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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Door-to-Balloon Times Under 90 Min Can Be Routinely Achieved for Patients Transferred for ST-Segment Elevation Myocardial Infarction Percutaneous Coronary Intervention in a Rural Setting

James C. Blankenship, MD^_*,_*, Thomas D. Scott, DO^_*, Kimberly A. Skelding, MD^_*, Thomas A. Haldis, DO, Karen Tompkins-Weber, RN^_*, Marie Y. Sledgen, RN^_*, Michael A. Donegan, DO, Jeremy W. Buckley, MD, Jennifer A. Sartorius, MS^||, John McB. Hodgson, MD^_* and Peter B. Berger, MD^_*

^_* Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania
MeritCare Medical Center, Fargo, North Dakota
Evangelical Hospital, Lewisburg, Pennsylvania
Fairfield Medical Center, Lancaster, Ohio
^|| Center for Health Research, Geisinger Health System, Danville, Pennsylvania

Manuscript received January 18, 2010; revised manuscript received May 31, 2010, accepted June 6, 2010.

^_* Reprint requests and correspondence: Dr. James C. Blankenship, Department of Cardiology 21-60, Geisinger Medical Center, 100 North Academy Drive, Danville, Pennsylvania 17822 (Email: Jblankenship{at}geisinger.edu).

Objectives: The purpose of this study was to demonstrate the feasibility of routine transfer of ST-segment elevation myocardial infarction (STEMI) patients to achieve percutaneous coronary intervention (PCI) in less than 90 min from presentation.

Background: Many PCI hospitals have achieved routine door-to-balloon times under 90 min for patients with STEMI presenting directly to the hospital. However, few patients transferred from a non-PCI center undergo PCI within 90 min of presentation.

Methods: Our rural PCI hospital implemented a program in 2005 for rapid triage, transfer, and treatment of STEMI patients and made additional improvements in 2006 and 2007. Intervals between milestones in the STEMI triage/transfer/treatment process were assessed before and after implementation of the program.

Results: During the 5-year study period, 676 patients with 687 STEMIs were transferred from 19 community hospitals and underwent PCI. Median door-to-balloon time decreased from 189 min to 88 min (p < 0.001). The time intervals reflecting efficiency of the referring hospitals, transfer services, and PCI hospital all significantly improved. In 2008, median door-to-balloon times were <90 min for 6 of the 7 most frequently referring hospitals. Delays during off-hours presentation in 2004 were abolished after the program was implemented in 2005. In-hospital mortality decreased from 6% before to 3% after implementation of the program. In multivariate modeling, presentation before initiation of the STEMI program predicted increased risk of in-hospital mortality (odds ratio: 3.74, 95% confidence interval: 1.22 to 11.51, p = 0.021).

Conclusions: A program of rapid triage, transfer, and treatment of STEMI patients presenting to non-PCI hospitals can reduce in-hospital mortality and produce progressive improvements in door-to-balloon time such that median door-to-balloon times under 90 min are feasible.

Key Words: myocardial infarction • reperfusion time • STEMI systems • stents

Abbreviations and Acronyms   ECG = electrocardiography/electrocardiogram   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction

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