PURPOSE: Ideally, primary percutaneous coronary intervention (PPCI) for ST-segement elevation myocardial infarction (STEMI) should be performed within 90 minutes of hospital arrival since earlier reperfusion has translated into improved survival. However, during off hours (Monday to Friday 5 PM to 8 AM; and weekends), PPCI has a questionable outcome because of the delay in treatment, and few studies have even showed higher mortality during off-hours. We sought to determine if emergency physician initiated Code STEMI has any impact on reducing door-to-balloon-times at our tertiary care medical center during off-hours.
METHODS: We recorded door-to-balloon time for 27 STEMI patients from January 2006 to December 2006, serial activation process (SAP) presented during off hours. We compared this group with 46 STEMI from January 2007 to December 2007-Code STEMI (simultaneous activation of the cardiac catheterization personnel and the interventional cardiologist by the emergency physician) presented during off-hours. Our primary outcome was comparing median door-to-balloon time in both groups. Secondary end points included the 3 components of Door-to-balloon times (i.e. Door-to-ECG time), peak Troponin-I level within 24 hours, length of stay and all-cause in-hospital mortality.
RESULTS: During off-hours median Door-to-balloon time was 129 (89, 155) minutes (interquartile ranges) for patients in the SAP group, and 80 (68, 99) minutes in the Code STEMI group (P<0.001). Of the 3 components of door-to-balloon time analyzed, the ECG to cardiac catheterization laboratory time exhibited the largest area of improvement with 13 minutes absolute reduction in median door-to-balloon time (P=0.02). Median peak Troponin levels 62 versus 26 ng/mL (P=0.003), and hospital length of stay (4 versus 3 days, P=0.009) decreased. We did not see any statistically significant difference in all cause in- hospital mortality.
CONCLUSION: Emergency physician activation of the Code STEMI significantly reduces door-to-balloon time to within national standards of care during off-hours.
CLINICAL IMPLICATIONS: The present study identifies a simple and widely applicable strategy that leads to improvement in door-to-balloon times and quality of care of STEMI patients undergoing PPCI during off-hours.
DISCLOSURE: Rupen Parikh, No Financial Disclosure Information; No Product/Research Disclosure Information