Complacency, begone

As percutaneous coronary intervention (PCI) centers strive to improve outcomes of patients with ST elevation myocardial infarction (STEMI), obstacles to better outcomes draw intense scrutiny. Off-hours presentation has been identified as one such obstacle [1–7]. Higher mortality reported in patients who present during offhours has been attributed to longer door-to-device times, operator fatigue, lack of support staff, and biological diurnal variation [1–3]. In this issue of the Catheterization and Cardiovascular Intervention, Gonzalez et al. report an internal quality audit of patients transferred to their institution for PCI for STEMI [8]. They conclude that STEMI patients transferred for PCI off-hours (compared to on-hours) (a) ‘‘might have longer door-to-device times’’, but (b) ‘‘no conclusive differences in in-hospital mortality’’ and (c) their ‘‘results do not support any changes to current practice in our or similar institutions’’ other than efforts to improve door-to-device times. Gonzalez et al. deserve congratulations for analyzing and reporting their institutional outcomes. In this they set an example, which all institutions should follow. However, all three of their conclusions should be of concern to the critical reader. The authors conclude that off-hours patients have longer door-to-device times than do on-hours patients. Door-to-device times were under 120 minutes for 32.6% of on-hours patients versus 22.1% of off-hours patients (P 5 0.007). While true for this institution over the duration of the study, was it inevitable? Other institutions have reported similar door-to-device times for on-compared to off-hours patients [9,10]. Once proven possible, there is a new standard at which all systems should aim. This metric is worth pursuing, as door-to-device time has been linked to mortality [6,11]. Gonzalez et al.’s second conclusion that there were no differences in in-hospital mortality is substantiated by the in-hospital mortality of 8.2% for on-hours versus 6% for off-hours patients (P 5 ns). Some [1–3] but not all [6,9] studies comparing on-versus off-hours patients have reported excess mortality associated with off-hours presentation. In any case, other studies comparing on-versus off-hours mortality have cited onhours mortality of 4.7%, 3.7%, and 4.4% for nontransferred STEMI patients [1–3]. While comparing data across different studies may only be hypothesis-generating, the in-hospital mortality of 8.2% for off-hours patients reported by Gonzalez et al. is numerically larger and might prompt efforts to reduce it. Finally, the conclusion that ‘‘results do not support any changes to current practice in our or similar institutions’’ reflects a concerning complacency. The authors do acknowledge the need to reduce door-to-device times, but they attribute delays to transferring hospitals. Median door-to-device times under 90 minutes for transferred patients have been reported [10,12], and those results depend on close collaboration of transferring and receiving STEMI centers. Much of the responsibility for such collaboration rests with the receiving STEMI center. Next, the authors report that use of balloon pumps and intravascular ultra-sound were significantly less during off-hours. To the extent that these devices improve care, patients deserve to benefit from them equally during onand off-hours [13]. Finally, the overall mortality rate reported by Gonzalez et al. of 6.6% seems high compared to the 3–4% reported in other studies of transferred patients [10,14,15]. It is the responsibility of every interventional program to analyze its results and ceaselessly seek to lower the morbidity and mortality of the patients it serves.