JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 6, NO. 10, 2013
ª 2013 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00
http://dx.doi.org/10.1016/j.jcin.2013.05.018
Achieving Sustainable First Door-to-Balloon
Times of 90 Minutes for Regional Transfer
ST-Segment Elevation Myocardial Infarction
B. Hadley Wilson, MD,* Angela D. Humphrey, MS,y John C. Cedarholm, MD,*
William E. Downey, MD,* Robert H. Haber, MD,* Glen J. Kowalchuk, MD,*
Michael J. Rinaldi, MD,* Denise A. Miller, BSN,y Jennifer L. Sarafin, MSN,*
J. Lee Garvey, MDz
Charlotte, North Carolina
Objectives A network approach to transfer ST-segment elevation myocardial infarction (STEMI)
patients can achieve durable first door-to-balloon times (1st D2B) for percutaneous coronary
intervention (PCI) within 90 min.
Background Nationally, a minority of STEMI patients from referral centers obtain 1st D2B in <2 h and
even fewer in <90 min.
Methods Included were transfer STEMI patients from 9 network hospitals treated in 2007 compared
with 2008 to 2011 after installing the following initiatives: 1) established hospital referral system; 2)
goal-oriented performance protocols; 3) expedited transport by ground or air; 4) first hospital
activation of the PCI hospital catheterization laboratory; and 5) outreach coordinator and patient-level
web-based feedback to the referring hospital.
Results A total of 101 STEMI patients transported in 2007 were compared with 442 STEMI patients
transferred after starting these initiatives for STEMI from 2008 to 2011, with the median door-in to
door-out time decreased from 44 to 35 min (p < 0.0001), the median 1st D2B decreasing from 109.5 to
88.0 min (p < 0.0001), and the percentage under 90 min increased from 22.8% to 55.9% (p < 0.0001).
Overall, throughout the study period (2007 to 2011), the transport times remained consistent (median
36.5 vs. 36.0 min, p ¼ 0.98), whereas the PCI hospital D2B decreased from 20.0 to 16.0 min
(p < 0.0001). Length of stay and in-hospital mortality remained low at 3.0 days and under 4%,
respectively.
Conclusions A system-wide network program can achieve sustained (over 4 years) 1st D2B times of
<90 min. (J Am Coll Cardiol Intv 2013;6:1064–71) ª 2013 by the American College of Cardiology
Foundation
From the *Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, North Carolina; yDickson Advanced Analytics
Group, Carolinas HealthCare System, Charlotte, North Carolina; and the zDepartment of Emergency Medicine, Carolinas
Medical Center, Charlotte, North Carolina. Dr. Wilson serves as a consultant for Boston Scientific; and has received speaker
honoraria from Abiomed. Dr. Rinaldi is a consultant for Abbott Vascular. Dr. Garvey is a consultant for Philips Healthcare. All
other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Manuscript received January 11, 2013; revised manuscript received May 3, 2013, accepted May 28, 2013.
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OCTOBER 2013:1064–71
Reducing transfer delays from regional hospitals to hospitals
with percutaneous coronary intervention (PCI) is a major goal
to improve ST-segment elevation myocardial infarction
(STEMI) patient care outcomes in the United States and
elsewhere. Indeed, the 2011 American College of Cardiology/
American Heart Association/Society for Cardiovascular
Angiography and Interventions Guideline for Percutaneous
Coronary Intervention: Executive Summary recommends as
a systems goal primary PCI for STEMI patients presenting
to a hospital without PCI capability within 120 min of first
medical contact (1). Even so, nationally, only about 25% of
STEMI patients from regional transfer hospitals obtain
first door-to-balloon time (1st D2B) within 2 h (2).
Numerous papers have highlighted the criticality of reducing time to reperfusion (3–12), and the National
Registry of Myocardial Infarction database indicated
that there are 6.3 fewer deaths per 1,000 patients treated
for each 15-min improvement in time to reperfusion (13).
However, even among hospitals actively participating in
the institutionally aware Acute Coronary Treatment and
Intervention Outcomes Network Registry (ACTION
Registry)–Get With the Guidelines reported in 2009,
only 53% of patients receive 1st D2B within 2 h and only
21% within 90 min (14).
