. Annual D2B times decreased significantly from a median of 86 min (IQR 65-109) in 2005 to 63 min (IQR 47-80) in 2011 (p<0·0001) with a concurrent rise in risk-adjusted in-hospital mortality (from 4·7% to 5·3%; p=0·06) and risk-adjusted 6-month mortality (from 12·9% to 14·4%; p=0·001). In multilevel models, shorter patient-specific D2B times were consistently associated at the individual level with lower in-hospital mortality (adjusted OR for each 10 min decrease 0·92; 95% CI 0·91-0·93; p<0·0001) and 6-month mortality (adjusted OR for each 10 min decrease, 0·94; 95% CI 0·93-0·95; p<0·0001). By contrast, risk-adjusted in-hospital and 6-month mortality at the population level, independent of patient-specific D2B times, rose in the growing and changing population of patients undergoing pPCI during the study period. Shorter patient-specific D2B times were consistently associated with lower mortality over time, whereas secular trends suggest increased mortality risk in the growing and changing pPCI population. The absence of association of annual D2B time and changes in mortality at the population level should not be interpreted as an indication of its individual-level relation in patients with STEMI undergoing primary PCI. National Heart, Lung, and Blood Institute.

KNOWLEDGE TRANSLATION TO REDUCE DELAYS OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS IN QUÉBEC - INSIGHTS FROM THE AMI ON TIME STUDY

We previously showed prolonged delays of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation (STEMI) at 17 Québec hospitals in 2003 (median door-to-balloon (D2B) time: 102 minutes (mins)) for patients who presented directly to hospitals with on-site PCI facility (PCI-hospital). The primary objective of this study is to determine whether knowledge translation (KT) increases the adoption of AHA recommended strategies to reduce D2B time. The AMI-ONTIME study was a pre-post study evaluating the effectiveness of KT in increasing the adoption of the following strategies: (1) emergency physician (EP)’s direct activation of PCI-personnel, (2) single-number page system, (3) PCI personnel to be ready within 30 min of activation and (4) rapid feedback of D2B time. The primary endpoint was the proportion of PCI-hospitals which implemented all four strategies. We also evaluated the proportions of PCI-hospitals that accepted patients with STEMI at all times, maintain adequate volumes of PCI and dedicated personnel for quality control of primary PCI. We sent surveys to all 13 Québec PCI-hospitals in 2009 and in 2013. The response rates were 100% for both 2009 surveys. The KT interventions were networking between pre-hospital and in-hospital personnel, identification and resolution of obstacles to prompt primary PCI, use of opinion leaders, evaluation and feedback of STEMI care, hospital-based STEMI team and educational website. We also measured prospectively D2B times in patients who underwent primary PCI, without inter-hospital transfer, during 2010-2011. During the same time intervals, beside from the AMI-ON TIME study, there were several noteworthy provincial initiatives such as Ministry of Health’s mandated retrospective studies of D2B times, provincial guidelines of STEMI treatment and ongoing University of Montréal’s prospective registry of D2B times. The median D2B time was 74 mins in 2010-11 for patients who underwent primary PCI without inter-hospital transfer in Québec (68% of patients underwent primary PCI within 90 mins). Adoption rates of AHA recommended strategies are shown in the Table below. * denote statistically significant differences between values obtained before and after KT (p values <0.001) Increased adoption of AHA-recommended strategies was associated with reduction in D2B time in Québec. These improvements in STEMI care may have been partially due to KT interventions combined with the other province-wide initiatives mentioned above. However, a few strategies remained under-used such as single-number page system and rapid feedback of D2B time. Emphasis on these interventions should be made for timelier primary PCI in Québec.

TCT-31 Impact of Hospital vs. Home call for Fellows and Cath Lab Team on Door to Balloon Times

For patients presenting with ST segment elevation myocardial infarction (STEMI), door-to-balloon (or first device) time (D2B) is effected by multiple patient and system-based factors. We hypothesized that fellow and/or catheterization (cath) team in-hospital call would result in decreased D2B time

STOP STEMI©-a novel medical application to improve the coordination of STEMI care: a brief report on door-to-balloon times after initiating the application.

Objective:The objective of our study was to evaluate the effect of the STOP STEMI© medical application on door-to-balloon (D2B) time in patients arriving to our emergency department with an acute ST Elevation Myocardial Infarction (STEMI). STOP STEMI© is a novel medical application developed by physicians to improve the coordination and communication tasks essential to rapid assessment and care of the patients suffering from a STEMI.Methods:We conducted a retrospective before and after review of the Good Shepherd Health System STEMI quality assurance/improvement dashboard for a 10-month period between November, 2012 and September, 2013 (4 months before STOP STEMI© and 6 months after). Data was collected using a standard data collection form and entered on the dashboard by a STEMI coordinator blinded to study objectives. We calculated the average D2B times before and after initiation of STOP STEMI© along with the improvement in the benchmarks of D2B less than 90 min and D2B less than 60 minutes. A subgroup analysis of Center for Medicare and Medicaid services (CMS) reportable cases was conducted to evaluate these benchmarks in the subset of patients meeting the criteria for CMS reporting by our facility.Results:During the study period, we received 155 STEMI patients, average 0.5 patients per day. One hundred twelve of the patients underwent percutaneous coronary intervention (PCI), 37 preSTOP STEMI©, and 75 postSTOP STEMI©. Of the 112 PCI cases, 7 were excluded leaving 105 cases for analysis, 36 preapplication and 69 postapplication. We found a 22% reduction in the average door-to-balloon time after implementing the STOP STEMI© application (91–71 minutes) respectively, the average difference of 20 minutes P = 0.05 (95% CI, -1–40minutes). In the analysis of CMS reportable cases (n = 64 cases), we observed a decrease in the average D2B of 15 minutes (68–53 minutes), a 22% reduction P = 0.03 (95% CI 1–29min). In the CMS reportable cases, we saw an improvement in the D2B time less than 90 minutes from 78–95% and less than 60 minutes D2B improvement from 56–80%. We also observed an appropriate absolute reduction in PCI resource utilization by 11%.Conclusions:In this cohort of patients, the utilization of STOP STEMI© decreased the average door-to-balloon times by 22% in the patients with acute STEMI arriving at our emergency department. This effect was maintained when looking at the subset of all STEMI cases reportable to CMS. We also observed modest improvements in meeting the less than 60-minute, less than 90-minute benchmarks, and improvements in the resource utilization.