Door In/Door Out Times and Outcomes, and Ways to Improve Them

Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI. Door-in to door-out (DIDO) time (time from arrival to discharge at the STEMI referral hospital), is a new clinical performance measure from Medicare/CMS, with a DIDO time of < 30 minutes recommended to expedite reperfusion care (although Mission:Lifeline recommends a DIDO goal of < 45 min).

In this study (1) the authors performed a retrospective analysis of 14,821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry–Get With the Guidelines between January 2007 and March 2010. The median DIDO time was 68 minutes, with only 11% having a DIDO < 30 min, only 44% < 60 min, and a more than a third (35%) >90 min. However, they did find that DIDO time improved decreasing from 90 min initially to 58 min over the 2 year study period.

Predictors of longer DIDO time included off-hour presentation, non-EMS arrival, and hemodynamic instability. Interestingly, contra indications to fibrinolytics was not a predictor of delays, and were infrequently seen.

An important finding was that longer DIDO times were associated with higher mortality. Patients who had a DIDO time < 30 min compared to those with a DIDO time of > 30 min had 2 fold increase in mortality, from 2.7 to 5.5%. After multivariate analysis, there was a step-wise increase in mortality for longer DIDO times. As compared to patients with a DIDO time of < 30 min, those with a DIDO time of 30-60 min had a 34% increased risk for death, rising to an 86% increased risk if DIDO was >90 min.

An important of this study was that given prolonged transport times, patients should be considered for fibrinolytics more frequently.

How can DIDO time be reduced? A recent article by Seth Glickman and colleagues from RACE looking at 436 STEMI pts from 55 non-PCI hospitals and examined factors associated with faster DIDO times (2).

For EMS, these included increased use of pre-hospital ECGs, programs for EMS to teach STEMI recognition, using, local ambulance to transport to a PCI center if it was < 50 miles away, and keeping the patient on the EMS stretcher.

For the ED, they included obtaining ECG within 10 min, and a single call to activate PCI.

For the Hospital, it was having a dedicated STEMI reperfusion team with committed leadership, and a hospital specific reperfusion protocol (so know if going to give lytics or not).

FEEDBACK to all areas was critical.

References and links to articles

  1. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. Wang TY, Nallamothu BK, Krumholz HM, Li S, Roe MT, Jollis JG, Jacobs AK, Holmes DR, Peterson ED, Ting HH. JAMA. 2011 Jun 22;305(24):2540-7.
    http://jama.ama-assn.org.proxy.library.vcu.edu/content/305/24/2540.long
  2. Care processes associated with quicker door-in-door-out times for patients with ST-elevation-myocardial infarction requiring transfer: results from a statewide regionalization program. Glickman SW, Lytle BL, Ou FS, Mears G, O'Brien S, Cairns CB, Garvey JL, Bohle DJ, Peterson ED, Jollis JG, Granger CB. Circ Cardiovasc Qual Outcomes. 2011 Jul 1;4(4):382-8.
    http://circoutcomes.ahajournals.org/content/4/4/382.long