577294

research-article2015
CNU0010.1177/1474515115577294CNU577294European Journal of Cardiovascular NursingMartin et al.

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY ®

European Journal of Cardiovascular Nursing

The impact on long term health

1­–8
© The European Society of Cardiology 2015
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DOI: 10.1177/1474515115577294

a period of process change to reduce cnu.sagepub.com

door to balloon time

Lorelle Martin1,2, Maria Murphy1,2, Andrew Scanlon1, David Clark1

and Omar Farouque1

Abstract
Background: Guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend a
‘door to balloon time’ (DTBT) within 90 minutes. It is unclear whether strategies to reduce DTBT translate to improved
longer-term health outcomes for STEMI patients.
Aims: This study sought to determine whether implemented strategies to improve timely management of STEMI reduced
DTBT and impacted upon health outcomes such as length of stay, unplanned readmission and 12-month mortality.
Predictors of timely management for STEMI were also examined.
Methods: A five-year review was undertaken on primary percutaneous coronary intervention for STEMI in one tertiary
hospital. Comparisons were made between process change groups and DTBT. Logistic regression identified predictors
of timely management.
Results: 470 STEMI patients underwent immediate primary percutaneous coronary intervention. Process change
improved the median DTBT (109 min vs. 72 min, p<0.001) with no significant effect on length of stay (p=0.83), unplanned
cardiac readmissions (p=0.68) or 12-month mortality (9.0% vs. 8.6%, p=0.64). Those receiving timely treatment (i.e.
DTBT< 90 min) were younger (p<0.05), male (p<0.03), presented via ambulance (p<0.004), during business hours
(p<0.0001) and had a lower Thrombolysis In Myocardial Infarction score (p<0.006). Timely treatment was associated
with lower 12-month mortality (3.7% vs. 15.7%, p<0.0001) and increased uptake of inpatient cardiac rehabilitation
(p<0.005), with length of stay and unplanned readmission similar between groups (p=NS).
Conclusions: Process changes improved DTBT but had no effect on length of stay, readmission rate or 12-month
mortality. Yet, timely management was critical to 12-month outcomes. Further studies are required to explore the
barriers to timely treatment.

Keywords
Myocardial infarction, time, outcomes

Date received: 17 June 2014; revised: 10 February 2015; accepted: 22 February 2015

Introduction
Prompt reperfusion of the culprit coronary lesion using
primary percutaneous coronary intervention (PPCI) is the
preferred treatment strategy in ST-segment elevation myo-
cardial infarction (STEMI).1-3 The time dependent nature
of restoring epicardial blood flow using PPCI is well rec-
ognised with time to treatment, or door to balloon time
1LaTrobe University School of Nursing, Melbourne, Australia
2Department of Cardiology, Austin Health, Heidelberg, Australia
Corresponding author:
Lorelle Martin, Department of Cardiology, Austin Health, 145 Studley
Rd, Level 5 Cardiology Diagnostics, Heidelberg 3084, Australia.
Email: lorelle.martin@austin.org.au

