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Achieving Sustainable First Door-to-BalloonTimes of 90 Minutes for Regional TransferST-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, MDzCharlotte, 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 coronaryintervention (PCI) within 90 min.

Background Nationally, a minority of STEMI patients from referral centers obtain 1st D2B in <2 h andeven fewer in <90 min.

Methods Included were transfer STEMI patients from 9 network hospitals treated in 2007 comparedwith 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 hospitalactivation of the PCI hospital catheterization laboratory; and 5) outreach coordinator and patient-levelweb-based feedback to the referring hospital.

Results A total of 101 STEMI patients transported in 2007 were compared with 442 STEMI patientstransferred after starting these initiatives for STEMI from 2008 to 2011, with the median door-in todoor-out time decreased from 44 to 35 min (p < 0.0001), the median 1st D2B decreasing from 109.5 to88.0 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 (median36.5 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 CardiologyFoundation

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.

Abbreviationsand Acronyms

1st D2B = first door-to-

balloon

ACTION = Acute Coronary

Treatment and Intervention

Outcome Network

DIDO = door-in to door-out

PCI = percutaneous coronary

intervention

STEMI = ST-segment

elevation myocardial

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Reducing transfer delays from regional hospitals to hospitalswith percutaneous coronary intervention (PCI) is a major goalto improve ST-segment elevation myocardial infarction(STEMI) patient care outcomes in the United States andelsewhere. Indeed, the 2011AmericanCollege ofCardiology/American Heart Association/Society for CardiovascularAngiography and Interventions Guideline for PercutaneousCoronary Intervention: Executive Summary recommends asa systems goal primary PCI for STEMI patients presentingto a hospital without PCI capability within 120 min of firstmedical contact (1). Even so, nationally, only about 25% ofSTEMI patients from regional transfer hospitals obtainfirst door-to-balloon time (1st D2B) within 2 h (2).Numerous papers have highlighted the criticality of re-ducing time to reperfusion (3–12), and the NationalRegistry of Myocardial Infarction database indicatedthat there are 6.3 fewer deaths per 1,000 patients treatedfor each 15-min improvement in time to reperfusion (13).However, even among hospitals actively participating inthe institutionally aware Acute Coronary Treatment andIntervention Outcomes Network Registry (ACTIONRegistry)–Get With the Guidelines reported in 2009,only 53% of patients receive 1st D2B within 2 h and only21% within 90 min (14).

Although in 2008 the American College of Cardiology/American Heart Association Performance Measures forAcute Myocardial Infarction recommended 2 new perfor-mance measures: time spent at the first hospital (transfercenter) with a goal of �30 min, and total time to pri-mary PCI with a goal of �90 min (15); subsequent2013 STEMI guidelines have further clarified a firstmedical contact to balloon goal of 120 min for transferredpatients. (The 2013 STEMI guidelines specify “immediatetransfer to a PCI-capable hospital for primary PCI is therecommended triage strategy for patients with STEMIwho initially arrive or are transported to a non–PCI-capable hospital, with an ideal first medical contact todevice time system goal of 120 min or less”) (16). In lightof all of these, we programmatically instituted a systematicapproach to regional transfer STEMI patients in ournetwork to achieve consistent improved reperfusion times.

Methods

PCI Center. The PCI Center in this study, CarolinasMedical Center, is an 888-bed tertiary care academichospital of the University of North Carolina, School ofMedicine, 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 PCIcenter is part of a network of hospitals (CarolinasHealthcare System) that own and operate 4 helicopterbased at 4 sites in the region, as well as numerous ground

ambulances. Carolinas Medical Center and all of thereferral centers discussed in this report are accredited bythe Society of Cardiovascular Patient Care as Chest PainCenters (17). Ambulance transport versus helicoptertransport was at the discretion of the treating emergencymedicine physician in collaboration with the receivingphysicians (cardiologist or emergency medicine) at thePCI center.

