Transporting without infusions: effect on door-to-needle time for acute coronary syndrome patients

Standard of care for patients with acute coronary syndrome/ST-segment elevation myocardial infarction (ACS/STEMI) is rapid revascularization of ischemic myocardium. Current optimal treatment is primary percutaneous coronary intervention (PCI) within 90 minutes after the patient accesses the health care system, and strategies to lower this time may improve outcomes.

To compare interhospital transport times (TTs) before and after instituting a no-medication-infusion policy during transport of ACS patients. Our hypothesis was that transporting patients using only bolus medications would significantly reduce transport times without increasing hospital length of stay (LOS) or increasing mortality.

We conducted an institutional review board (IRB)-approved retrospective chart review of all patients transferred from an outlying hospital to a primary PCI center using either critical care helicopter or ground transport. The study period was January 2006 through January 2008, with the policy of discontinuing infusions instituted in April 2007. The TT was calculated using departure and arrival times from dispatch logs. The LOS was determined via electronic medical record review. The TT and LOS differences were calculated using two-tailed t-tests with Welch's correction where appropriate. Results. A total of 154 ACS/STEMI transports were completed during the study period (74 before and 80 after policy initiation). The mean (+/- standard error of the mean) TT was 43.5 +/- 1.2 minutes before the policy and 37.1 +/- 0.9 minutes after the policy (p < 0.01). To specifically address different transport distances, we analyzed TTs from an identical group of referral hospitals in both the before- and after-policy groups. A significant reduction in TT remained in this after-policy group (TTs 43.5 +/- 1.2 minutes before the policy and 37.1 +/- 0.9 minutes after; p = 0.01). Data on LOS were available for 127 patients (58 patients before and 69 patients after) and averaged 4.6 +/- 0.8 days prior to the new policy and 3.9 +/- 0.4 days after (p = 0.41). Overall, only one patient died (after-policy group) (p = not significant).

A policy of transferring patients from one hospital directly to a cardiac catheterization laboratory using only bolus medications significantly reduces total door-to-needle time without adverse effects on LOS or mortality. Other institutions may want to consider such policies for interfacility transport of ACS patients.