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2 European Journal of Cardiovascular Nursing
(DTBT), representing a major determinant of mortality
and morbidity.4-7
Both national and international guidelines for the man-
agement of STEMI suggest a DTBT timeframe of ⩽ 90
min from hospital presentation to first device.1-3 More
recently, evidence-based strategies to achieve a DTBT ⩽
90 min have been incorporated into these guidelines.
Strategies include a single call activation within the hospi-
tal setting and pre-hospital activation such as transmission
of ECG by paramedics to alert the cardiac catheterisation
laboratory.8 There are published examples of the effect
implementation of these system-based strategies has on
reducing DTBT and 30-day mortality.9-16 However, there is
limited data on the impact these strategies have on longer-
term health outcomes.
One metropolitan Australian hospital implemented two
process changes over a period of 18 months that synthesised
some of these system-based strategies to improve DTBT.
The first process change introduced a single and simultane-
ous page to the cardiology team to facilitate rapid access to
the cardiac catheterisation laboratory for PPCI; this was
called the ‘Cath Lab Code’. The second process change
integrated the Cath Lab Code with a pre-hospital notifica-
tion system activated by paramedics in the field. Prior to
these process changes, no coordinated approach to facilitate
care for STEMI patients upon arrival to this hospital were in
place. Prospective collection of DTBT on STEMI patients
occurred prior to these process changes and continued
throughout the implementation of process changes.
What is novel and interesting about this study is that the
cohort of consecutive STEMI patients were evaluated in
several ways. The objective of this study was to assess
whether the implementation of process change to improve
timely treatment had any impact on long-term health out-
comes. Additional aims were to reveal barriers to timely
management of STEMI and identify the predictors of a
DTBT ⩽ 90 min.
Methods
Study design and population
This study was conducted with the approval of institu-
tional Human Research and Ethics Committees (HRECs)
and conforms with the principles outlined in the Declaration
of Helsinki.17 An observational-correlational method was
used with a retrospective cohort design. The relationship
between DTBT and both in-hospital and long-term health
outcomes was examined on a population of 470 consecu-
tive STEMI patients that received PPCI using a retrospec-
tive chart review. The timeframe for this review was
between December 2006 and April 2011. The pre process
period was until March 2008. The post process change
occurred after this time. Inclusion criteria for this study
were all STEMIs who presented to the emergency depart-
ment at this centre, proceeded to have a PPCI and recorded
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a discharge diagnosis of STEMI, that is, ICD-10 code I20
and I21. Exclusion criteria were all those who did not pre-
sent to the emergency department with STEMI criteria.
A chart audit tool was devised. Baseline characteristics
such as age, gender and modifiable cardiac risk factors
were recorded. Clinical risk profile was assessed using the
Thrombolysis In Myocardial Infarction (TIMI) risk score.
This composite scoring system uses age, risk factors, onset
of symptoms, location of infarct and Killip class to deter-
mine the clinical risk on admission to hospital.18
Presentation characteristics were of interest to assist in
identifying potential sources of time delay to treatment
revealed in the literature.19-22 Time of day and day of week
were recorded, along with the mode of transport to hospi-
tal, that is, self-presentation or presentation via ambulance
with or without pre-hospital notification. A presentation
within the operating hours of the Cardiac Catheterisation
Laboratory (Monday to Friday 0800–1800 hours) was
defined as ‘in hours’; anything outside this time was con-
sidered ‘out of hours’. The time from onset of symptoms to
hospital door time was also recorded to assess concord-
ance with the national guidelines, with the ideal timeframe
being 60–180 min.1
The DTBT was a primary endpoint for this study. For
the most part DTBT was documented prospectively. At the
start of this study there was no official structure in place to
expedite the management of the STEMI patient. The base-
line DTBT of ‘usual care’ was established, and used to
assess concordance with the national and international
guidelines.1-3 The study continued in context of two pro-
cess changes to improve DTBT in the cardiac catheterisa-
tion laboratory. These patients had their individual DTBT
measured prospectively at the time of treatment.
Immediate health outcomes such as in-hospital mortal-
ity and length of stay in days were also endpoints in this
study, along with completion of inpatient cardiac rehabili-
tation for the indexed admission. These variables were
recorded to provide a comparison between the cohort stud-
ied and the literature, which reports that timely percutane-
ous intervention is associated with reduced length of stays
and in-hospital mortality.16,23
Importantly, long-term health outcomes also formed
part of the primary endpoints of this study, specifically:
30-day mortality, 12-month mortality, unplanned cardiac
admissions up to one-year post index admission. The
Melbourne Interventional Group registry24 provided mor-
tality rates and unplanned cardiac admission rates up to 12
months post indexed admission. The uptake of the adjunc-
tive services such as the outpatient based cardiac rehabili-
tation programme was also documented sourcing the
hospital’s cardiac rehabilitation department database.
Data validity
There were several measures taken to ensure validity of the
