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An unexpected silver lining to Katrina: elimination of inter-campus transfer delay in STEMI care.

INTRODUCTION

ST-elevation myocardial infarction (STEMI) is a time-critical illness in which successful reperfusion is associated with decreased morbidity and mortality. Primary percutaneous coronary intervention (PCI) is the preferred treatment strategy for STEMI, assuming it can be delivered in a timely manner. (1) The door-to-balloon (DTB) time, defined as the time between arrival to the hospital and PCI for patients with STEMI, is an important quality standard; a systems-goal of DTB [less than or equal to] 90 minutes is strongly associated with improved survival. (2) Despite aggressive measures to reduce DTB, recent surveys have shown that only 20% of US hospitals are able to reach the benchmark of [less than or equal to] 90 minutes. (3-4) Nationally, only a quarter of hospitals have primary PCI capabilities, highlighting the need for efficient inter-hospital transfer to reduce delays in reperfusion. (5) Complicating the assessment of inter-hospital transfer delay is the fact that national reporting metrics for STEMI exclude patients undergoing inter-hospital transfer for primary PCI. Although variations in this complex process are inevitable, some delays may be preventable through process redesign. (6)

The goal of our study was to evaluate an often overlooked barrier to reperfusion in hospitals where the emergency department (ED) and cardiac catheterization laboratory (CCL) are in separate buildings and to study the impact of inter-campus ambulance transport on reperfusion times.

METHODS

Prior to the landfall of Hurricane Katrina, the emergency department (ED) at the Medical Center of Louisiana at New Orleans (MCLNO) was located in the old Charity Hospital building, whereas the cardiac catheterization lab (CCL) was located two blocks away in the University Hospital building. Patients presenting to the Charity Hospital ED had to be transported via ambulance to the CCL, resulting in an extra element of delay in patient care. Recommendations from national organizations, such as the American College of Cardiology's D2B Alliance, were in place prior to the storm; CCL physicians and staff were activated using a single pager system, with a mandate to report to the hospital within 30 minutes. While protocols for pre-hospital activation were not formally in place yet, efforts were ongoing to educate and encourage emergency medical services to notify the receiving ED prior to arrival. In addition, recognizing the need for expedited intercampus transfer, an ambulance was always positioned at the Charity Hospital ED to bring patients to the CCL across campus.

[FIGURE 1 OMITTED]

Hurricane Katrina rendered the Charity Hospital building unusable and all clinical services from that building, including the ED, were moved into the University Hospital building. This building, which reopened in October 2006 as the Interim LSU Public Hospital, now houses both the CCL (as it did prior) and the ED, thereby eliminating the need for intercampus ambulance transport for STEMI patients.

Between January 2004 and June 2011, all patients with ST-elevation myocardial infarctions presenting to the Medical Center of Louisiana at New Orleans were analyzed; door-to-balloon times for all patients were recorded as occurring prior to August 2005 (dual-campus) and after October 2006 (single-campus).

RESULTS

Between January 2004 and August 2005, 28 patients with ST-elevation myocardial infarction presented to the MCLNO emergency department and were treated with primary PCI. Between October 2006 and June 2011, 97 patients with STEMI presented to the MCLNO ED and were treated with primary PCI.

The average door-to-balloon time in the dual-campus cohort was 156.5 ([+ or -] 62.6) minutes; the average door-to-balloon time in the single-campus cohort was 90.7 ([+ or -] 54.3) minutes. A significant decrease was noted in the DTB time over the study period (Figure 1). In the dual-campus set-up, 10% of patients were treated under the guideline-recommended timeline of 90 minutes; after the reopening of the hospital as a single-campus, the percentage of patients treated [less than or equal to] 90 minutes increased to 67% (Table 1).

DISCUSSION

Minimizing time to reperfusion in patients presenting with STEMI has a significant effect on reducing morbidity and mortality. (1), (7-12) On the basis of these studies, a 90-minute door-to-balloon time has been established as a benchmark for performance. (13) Hospitals throughout the US have focused attention on strategies to meet that benchmark. Various strategies have been proposed, but few of these address inter-campus transport. In medical centers in which the Cardiac Catheterization Lab (CCL) and Emergency Department (ED) are in separate buildings, inter-campus transport is a potential source for delay in timely reperfusion.

Prior to August 2005, the ED and CCL at MCLNO were located in separate buildings two blocks apart. Patients diagnosed with STEMI in the ED were transported via ambulance to a separate building down the street to undergo primary PCI. Valuable time was spent in this transport, resulting in delayed time to reperfusion. Supplemental measures to reduce DTB times, such as having an ambulance pre-positioned at the Charity Hospital ED at all times, did not result in effective reductions in time to reperfusion. The process of STEMI care at our institution changed after Hurricane Katrina forced the closure of one campus at MCLNO. When the hospital reopened in October 2006, the ED was moved into the same building as the CCL. This eliminated inter-campus transport as a source for delay in timely reperfusion. In our analysis, we examined the effect of inter-campus transport on DTB times at MCLNO. By moving the ED and CCL into a single building, the DTB time was reduced by an average of 65.8 minutes and a higher number of patients (67% vs 10%) were treated within 90 minutes. This improvement demonstrates that reducing or eliminating inter-campus transport, while not the sole factor at play here, has a significant effect on DTB time and potentially on patient outcomes. Other elements of care likely also improved over this time period, but it is reasonable to conclude that inter-campus transport plays an important role on DTB time.

