Hospital Transfers for PCI Rarely Fast Enough

Few heart attack patients get transferred from community hospitals for primary percutaneous coronary
intervention (PCI) within the recommended 30-minute window, according to a national study. And, sex
differences prevail for women who have an average 8.9 minutes longer response time for treatment than
among men

Only 9.7% of ST-segment elevation myocardial infarction (STEMI) patients transferred for PCI
got in and out of the initial hospital within 30 minutes, Harlan . Krumholz, MD, of Yale University,
and colleagues reported in the Nov. 28 issue of the Archives of Internal Medicine.

The door-in to door-out time was at least an hour for most patients and exceeded 90 minutes for
31% in the analysis of hospital performance monitoring data from the Centers for Medicare and
Medicaid Services (CMS).

Prior research has shown a 56% higher risk of dying in the hospital with a door-in to door-out
time of over 30 minutes, Krumholz' group noted.
But a decade of failure to reach the benchmark despite strenuous efforts to speed up transfers
points to "immovable obstacles," Rita F. Redberg, MD, MSc, of the University of California San
Francisco and editor of the journal, argued in an accompanying editorial.
"It is time to reconsider transferring patients with STEMI for primary PCI," she concluded.
"Timely reperfusion by thrombolytics, not late primary PCI via transfer, will save lives."
The most lives would be saved by giving thrombolytic therapy in the ambulance when patients
can't be taken straight to a primary PCI hospital.
"Transfer should not be performed unless the patient is at high risk and there is reason to believe
that with transfer the patient will receive primary PCI within 60 minutes," Redberg added.
CMS started collecting patient-level data on door-in to door-out time for STEMI transfers for
primary PCI in 2009 as part of its hospital performance monitoring.
Krumholz and colleagues retrospectively analyzed the mandatory reporting data on 13,776 such
patients -- not limited to Medicare beneficiaries -- seen in 2009 at 1,034 hospitals reporting on at
least five patients each.
They found a median door-in to door-out time of 68 minutes. Just 1.3% of the hospitals had a
median time of 30 minutes or less.
Door-in to door-out times were over 43 minutes for 75% of patients with no contraindication to
thrombolytic therapy, while 25% of these patients spent more than 110 minutes at the transferring
hospital.
For these patients, outcomes would likely have been better if they had gotten fibrinolytic therapy
and then PCI within three to 24 hours, based on American College of Cardiology/American Heart
Association performance measures for STEMI, the researchers noted.
They pointed to "tremendous variability" in average transfer times not only among hospitals but
also across patient groups and geographic areas.
After adjustment for other factors, aspects associated with delayed transfer for primary PCI were
(all P<0.001):
• African American ancestry, with a mean time of 9.1 minutes longer than among white
patients
• Younger age, with 18- to 35-year olds averaging 18.3 minutes longer to transfer
compared with 46- to 55-year olds
 • Contraindication to fibrinolytic therapy, with an average of 6.9 minutes longer than
without contraindications
• Evaluation at a rural hospital, which delayed transfer 15.3 minutes compared with being
seen at an urban hospital initially
• Evaluation at a hospital in New England versus the East and West North Central regions

"Although these findings could result from differences in presentation or other clinical factors,
we cannot exclude the possibility that quality of care varies by these patient characteristics,"
Krumholz' group noted in the paper.

Their analysis couldn't determine overall door-to-balloon time, as it lacked data on transit time
to the second hospital or on how rapidly patients were treated once they arrived along with no data
on patient outcomes.

But the median time to transfer of over one hour for most patients suggested a clear challenge in
getting patients reperfused within the recommended 90 minutes, which appeared to be more of a
systematic problem than one due to legitimate reasons for delays in certain individual patients, the
group concluded.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

Herrin J, et al "National performance on door-in to door-out time among patients transferred for
primary percutaneous coronary intervention" Arch Intern Med 2011; 171: 1879-1886.

Redberg RF "Reconsidering transfer for percutaneous coronary intervention strategy: time is of

the essence" Arch Intern Med 2011;
http://archinte.ama-assn.org/cgi/content/extract/archinternmed.2011.566v2