data. Accurate DTBT was ensured by regular calibration of
Martin et al. 3
the 12 lead ECG machines in the emergency department
and weekly calibration of the wall clocks in the Cardiac
Catheterisation Laboratory to this website: http://www.
timeanddate.com/worldclock/city. In this study, ‘door time’
remained defined as first medical contact in the emergency
department, and balloon time was defined as the time of
first balloon inflation or aspiration device.25 These time-
frames were prospectively documented and confirmed by
the audit team manager. The collected data was entered
onto a password protected Microsoft Excel spreadsheet.
Data was entered by one and checked by another clinician
to ensure data input accuracy.
Statistical analysis
Statistical analysis was performed using Statistical
Package for Social Sciences (SPSS) version 19 for Mac
(SPPS Inc., IL, USA). Descriptive statistics were calcu-
lated to summarise the characteristics of the cohort.
Categorical variables were expressed as counts and per-
centages. Continuous variables were expressed as mean ±
standard deviation (SD) or median and inter-quartile range
(IQR) as appropriate. Statistical significance was set at α =
0.05. Inferential statistics were used to investigate the rela-
tionship between the discrete variables generated from the
chart audit. In particular, a comparison was undertaken for
patients who presented pre process change and those who
presented post the implementation of the Cath Lab Code.
Additionally, a comparison was made between all those
who recorded a DTBT ⩽ 90 min and all those who
recorded a DTBT > 90 min.
Further analysis was performed using logistic regres-
sion to determine predictors of DTBT ⩽ 90 min. The vari-
ables used were the statistically significant variables from
univariate analysis of the data. Logistic regression is
reported to assist in determining which variables affect the
probability of a particular outcome.26 The goodness of fit
statistic was tested using the Hosmer–Lemeshow test to
ascertain whether the proportions of the variables tested
were of equal magnitude.27,28
A power calculation was used to ensure this study was
sufficiently powered. The improvement in time to treat-
ment or DTBT was considered a primary endpoint. The
recommended sample size to determine efficacy of the
new Cath Lab Code and pre-hospital notification
systems was calculated to be 102 patients using the soft-
ware freely available at http://www.raosoft.com/sample-
size.html. This was based on the data from existing
hospital data which stated the median DTBT prior to any
process change was 109 minutes for 156 consecutive
patients. Additionally, the response distribution figure
was based on the 2006 American Heart Association and
American College of Cardiology (AHA/ACC) recom-
mendations that a DTBT <90 min should be achieved
75% of the time.
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Results
Between December 2006 and April 2011, the total number
of patients admitted via the emergency department with
STEMI to the cardiac catheterisation laboratory for PPCI
and included in this study was 470. There were 362 (77%)
males and the mean age of the total cohort was 64±13 years.
Comparison between the process change groups is sum-
marised in Table 1. There was homogeneity for all baseline
clinical characteristics when comparing groups. Timely
management of STEMI improved by 37 min post imple-
mentation of process change (median (IQR1–3) DTBT
109 (76–136) min vs.72 (48–97) min, p<0.001).
Additionally, the percentage of patients achieving a DTBT
< 90 min improved (37% vs. 69%, p<0.0001). The median
(IQR1–3) length of stay was similar between groups 4
(3–5) vs. 4 (3–5) days, p=0.83. Readmission rates was also
similar between groups (12.8% vs. 11.1%, p=0.68) of
patients having at least one unplanned cardiac readmis-
sion. Interestingly, the unadjusted mortality rate between
groups revealed a numerically higher rate for the post pro-
cess change group for two of the three indexed timeframes,
although this was not statistically significant: in-hospital
(5.1% vs. 7.6%, p=0.31); 30-day mortality (5.1% vs. 8.0%,
p=0.42). In contrast, the non-statistically significant trend
of less mortality for the post process change group was at
12 months (9.0% vs. 8.6%, p=0.64).
The comparison between patients who received timely
care (i.e. DTBT ⩽ 90 min) and those who did not is sum-
marised in Table 2. Patients with DTBT ⩽ 90 min were
younger (63.0 ± 12.6 vs. 65.5± 14.2 years, p=0.05) and were
male (81% vs. 73%, p<0.03). Those who recorded timely
DTBT presented during business hours (55% vs. 32%,
p<0.0001) and via ambulance (84% vs. 73%, p<0.004).
Patients who reported chest pain on arrival were more likely
to have a DTBT ⩽ 90 min (90% vs. 83%, p<0.01). Patients
who had a TIMI risk score < 5 were more likely to receive
timely treatment; 62% vs. 38%, p<0.006. Interestingly, cur-
rent smokers were also more likely to receive timely man-
agement (42% vs. 33%, p=0.05). Patients with a DTBT ⩽ 90
min were more likely to receive inpatient cardiac rehabilita-
tion (88% vs. 78%, p<0.005). There was no statistically sig-
nificant difference in length of stay between groups (4 (3–5)
vs. 4 (3–5) days, p=0.39) or number of unplanned cardiac
admissions to 12 months (11.7% vs. 11.7%, p=0.72). Patients
who had a DTBT ⩽ 90 min recorded an improved survival
advantage over the three indexed timeframes: in-hospital
(3.7% vs. 11.2%, p<0.001); 30-day mortality (3.7% vs.
11.7%, p<0.001); 12-month mortality (3.7% vs. 15.7%,
p<0.0001).
Predictors of a DTBT ⩽90 min were determined using
logistic regression and are summarised in Table 3 and
Appendix 1 in the Supplementary Material. Patients who
presented to hospital post the implementation of process
change were more likely to receive timely management
4 European Journal of Cardiovascular Nursing