Patients. All consecutive STEMI patients who were trans-ported to the PCI receiving hospital from a 9-hospitalreferral network with a median transport time <60 minand a minimum of 5 emergency regional transfers forprimary PCI in 2007 (n ¼ 101) were compared with thosetransported after institution of a comprehensive systematicapproach to regional transfer of STEMI patients (n ¼ 442)during a 4-year period from 2008 to 2011. Five compo-nents of an expedient system-wide approach to transferSTEMI care were identified and instituted between thesetime periods. Implementation included: 1) an established

hospital referral system networkwith uniform transfer algorithms(Fig. 1); 2) a goal-oriented per-formance protocol emphasizingtime at the regional transfer hos-pital �30 min (Fig. 2); 3) expe-dited transport by ground or airwith median transport times�60 min within a 50-mile radius;4) a single call system to activatethe PCI catheterization laboratoryby the regional transfer hospital;and 5) an outreach coordinatorsupervising real-time entry and worldwide web–based feedback of patient transport timesand outcomes imminently available to the regional transferhospital for programmatic and institutional improvement(Fig. 3).

Data collection and analysis. The following definitions(Table 1) and time metrics were recorded and provided foranalysis and feedback:

1. Transfer hospital timedcalculated from time of arrival atthe transfer hospital to time of departure from the transferhospital (also known asdoor-in to door-out [DIDO] time).

2. Transport timedcalculated from transfer hospitaldeparture time to arrival at PCI hospital.

3. PCI door-to-balloon (PCI D2B)dcalculated fromtime of arrival at the PCI hospital to time of firstdevice (balloon or aspiration catheter, not guidewire)deployment during PCI.

4. 1st D2Bdcalculated from time of arrival at the transferhospital to time of first device (balloon or aspirationcatheter, not guidewire) deployment during PCI.

infarction

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 thePCI receiving center denoted by the “tree of life” symbol. PCI ¼ percutaneous coronary intervention; STEMI ¼ ST-segment elevation myocardial infarction. Screenshotof map ª 2013 Google.

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In addition, we evaluated and compared patient out-comes, including length of stay and mortality, over thecourse of the study. The ACTION database collectionand study were approved by the institutional review boardof the primary PCI hospital and Carolinas HealthcareSystem.Statistical analysis. Statistical analysis was performedutilizing standard tests for comparing 2 groups. The Krus-kal-Wallis test was used to analyze median times by regionaltransfer patients in 2007 to median times for those from2008 to 2011 after implementation of a system-wide

approach. The Fisher’s exact test was used to equate distri-bution of patients reaching time goals between these periodsas well.

Results

Implementation of system-wide initiatives for transfer STEMIafter 2007. In 2007, the PCI hospital treated 377 STEMIpatients, of which 101 were transferred from the networkhospitals. During 2008 to 2011, the PCI hospital received2,362 STEMI patients, with 442 from the network

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 thetransporting 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 asto reduce the need for verbal report between facilities. EMS ¼ emergency medical service; other abbreviations as in Figure 1.

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hospitals (Table 2). Following implementation of thissystematic approach, the median DIDO time at the9 transfer STEMI hospitals declined from 44 min to 35 min(p < 0.0001), whereas the median transport time remainedconsistent (36.5 min vs. 36.0 min, p ¼ 0.98). PCID2B 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% during2008 to 2011 (Table 3). The 1st D2B decreased froma median of 109.5 min in 2007 to 88 min (p < 0.0001)by 2008 to 2011, and the percentage of patients treatedwithin the 90-min goal more than doubled (22.8% to 55.9%,p < 0.0001) (Fig. 4). This happened with more helicoptertransports (21% [n ¼ 21] in 2007 vs. 48% [n ¼ 214] in

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 thetreatment of that patient. Data provide near real-time assessment of achieving benchmarks, allowing for immediate review and follow-up of outliers. (Real hospitalnames 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.

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2008 to 2011, p < 0.0001) and more patients from fartheraway (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 timeimprovements during the same time frame from 2007until 2008 to 2011, length of stay remained unchangedat 3 days (p ¼ 0.2207), and in-hospital mortality remained<4% (p ¼ 0.96).

