Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention
Authors: Tracy Y. Wang
Journal: JAMA (2011)

nary intervention (PCI) is the preferred method of reperfusion for patients with STsegment elevation myocardial infarction (STEMI), 1 yet approximately 75% of hospitals in the United States currently do not have acute PCI capability. 2 Patients with STEMI who present initially to these STEMI referral hospitals are frequently transferred to a STEMI receiving hospital for primary PCI.However, previous studies have highlighted the substantial delays in interhospital transfer that result in delayed reperfusion and can be associated with worse patient outcomes. 3,4 critical component of the interhospital transfer process is related to its initiation at the STEMI referral hospital.Most important, the duration of time from arrival to discharge at the first hospital (ie, the door-in to door-out [DIDO] time) is largely unknown. 5Furthermore, patient characteristics related to substantial delays in DIDO time, as well as the effect of this initial delay on subsequent treatment and outcomes, are also uncertain.The DIDO measure is increasingly being advocated as an important metric of processes of care to expedite reperfusion, and a national benchmark of less than 30 minutes has been recommended by the 2008 American College of Cardiology/American Heart Association Context Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI.Door-in to door-out (DIDO) time, defined as the duration of time from arrival to discharge at the first or STEMI referral hospital, is a new clinical performance measure, and a DIDO time of 30 minutes or less is recommended to expedite reperfusion care.Objective To characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less.Design, Setting, and Patients Retrospective cohort of 14 821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry-Get With the Guidelines between January 2007 and March 2010.Main Outcome Measures Factors associated with a DIDO time greater than 30 minutes, overall DTB times, and risk-adjusted in-hospital mortality. ResultsMedian DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1627 patients (11%) had DIDO times of 30 minutes or less.Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and non-emergency medical services transport to the first hospital.Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60% [95% confidence interval {CI}, 57%-62%] vs 13% [95% CI, 12%-13%]; PϽ.001).Among patients with DIDO times greater than 30 minutes, only 0.6% (95% CI, 0.5%-0.8%)had an absolute contraindication to fibrinolysis.Observed in-hospital mortality was significantly higher among patients with DIDO times greater than 30 minutes vs patients with DIDO times of 30 minutes or less (5.9% [95% CI, 5.5%-6.3%]vs 2.7% [95% CI, 1.9%-3.5%];PϽ.001; adjusted odds ratio for in-hospital mortality, 1.56 [95% CI, 1.15-2.12]). ConclusionA DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.