Table 1.  Comparison of pre process change and post process change groups.

Demographics and baseline characteristics Pre process change n=156 Post process change p value
n (% within group) unless n=314 n (% within group)
stated otherwise unless stated otherwise
Age (mean ± SD), years 63±13 64±13 0.40
Symptom onset (medianIQR1–3), min 114(75–227) 114(76–286) 0.28
Sex 0.17
Male 115 (74%) 249 (80%)  
Female 41 (26%) 65 (20%)  
Type of presentation to hospital 0.60
Self presentation 34 (22%) 62 (20%)  
Ambulance 122 (78%) 252 (80%)  
Time of day 0.24
In operating hours 77 (49%) 137 (44%)  
Out of operating hours 79 (51%) 177 (56%)  
First cardiac admission 116 (74%) 250 (80%) 0.17
Chest pain on admission 138 (89%) 273 (87%) 0.85
TIMI risk score < 5 112 (72%) 214 (68%) 0.46
Location of infarct 0.67
Anterior 67 (42%) 137(44%)  
Inferior 73 (47%) 154 (49%)  
Other 16 (11%) 23 (7%)  
Family history 55 (35%) 130 (41%) 0.20
Hypertension 80 (51%) 178 (57%) 0.27
Diabetes 37 (24%) 57 (18%) 0.14
Lipids 83 (54%) 143 (46%) 0.10
Smoker 50 (32%) 130 (41%) 0.06
Intra aortic balloon pump pre PCI 13 (8.3%) 19 (6.1%) 0.36
DTBT (medianIQR1–3), min 109(76–136) 72(48–97) 0.001
DTBT < 90 min 57 (37%) 216 (69%) 0.0001
Health outcomes  
Length of stay (medianIQR1–3), days 4(3–5) 4(3–5) 0.83
Inpatient cardiac rehab 140 (90%) 252 (80%) 0.06
Outpatient cardiac rehab 76 (49%) 140 (45%) 0.45
In-hospital mortality 8 (5.1%) 24 (7.6%) 0.31
30-day mortality 8 (5.1%) 25 (8.0%) 0.42
12-month mortality 14 (9.0%) 27 (8.6%) 0.64
Unplanned cardiac re-admission to 12 months 20 (12.8%) 35 (11.1%) 0.68

DTBT: door to balloon time; IQR: inter-quartile range; PCI: percutaneous coronary intervention; TIMI: Thrombolysis In Myocardial Infarction