Although in 2008 the American College of Cardiology/
American Heart Association Performance Measures for
Acute Myocardial Infarction recommended 2 new performance measures: time spent at the first hospital (transfer
center) with a goal of 30 min, and total time to primary PCI with a goal of 90 min (15); subsequent
2013 STEMI guidelines have further clarified a first
medical contact to balloon goal of 120 min for transferred
patients. (The 2013 STEMI guidelines specify “immediate
transfer to a PCI-capable hospital for primary PCI is the
recommended triage strategy for patients with STEMI
who initially arrive or are transported to a non–PCIcapable hospital, with an ideal first medical contact to
device time system goal of 120 min or less”) (16). In light
of all of these, we programmatically instituted a systematic
approach to regional transfer STEMI patients in our
network to achieve consistent improved reperfusion times.
Methods
PCI Center. The PCI Center in this study, Carolinas
Medical Center, is an 888-bed tertiary care academic
hospital of the University of North Carolina, School of
Medicine, in metropolitan Charlotte, North Carolina,
serving 38 counties and a population >5 million people.
Primary PCI services and an active STEMI program 24 h,
7 days a week have been ongoing since 2005. The PCI
center is part of a network of hospitals (Carolinas
Healthcare System) that own and operate 4 helicopter
based at 4 sites in the region, as well as numerous ground
Wilson et al.
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ambulances. Carolinas Medical Center and all of the
referral centers discussed in this report are accredited by
the Society of Cardiovascular Patient Care as Chest Pain
Centers (17). Ambulance transport versus helicopter
transport was at the discretion of the treating emergency
medicine physician in collaboration with the receiving
physicians (cardiologist or emergency medicine) at the
PCI center.
Patients. All consecutive STEMI patients who were transported to the PCI receiving hospital from a 9-hospital
referral network with a median transport time <60 min
and a minimum of 5 emergency regional transfers for
primary PCI in 2007 (n ¼ 101) were compared with those
transported after institution of a comprehensive systematic
approach to regional transfer of STEMI patients (n ¼ 442)
during a 4-year period from 2008 to 2011. Five components of an expedient system-wide approach to transfer
STEMI care were identified and instituted between these
time periods. Implementation included: 1) an established
hospital referral system network
with uniform transfer algorithms
Abbreviations
(Fig. 1); 2) a goal-oriented perand Acronyms
formance protocol emphasizing
1st D2B = first door-totime at the regional transfer hosballoon
pital 30 min (Fig. 2); 3) expeACTION = Acute Coronary
dited transport by ground or air
Treatment and Intervention
with median transport times
Outcome Network
60 min within a 50-mile radius;
DIDO = door-in to door-out
4) a single call system to activate
PCI = percutaneous coronary
the PCI catheterization laboratory
intervention
by the regional transfer hospital;
STEMI = ST-segment
and 5) an outreach coordinator
elevation myocardial
infarction
supervising real-time entry and
worldwide web–based feedback of patient transport times
and outcomes imminently available to the regional transfer
hospital for programmatic and institutional improvement
(Fig. 3).
Data collection and analysis. The following definitions
(Table 1) and time metrics were recorded and provided for
analysis and feedback:
1. Transfer hospital timedcalculated from time of arrival at
the transfer hospital to time of departure from the transfer
hospital (also known as door-in to door-out [DIDO] time).
2. Transport timedcalculated from transfer hospital
departure time to arrival at PCI hospital.
3. PCI door-to-balloon (PCI D2B)dcalculated from
time of arrival at the PCI hospital to time of first
device (balloon or aspiration catheter, not guidewire)
deployment during PCI.
4. 1st D2Bdcalculated from time of arrival at the transfer
hospital to time of first device (balloon or aspiration
catheter, not guidewire) deployment during PCI.
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Figure 1. Regional Map of PCI Referral Centers and PCI Receiving Center
Blue hospital symbols (H) denote the location of each PCI referral center within the STEMI referral network that are within a 25-mile radius and a 50-mile radius of the
PCI receiving center denoted by the “tree of life” symbol. PCI ¼ percutaneous coronary intervention; STEMI ¼ ST-segment elevation myocardial infarction. Screenshot
of map ª 2013 Google.