Discussion

Although many cities and some regions worldwide havedeveloped mature regional transfer STEMI programs, todate, only 2 studies have reported median 1st D2B under90 min for transfersdonly 37 and 187 patients, respectively,with significantly shorter transfer times (flight times

Table 1. STEMI Patient Types

STEMI (nontransfer) Patient arriving by privately operated vewith first ECG being positive for STEMACTION Registry exclusion criteria.

Transfer STEMI Patient transferred from a PCI referral creperfusion strategy, and does not m

Other STEMI Patient regardless of hospital origin whreceive PCI as a primary reperfusionACTION Registry. Examples include prequiring CABG, patients treated wit

Cancel STEMI Patient regardless of hospital of origindocumentation of the cancellation eitof reasons for cancellation include c

ACTION ¼ Acute Coronary Treatment and Intervention Outcome Network; CABG ¼coronary intervention; STEMI ¼ ST-segment elevation myocardial infarction.

<10 min and drive times <40 min) (18,19). Furthermore,helicopter transport was utilized in over 80% of thesecases. Therefore, this is the first report of a regional net-work system of hospitals approaching the 2008 Ameri-can College of Cardiology/American Heart Associationrecommendations of <30 min spent at the transfer hospital,DIDO (median 35 min), and total time 1st D2B within 90min over a 4-year period (Table 3). We believe these goalswere achieved through the implementation of 5 key strate-gies including establishing a mature hospital referral net-work; a time goal–oriented transfer protocol; a moreresponsive transport system by ground ambulance or heli-copter �60 min a standard of empowering the transferhospital physician to activate the PCI hospital catheteriza-tion laboratory; and an online feedback tracking systemof transport times and patient outcomes available by the

Definition

hicle or emergency medical services directly to the PCI receiving centerI. Patient has PCI as the primary reperfusion strategy and does not meet

enter with first ECG being positive for STEMI, PCI as the primaryeet ACTION Registry exclusion criteria

o has a STEMI paged out without cancellation, and the patient does notstrategy, or patient has a reason for delay that would be exclusion foratients receiving only a diagnostic catheterization, rescue PCI, patientsh thrombolytics.

who has a STEMI paged out but subsequently cancelled with officialher in the medical record or from the hospital paging system. Exampleshanges in the ECG and/or status/symptom changes.

coronary artery bypass grafting; ECG ¼ electrocardiogram; PCI ¼ percutaneous

Table 2. Overall STEMI Volumes and Patient Demographics for Single-Center PCI Receiving Facility

2007 2008 2009 2010 2011Combined2008–2011

STEMI type

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

Transfer STEMI from PCI referral network*

N 101 136 122 93 91 442

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.

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worldwide web to the transfer hospital. By accrediting allhospitals in our network by the Society of CardiovascularPatient Care as Chest Pain Centers, we improved qualityand outcomes by sharing best practices monthly (includingcommitted and coordinated ambulance or helicopter trans-port), by activating the PCI catheterization laboratorythrough a central single call-in switchboard, and by deliv-ering process improvement solutions to each team memberfor early heart attack care. Our uniform transport algorithmand performance protocol (Fig. 2) are in keeping withour participation in the North Carolina RACE-ER(Reperfusion of Acute Myocardial Infarction in CarolinaEmergency Departments–Emergency Response) project andemphasized a DIDO goal of <30 min (20), and the abilityof the PCI referring hospital to activate the STEMI cath-eterization laboratory team at the PCI receiving hospital. Inaddition, our improved arrival at the PCI hospital toreperfusion times were only achieved through a nonvarying“hard-wired direct trauma approach” from helicopter orambulance straight to the catheterization laboratory. There,

Table 3. Performance Measures for Transfer STEMI Patients From PCIReferral Network

2007(n ¼ 101)