(odds ratio (OR) 5.61, confidence interval (CI) 3.53–8.92,
p<0.0001). Presenting during business hours (OR 3.90, CI
2.49–6.10, p<0.0001) and via ambulance (OR 2.61, CI 1.57–
4.33, p<0.0001) was also a predictor of timely care.
Presenting with chest pain was a strong predictor of DTBT
⩽ 90 min (OR 2.02, CI 1.31–3.13, p<0.002), along with a
TIMI risk score < 5 (OR 2.36, CI 1.49–3.74, p<0.0001).
Discussion
This study examined the health outcomes to 12 months for
patients presenting to hospital with STEMI and receiving
PPCI, whilst hospital processes changed to improve
DTBT. Findings from this study demonstrated a statisti-
cally significant and 37 min decrease in time when process
changes were implemented. The achievement of timely
treatment, that is, DTBT < 90 min, also improved by 32%
once strategies were put in place. Our findings reaffirm the
conclusions of previous studies evaluating the effect pro-
cess change has on DTBT and that a coordinated approach
before and upon arrival at hospital improves systems of
care for the STEMI patient.9-16
One of the primary endpoints of this study was mortal-
ity, in particular long-term (12-month) mortality. The
implementation of strategies to reduce DTBT had no effect
on 12-month unadjusted mortality for this cohort. Indeed
mortality rates were higher in the post process change
group until 12 months, when it was numerically lower with
no statistically significant difference identified (9.0% vs.
8.6%, p=0.64). This finding concurred with the results of a

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Martin et al. 5

Table 2.  Comparison of DTBT ⩽ and > 90 min groups.

Demographics and baseline characteristics DTBT ⩽ 90 min n=273 DTBT > 90 min n=197 n p value
n (% within group) unless (% within group) unless
stated otherwise stated otherwise
Age (mean ± SD), years 63.0 ± 12.6 65.5 ± 14.2 0.05
Symptom onset (medianIQR1–3), min 106(71–204) 149(85–309) 0.05
Sex 0.03
Male 221 (81%) 143 (73%)  
Female 52 (19%) 54 (27%)  
Type of presentation to hospital 0.004
Self presentation 43 (16%) 53 (27%)  
Ambulance 230 (84%) 144 (73%)  
Time of day 0.0001
In operating hours 151 (55%) 63 (32%)  
Out of operating hours 122 (45%) 134 (68%)  
First cardiac admission 220 (81%) 146 (74%) 0.09
Chest pain on admission 247 (90%) 167 (83%) 0.01
TIMI risk score < 5 203 (62%) 123 (38%) 0.006
Location of infarct 0.14
Anterior 108 (40%) 96 (49%)  
Inferior 145 (53%) 82 (42%)  
Other 20 (7%) 19 (9%)  
Family history 114 (42%) 71 (36%) 0.22
Hypertension 141 (52%) 117 (60%) 0.11
Diabetes 50 (18%) 44 (23%) 0.29
Lipids 138 (51%) 88 (45%) 0.26
Smoker 115 (42%) 65 (33%) 0.05
Intra aortic balloon pump 14 (5%) 18 (9%) 0.09
pre PCI
Health outcomes  
Length of stay (medianIQR1–3), days 4(3–5) 4(3–5) 0.39
Inpatient cardiac rehab 239 (88%) 153 (78%) 0.005
Outpatient cardiac rehab 134 (49%) 82 (42%) 0.546
In-hospital mortality 10 (3.7%) 22 (11.2%) 0.001
30-day mortality 10 (3.7%) 23 (11.7%) 0.001
12-month mortality 10 (3.7%) 31 (15.7%) 0.0001
Unplanned cardiac readmission (to 12 months) 32 (11.7%) 23 (11.7%) 0.72

DTBT: door to balloon time; IQR: inter-quartile range; PCI: percutaneous coronary intervention; TIMI: Thrombolysis In Myocardial Infarction

Table 3.  Logistic regression.