In addition, we evaluated and compared patient outcomes, including length of stay and mortality, over the
course of the study. The ACTION database collection
and study were approved by the institutional review board
of the primary PCI hospital and Carolinas Healthcare
System.
Statistical analysis. Statistical analysis was performed
utilizing standard tests for comparing 2 groups. The Kruskal-Wallis test was used to analyze median times by regional
transfer patients in 2007 to median times for those from
2008 to 2011 after implementation of a system-wide
approach. The Fisher’s exact test was used to equate distribution of patients reaching time goals between these periods
as well.
Results
Implementation of system-wide initiatives for transfer STEMI
after 2007. In 2007, the PCI hospital treated 377 STEMI
patients, of which 101 were transferred from the network
hospitals. During 2008 to 2011, the PCI hospital received
2,362 STEMI patients, with 442 from the network
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Figure 2. Transfer Documentation: “Boarding Pass”
This document is utilized by emergency department staff at PCI referral centers to expedite the transfer process and to provide essential information needed by the
transporting EMS agency. In addition, the information is transmitted to the PCI receiving center to provide vital information in advance of the patient’s arrival as well as
to reduce the need for verbal report between facilities. EMS ¼ emergency medical service; other abbreviations as in Figure 1.
hospitals (Table 2). Following implementation of this
systematic approach, the median DIDO time at the
9 transfer STEMI hospitals declined from 44 min to 35 min
(p < 0.0001), whereas the median transport time remained
consistent (36.5 min vs. 36.0 min, p ¼ 0.98). PCI
D2B median time decreased from 20 min to 16 min
(p < 0.0001), and the overall percentage achieving this in
<30 min increased from 72.3% in 2007 to 93.4% during
2008 to 2011 (Table 3). The 1st D2B decreased from
a median of 109.5 min in 2007 to 88 min (p < 0.0001)
by 2008 to 2011, and the percentage of patients treated
within the 90-min goal more than doubled (22.8% to 55.9%,
p < 0.0001) (Fig. 4). This happened with more helicopter
transports (21% [n ¼ 21] in 2007 vs. 48% [n ¼ 214] in
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Figure 3. Example of the Web-Based STEMI Feedback Report
Data are typically available within 48 h of the transfer. The data are accessible to the PCI receiving center, the PCI referral center, and the EMS agencies involved in the
treatment of that patient. Data provide near real-time assessment of achieving benchmarks, allowing for immediate review and follow-up of outliers. (Real hospital
names are used in the actual tool instead of “PCI Receiving Center” and “PCI Referral Center” as used in this example.) Abbreviations as in Figures 1 and 2.
2008 to 2011, p < 0.0001) and more patients from farther
away (27% [n ¼ 27] in 2007 from 25 to 50 miles vs.
49% [n ¼ 218] in 2008 to 2011, p < 0.0001).
Length of stay and mortality. Despite these system and time
improvements during the same time frame from 2007
until 2008 to 2011, length of stay remained unchanged
at 3 days (p ¼ 0.2207), and in-hospital mortality remained
<4% (p ¼ 0.96).
Discussion
Although many cities and some regions worldwide have
developed mature regional transfer STEMI programs, to
date, only 2 studies have reported median 1st D2B under
90 min for transfersdonly 37 and 187 patients, respectively,
with significantly shorter transfer times (flight times
<10 min and drive times <40 min) (18,19). Furthermore,
helicopter transport was utilized in over 80% of these
cases. Therefore, this is the first report of a regional network system of hospitals approaching the 2008 American College of Cardiology/American Heart Association
recommendations of <30 min spent at the transfer hospital,
DIDO (median 35 min), and total time 1st D2B within 90
min over a 4-year period (Table 3). We believe these goals
were achieved through the implementation of 5 key strategies including establishing a mature hospital referral network; a time goal–oriented transfer protocol; a more
responsive transport system by ground ambulance or helicopter 60 min a standard of empowering the transfer
hospital physician to activate the PCI hospital catheterization laboratory; and an online feedback tracking system
of transport times and patient outcomes available by the
Table 1. STEMI Patient Types
Definition
STEMI (nontransfer)
Patient arriving by privately operated vehicle or emergency medical services directly to the PCI receiving center
with first ECG being positive for STEMI. Patient has PCI as the primary reperfusion strategy and does not meet
ACTION Registry exclusion criteria.
