Understanding timely STEMI treatment performance: A 3-year retrospective cohort study using diagnosis-to-balloon-time
Maame Yaa A B Yiadom1, Olayemi O Olubowale1, Cathy A Jenkins2
1Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA.
Insights
Timeliness of ST-segment elevation myocardial infarction (STEMI) treatment varies by initial diagnosis location. Diagnosis-to-balloon time highlights care gaps, complementing door-to-balloon time for STEMI pathways.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- ST-segment elevation myocardial infarction (STEMI) treatment pathways involve multiple locations, including referring facilities, emergency medical services (EMS), and percutaneous coronary intervention (PCI) centers.
- Door-to-balloon time (DBT) is a standard metric, but may not fully capture the timeliness of STEMI care when diagnosis occurs outside the PCI center's emergency department (ED).
Purpose of the Study:
- To quantify differences in STEMI treatment mobilization time based on the location of the initial diagnostic electrocardiogram (ECG).
- To identify opportunities for improving STEMI care processes by analyzing various time intervals.
Main Methods:
- A 3-year retrospective cohort study at a single center.
- Patients were classified by diagnostic ECG location: referring facility, EMS, or PCI center ED.
- Door-to-balloon time (DBT) and diagnosis-to-balloon time (dBT) with its subintervals were quantified.
Main Results:
- Median diagnosis-to-balloon times were shortest for ED-diagnosed STEMI (78 mins), followed by EMS-identified (89 mins), and longest for referred patients (140 mins).
- Conversely, referred patients had the shortest median door-to-balloon times (38 mins), followed by EMS-identified (64 mins), and ED-diagnosed (89 mins).
- Time differences reflect transport needs and pre-PCI center ED activation for referred and EMS-identified STEMI cases.
Conclusions:
- Diagnosis-to-balloon time (dBT) and its subintervals are valuable complements to door-to-balloon time (DBT) for evaluating STEMI treatment.
- Analyzing dBT highlights needs for faster STEMI identification in ED-diagnosed patients.
- Opportunities exist for out-of-hospital catheterization lab activation for EMS-identified STEMI and streamlined pathways for referred STEMI patients.
Objective:
From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-to-balloon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG.
Methods:
This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified door-to-balloon-time and diagnosis-to-balloon-time with its care subintervals.
Results:
Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-to-balloon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 minutes [IQR, 47-77]), whereas ED-diagnosed patients had the longest (89 minutes [IQR, 70-114]), reflecting diagnosis and catheterization lab activation frequently occurring before PCI center ED arrival for referred and EMS-identified patients.
Conclusions:
Diagnosis-to-balloon-time and its care subintervals are complementary to the traditional door-to-balloon-times as measures of the STEMI treatment process. Together, they highlight opportunities to improve timely identification among ED-diagnosed patients, use of out-of-hospital cath lab activation for EMS-identified patients, and encourage pathways for referred patients to bypass PCI center EDs.
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