Predictors of a DTBT < 90 min p value OR CI

Post process change to STEMI 0.0001 5.61 3.53–8.92
In hours presentation 0.0001 3.90 2.49–6.10
Ambulance presentation to emergency department 0.0001 2.61 1.57–4.33
TIMI risk score <5 0.0001 2.36 1.49–3.74
Chest pain on admission 0.002 2.02 1.31–3.13

N=470; χ2 = 114.86; df = 5; p<0.001 with 72% of cases correctly classified by model Hosmer–Lemeshow test p =0.29; demonstrating goodness of fit.
CI: confidence interval; DTBT: door to balloon time; OR: odds ratio; STEMI: ST-segment elevation myocardial infarction; TIMI: Thrombolysis In
Myocardial Infarction

related study by Drew et al.29 The Drew study analysed the significant difference in mortality between the control
utilisation of a pre-hospital ECG programme using a ran- group and the experimental group for STEMI patients,
domised control design, and found no statistically p=0.08, or over their entire acute coronary syndrome

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6 European Journal of Cardiovascular Nursing
sample of patients. More recently, Menees et al. reported
similar findings for 30-day mortality rates on their registry
data for 96,738 STEMI patients undergoing PPCI for
STEMI. The Menees study concluded that in-hospital and
30-day mortality remained virtually unchanged despite
improvements in DTBT over a four-year period with 515
participating hospitals.30
There are several possible explanations for the lack of
improvement in mortality post process change in our study,
some of which have been raised in a recent perspective
article by Bates and Jacob.31 In our study, the reduced time
in minutes was too small to reduce infarct size given the
total ischaemic time. Whilst total ischaemic time was not
specifically analysed in this study, importantly, onset of
symptoms was. The limitation with this metric is that onset
of symptoms was retrieved retrospectively from the patient
chart and was documented in 96% (n=454) of cases, mak-
ing precise evaluation of total ischaemic time reliant on
patient recall and clinician documentation. Pre-hospital
delay that is primarily patient related is a significant bar-
rier to timely treatment and an area that requires further
exploration and operational definitions.32,33 This leads to
the second explanation, that initiation of treatment may
have been too late for some patients and hence skewed the
mortality benefit. Third, it is also feasible that the wide-
spread implementation over the past decade of evidence-
based therapies for the management of STEMI has reduced
mortality as much as possible. Finally, this was an obser-
vational study that examined association between groups,
not causality, reducing the ability to interpret the data.
This study also examined the difference between groups
for those who achieved timely treatment and those who did
not, as measured by DTBT. There were several factors
found to influence timely reperfusion of the culprit coro-
nary artery. Age was shown to be a barrier to timely treat-
ment in this cohort. The mean age was found to be
significantly higher for those who did not achieve timely
treatment; 63 ± 12.6 vs. 66 ± 14.2 years, p<0.03. This dif-
ference could be attributed to many factors, such as num-
ber of co-morbidities and functional limitations associated
with advancing age, which in turn could delay the decision
of appropriate care.
Gender was also identified as a barrier to timely inter-
vention. There were a higher percentage of women who
had a DTBT > 90 min, p <0.03. One possible explanation
for this difference could be attributed to age. Interestingly,
for this cohort females on average were 10 years older than
males; 72 ± 12 compared with 62 ± 13 years respectively.
Increased age for women presenting with STEMI is
reported in the literature, along with co-morbid conditions
and atypical presenting symptoms.34,35
An unexpected finding was that being a current smoker
was associated with a lower DTBT, p=0.05. The literature
is sparse but cigarette smokers are reported as more likely
to present with STEMI than NSTEMI.36 This may be partly
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explained by the fact that smokers have a higher propensity
for coronary thrombosis,37 which may lead to a presenta-
tion that is typical, contributing to rapid recognition of
symptoms and hence timely treatment. Further investiga-
tion would be required to explore this notion.
Predictors of timely management of STEMI in this
study were five-fold; presenting during business hours, pre-
senting via ambulance, presenting with chest pain, record-