In addition to measures proposed by the American College of Cardiology's D2B Alliance and the American Heart Association's Mission: Lifeline programs, hospital systems should focus attention on measures to minimize or eliminate patient transport. (14) In hospitals in which the ED and CCL do not share a building, systems should be in place to efficiently and quickly move patients to the CCL. Furthermore, newly built hospitals should be designed with the ED and CCL in close proximity. While Hurricane Katrina was devastating to the city of New Orleans, it did provide an upside in this particular instance. The closure of one campus provided an unexpected opportunity for system improvement at MCLNO.

REFERENCES

(1.) Minutello RM, Kim L, Aggarwal S et al. Door-to-balloon time in primary percutaneous coronary intervention predicts degree of myocardial necrosis as measured using cardiac biomarkers. Tex Heart Inst J 2010;37:161-165.

(2.) Gibson CM, Pride YB, Frederick PD et al. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. American Heart Journal 2008;156,1035-1044.

(3.) Moscucci M, Eagle KA. Reducing the door-to-balloon time for myocardial infarction with ST-segment elevation. N Engl J Med 2006;355:2364-2365.

(4.) Chakrabarti A, Krumholz HM, Wang Y et al. for the National Cardiovascular Data Registry. Time-to-reperfusion in patients undergoing interhospital transfer for primary percutaneous coronary intervention in the US: An analysis of 2005 and 2006 data from the National Cardiovascular Data Registry. J Am Coll Cardiol 2008;51:2442-2443.

(5.) Secemsky EA, Lange D, Ho JE et al. Improvement in Revascularization Time After Creation of a Coronary Catheterization Laboratory at a Public Hospital. Arch Intern Med 2012;172:193-194.

(6.) Bradley EH, Roumanis SA, Radford MJ et al. Achieving Door-to-Balloon Times That Meet Quality Guidelines: How Do Successful Hospitals Do It? J Am Coll Cardiol 2005;46:1236-1241.

(7.) Cannon CP, Gibson CM, Lambrew CT et al. Relationship of Symptom-Onset-to-Balloon Time and Door-to-Balloon Time With Mortality in Patients Undergoing Angioplasty for Acute Myocardial Infarction. JAMA: The Journal of the American Medical Association 2000;283:2941-2947.

(8.) Lambert L, Brown K, Segal E, et al. Association Between Timeliness of Reperfusion Therapy and Clinical Outcomes in ST-Elevation Myocardial Infarction. JAMA 2010;303:2148-2155.

(9.) Juliard JM, Feldman LJ, Golmard JL et al. Relation of mortality of primary angioplasty during acute myocardial infarction to door-to-Thrombolysis In Myocardial Infarction (TIMI) time. The American Journal of Cardiology 91, 1401-1405.

(10.) Brodie BR, Stuckey TD, Wall TC et al. Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 1998;32:1312-1319.

(11.) McNamara RL, Wang Y, Herrin J et al. Effect of Door-to-Balloon Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2006;47:2180-2186.

(12.) Berger PB, Ellis SG, Holmes DR et al. Relationship Between Delay in Performing Direct Coronary Angioplasty and Early Clinical Outcome in Patients With Acute Myocardial Infarction: Results From the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) Trial. Circulation 1999;100:14-20.

(13.) WRITING COMMITTEE, Krumholz HM, Anderson JL et al. ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and NonGCoST-Elevation Myocardial Infarction. Circulation 2006;113:732-761.

(14.) Bradley EH, Herrin J, Wang Y et al. Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction. N Engl J Med 2006;355:2308-2320.

Murtuza Ali, MD; Daniel Englert, MD; Navneet Sharma, BS; Neeraj Jain, MD

Dr. Ali is an Assistant Professor of Medicine, Section of Cardiology, at the LSU School of Medicine in New Orleans. Dr. Englert is a Resident in Internal Medicine at the LSU School of Medicine in New Orleans. Mr. Sharma is a student at the LSU School of Medicine in New Orleans. Dr. Jain is an Associate Professor of Medicine, Section of Cardiology, at the LSU School of Medicine in New Orleans.
Table 1: DTB times and percentage of patients treated
under guideline-recommended time of [less than or equal to]
90 minutes

                  DTB time (mins)        Patients treated
                                      [less than or equal to]
                                           90 minutes (%)

Dual campus     156.5 [+ or -] 62.6             10
Single campus    90.7 [+ or -] 54.3             67
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Author:Ali, Murtuza; Englert, Daniel; Sharma, Navneet; Jain, Neeraj
Publication:The Journal of the Louisiana State Medical Society
Article Type:Report
Geographic Code:1U7LA
Date:Jul 1, 2012
Words:1680
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