2008–2011(n ¼ 442) p Value*

Time at first hospital, min 44 (31–56) 35 (25–46) <0.0001

�30 min, % 21.8 38.0 0.0018

Transport time, min 36.5 (30–47) 36 (30–45) 0.98

�30 min, % 29.7 25.6 0.3842

PCI hospital to reperfusion, min 20 (16–33) 16 (11–20) <0.0001

�30 min, % 72.3 93.4 <0.0001

First hospital to reperfusion, min 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

Length of stay, days 3.0 (2.0) 3.0 (2.0) 0.2207

In-hospital mortality, % 3.96 3.85 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 thecardiologist from the patient on the gurney immediatelybefore transfer to the catheterization laboratory table. Al-though we did not assess the relative contribution of each ofthese factors to overall system improvement, other reportshave shown some importance to all of these strategies andthe greatest gains with multiple achievements (12,21). Thissystematic approach has achieved sustainable 1st D2B timesof 88 min, significantly shorter than the 120 min recen-tly reported from the ACTION Registry–Get With theGuidelines database (22).Study limitations. Limitations to this report include thatthis was a single “hub-and-spoke” system for our regionand that mortality, length of stay, and other outcomes didnot improve significantly despite multiple previous reportslinking mortality to delay to PCI (23,24). This may haveoccurred because of the relatively good baseline timemetrics in 2007, highlighted by a low initial median 1stD2B of 109.5 min, better than that reported by otherprograms after interventions for improvement were well inplace (9,20). Although details regarding patient severity,clinical differences in those transported by helicopter, andincidence of shock were missing, basic demographicsacross the centers as noted in Table 2 were equivalent. Inthe earlier years of data collection in this report, as well asnationwide, first medical contact and total ischemia timefor transported patients were not identified trackingelements. We began to collect these metrics in late 2009.Therefore, we were unable to compare these data betweenthe 2 time frames. However, our data from 2011 indicatethat the true median first medical contact to reperfusionwas 87 min and is similar to our reported 1st D2B reper-fusion of 88 min from 2008 to 2011, but still, theincompleteness of these data represent a limitation of thisstudy. Because our total ischemia times could not beassessed and compared, this may explain the lack ofimprovement in length of stay and mortality despite thewell-established fact that most transport time reductionsusually lead to reduced mortality (mainly in those with

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 fromthe PCI hospital to reperfusion (green) and later sustained improvements in median time at the first hospital (blue). As expected, transport times remained relativelyconstant over the time period (red). Y20017Q1 ¼ year 2007, quarter 1; Y2011Q4 ¼ year 2011, quarter 4; other abbreviations as in Figure 1.

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infarctions of <3 h duration) (23,24). In any event, thesignificant improvements in the time metrics with ourprogram highlight that it is possible to regularly achieve 1stD2B times <90 min for a regional transfer STEMInetwork. Future efforts for systems of care improvementsshould concentrate on reducing total ischemia time bypublic education of early signs and symptoms of heartattack, as well as calling 911 rather than using privatevehicle transport to emergency departments.

Conclusions

The implementation of multiple system-wide initiatives fortransfer STEMI along with advanced transport protocolsand patient-level feedback can achieve durable 1st D2Btimes within 90 min for a transfer STEMI network havingtransport times consistently <60 min.

AcknowledgmentsThe authors acknowledge the following hospitals andtheir STEMI teams, and numerous emergency medicalservice agencies who were instrumental in facilitatingthe implementation of the transfer protocol: CarolinasMedical Center (CMC)-Lincoln, CMC-Union, CMC-Pineville, CMC-University, Cleveland Regional MedicalCenter, Kings Mountain Hospital, Iredell MemorialHospital, Lake Norman Regional Medical Center, RowanMedical Center, Mecklenburg EMS Agency, MEDIC, andCarolinas HealthCare System’s MEDCENTER AIR. Theyalso acknowledge the significant contribution of RomanoPaul (Carolinas HealthCare System) for the web-basedreporting tool, Anne Olsen (Blazon Productions) for the

creation of the article’s map, and Norma Wright for hertechnical 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 Carolina28203. E-mail: hadley.wilson@carolinashealthcare.org.

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Key Words: infarction - ST-segment elevation - systemsof care - transfer.