ing a TIMI risk score <5, and presenting to hospital after
the implementation of process change. This logistic regres-
sion model correctly classified cases 72% of the time with
the Hosmer–Lemeshow test demonstrating goodness of fit,
p=0.29.
Presentation during the operating hours of the cardiac
catheterisation laboratory was found to be a predictor of
DTBT ⩽ 90 min (OR 3.9, CI 2.496.1, p<0.0001). Time of
presentation has been thoroughly explored in the literature
and our findings were comparable to the effect this varia-
ble has on timely intervention.20-22
Presentation to hospital via ambulance was also a pre-
dictor of expedited timely treatment (OR 2.6, CI 1.57–
4.33, p<0.0001). This variable was dichotomised between
self-presentation and any ambulance arrival, including
arriving with pre-hospital notification. This finding con-
curred with the literature, which demonstrates a strong
association between pre-hospital notification, in particular,
and timely treatment.15
Presenting with chest pain was also a predictor of a
DTBT⩽ 90 min (OR 2.02, CI 1.31–3.13, p<0.002). The
literature acknowledges that presenting symptoms in
STEMI are often erratic, unpredictable and follow a pattern
that differs in severity and quality from patient to patient.38
Therefore it follows that ischemic chest pain that is typical
in nature is more recognisable, which once confirmed with
a 12-lead ECG leads to prompt treatment within the recom-
mended 90 minutes.
A calculated TIMI risk score < 5 was a predictor of
DTBT ⩽ 90 minutes (OR 2.36,CI 1.49-3.74, p<0.001). In
general, a TIMI risk score < 5 reflects a level of haemody-
namic stability that would allow safe and prompt transport
from emergency department to the cardiac catheterisation
laboratory and hence access to timely treatment.
Finally, presenting post process change to this single
site tertiary level hospital was a predictor of timely man-
agement for STEMI. As aforementioned, the process
changes implemented had a statistically significant effect
on DTBT, and when included in the logistic regression
model were considered a predictor of timely treatment
(OR 5.61, CI 3.53–8.92, p<0.0001); a finding strongly
supported in the literature.9-16
Limitations
The limitations of this research include the absence of ran-
domisation and the difficulty in blinding data where
Martin et al. 7
exposure may be linked to hidden confounders, decreasing
the ability to generalise. The lack of an all-purpose mecha-
nism for controlling confounding variables is recognised
as a limitation to the research method.39 Furthermore,
whilst DTBT was measured prospectively, demographic
and procedural characteristics were retrospectively col-
lected with a chart review. When data is extracted retro-
spectively it is a conservative estimate of what is done and
which has also been documented.
Summary
This original investigation has reported on a cohort of
consecutive STEMI patients and analysed the health out-
comes in several ways. The comparison between time to
treatment, as measured by DTBT, revealed a statistically
significant difference in unadjusted mortality rates to 12
months for those who had a DTBT ⩽ 90 min, but not for
the same cohort of patients post implementation of strate-
gies to improve processes of care. Given the fact that
timely treatment improved with the implementation of
process change it was disappointing that this did not
translate to improved mortality. Further study is required
to analyse these results and determine the characteristics
of the patient groups failing to achieve DTBT ⩽ 90 min.
Targeted management could then be applied to negate the
contributing factors to prolonged management in STEMI.
Implications for practice
•• Timely management improves 12-month
mortality.
•• Process changes do not affect 12-month mortality.
•• Ambulance presentation in office hours with
chest pain and Thrombolysis In Myocardial
Infarction risk score < 5 are predictors of timely
management.
Acknowledgements
The authors would like to thank the nursing staff of the Austin
Health Cardiac Catheterisation Laboratory for their assistance in
data collection. In particular, Ms Rosie-Gehrig Mills, Ms Lee
Moore, Mr John Basile and Mr Peter Gleeson. Gratitude is also
extended to Ms Kerrie Charter who assisted with access to the
MIG registry data. Institutional research ethics was obtained
prior to the commencement of this observational study. The
Ethics Committee reference number was H2011/04271
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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