Transfer STEMI
Patient transferred from a PCI referral center with first ECG being positive for STEMI, PCI as the primary
reperfusion strategy, and does not meet ACTION Registry exclusion criteria
Other STEMI
Patient regardless of hospital origin who has a STEMI paged out without cancellation, and the patient does not
receive PCI as a primary reperfusion strategy, or patient has a reason for delay that would be exclusion for
ACTION Registry. Examples include patients receiving only a diagnostic catheterization, rescue PCI, patients
requiring CABG, patients treated with thrombolytics.
Cancel STEMI
Patient regardless of hospital of origin who has a STEMI paged out but subsequently cancelled with official
documentation of the cancellation either in the medical record or from the hospital paging system. Examples
of reasons for cancellation include changes in the ECG and/or status/symptom changes.
ACTION ¼ Acute Coronary Treatment and Intervention Outcome Network; CABG ¼ coronary artery bypass grafting; ECG ¼ electrocardiogram; PCI ¼ percutaneous
coronary intervention; STEMI ¼ ST-segment elevation myocardial infarction.
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Table 2. Overall STEMI Volumes and Patient Demographics for Single-Center PCI Receiving Facility
Combined
2008–2011
2007
2008
2009
2010
2011
STEMI (nontransfer)
113
121
122
101
106
450
Transfer STEMI
128
145
137
110
98
490
Other STEMI
103
218
239
201
293
951
Cancel STEMI
33
56
135
138
142
471
101
136
122
442
STEMI type
Transfer STEMI from PCI referral network*
N
93
91
Average age, yrs
58.2
58.2
56.5
57.0
57.0
57.4
Male, %
76.2
74.1
67.8
63.4
74.7
70.2
*PCI referral network includes only transfer hospitals within a 50-mile radius and a median transport time <60 min.
Abbreviations as in Table 1.
worldwide web to the transfer hospital. By accrediting all
hospitals in our network by the Society of Cardiovascular
Patient Care as Chest Pain Centers, we improved quality
and outcomes by sharing best practices monthly (including
committed and coordinated ambulance or helicopter transport), by activating the PCI catheterization laboratory
through a central single call-in switchboard, and by delivering process improvement solutions to each team member
for early heart attack care. Our uniform transport algorithm
and performance protocol (Fig. 2) are in keeping with
our participation in the North Carolina RACE-ER
(Reperfusion of Acute Myocardial Infarction in Carolina
Emergency Departments–Emergency Response) project and
emphasized a DIDO goal of <30 min (20), and the ability
of the PCI referring hospital to activate the STEMI catheterization laboratory team at the PCI receiving hospital. In
addition, our improved arrival at the PCI hospital to
reperfusion times were only achieved through a nonvarying
“hard-wired direct trauma approach” from helicopter or
ambulance straight to the catheterization laboratory. There,
Table 3. Performance Measures for Transfer STEMI Patients From PCI
Referral Network
2007
(n ¼ 101)
2008–2011
(n ¼ 442)
p Value*
44 (31–56)
35 (25–46)
<0.0001
21.8
38.0
36.5 (30–47)
36 (30–45)
29.7
25.6
20 (16–33)
16 (11–20)
<0.0001
72.3
93.4
<0.0001
109.5 (91–128)
88 (79–103)
<0.0001
90 min
22.8
55.9
<0.0001
120 min
60.4
90.1
<0.0001
3.0 (2.0)
3.0 (2.0)
3.96
3.85
Time at first hospital, min
30 min, %
Transport time, min
30 min, %
PCI hospital to reperfusion, min
30 min, %
First hospital to reperfusion, min
Length of stay, days
In-hospital mortality, %
0.0018
0.98
0.3842
0.2207
0.96
Values are median (interquartile range) or %. *p Values for medians from Kruskal-Wallis;
p values for percentages based on the Fisher’s exact test.
Abbreviations as in Table 1.
quick assessment and oral consent were obtained by the
cardiologist from the patient on the gurney immediately
before transfer to the catheterization laboratory table. Although we did not assess the relative contribution of each of
these factors to overall system improvement, other reports
have shown some importance to all of these strategies and
the greatest gains with multiple achievements (12,21). This
systematic approach has achieved sustainable 1st D2B times
of 88 min, significantly shorter than the 120 min recently reported from the ACTION Registry–Get With the
Guidelines database (22).
Study limitations. Limitations to this report include that
this was a single “hub-and-spoke” system for our region
and that mortality, length of stay, and other outcomes did
not improve significantly despite multiple previous reports
linking mortality to delay to PCI (23,24). This may have
occurred because of the relatively good baseline time
metrics in 2007, highlighted by a low initial median 1st
D2B of 109.5 min, better than that reported by other
programs after interventions for improvement were well in
place (9,20). Although details regarding patient severity,
clinical differences in those transported by helicopter, and
incidence of shock were missing, basic demographics
across the centers as noted in Table 2 were equivalent. In
the earlier years of data collection in this report, as well as
nationwide, first medical contact and total ischemia time
for transported patients were not identified tracking
elements. We began to collect these metrics in late 2009.
Therefore, we were unable to compare these data between
the 2 time frames. However, our data from 2011 indicate
that the true median first medical contact to reperfusion
was 87 min and is similar to our reported 1st D2B reperfusion of 88 min from 2008 to 2011, but still, the
incompleteness of these data represent a limitation of this
study. Because our total ischemia times could not be
assessed and compared, this may explain the lack of
improvement in length of stay and mortality despite the
well-established fact that most transport time reductions
usually lead to reduced mortality (mainly in those with
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ST-Segment Elevation Myocardial Infarction
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Figure 4. Median Times for Transfer of STEMI Patients by Quarter (Y2007Q1 to Y2011Q4)
Data show steady improvements in overall median time from first hospital to reperfusion (purple) that can be attributed to early improvements in median time from
the PCI hospital to reperfusion (green) and later sustained improvements in median time at the first hospital (blue). As expected, transport times remained relatively
constant over the time period (red). Y20017Q1 ¼ year 2007, quarter 1; Y2011Q4 ¼ year 2011, quarter 4; other abbreviations as in Figure 1.
infarctions of <3 h duration) (23,24). In any event, the
significant improvements in the time metrics with our
program highlight that it is possible to regularly achieve 1st
D2B times <90 min for a regional transfer STEMI
network. Future efforts for systems of care improvements
should concentrate on reducing total ischemia time by
public education of early signs and symptoms of heart
attack, as well as calling 911 rather than using private
vehicle transport to emergency departments.
Conclusions
The implementation of multiple system-wide initiatives for
transfer STEMI along with advanced transport protocols
and patient-level feedback can achieve durable 1st D2B
times within 90 min for a transfer STEMI network having
transport times consistently <60 min.
Acknowledgments
The authors acknowledge the following hospitals and
their STEMI teams, and numerous emergency medical
service agencies who were instrumental in facilitating
the implementation of the transfer protocol: Carolinas
Medical Center (CMC)-Lincoln, CMC-Union, CMCPineville, CMC-University, Cleveland Regional Medical
Center, Kings Mountain Hospital, Iredell Memorial
Hospital, Lake Norman Regional Medical Center, Rowan
Medical Center, Mecklenburg EMS Agency, MEDIC, and
Carolinas HealthCare System’s MEDCENTER AIR. They
also acknowledge the significant contribution of Romano
Paul (Carolinas HealthCare System) for the web-based
reporting tool, Anne Olsen (Blazon Productions) for the
creation of the article’s map, and Norma Wright for her
technical manuscript support.
Reprint requests and correspondence: Dr. B. Hadley Wilson,
The Sanger Heart & Vascular Institute, Carolinas Medical Center,
1001 Blythe Boulevard, Suite 300, Charlotte, North Carolina
28203. E-mail: [email protected].
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Key Words: infarction
of care - transfer.
-
ST-segment elevation
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systems