Elsevier

American Heart Journal

Volume 151, Issue 6, June 2006, Pages 1281-1287
American Heart Journal

Door-to-drug and door-to-balloon times: Where can we improve? Time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI)

https://doi.org/10.1016/j.ahj.2005.07.015Get rights and content

Background

To better understand hospital performance in door-to-drug and door-to-balloon times for patients with STEMI, we examined hospital-level variation in key subintervals of door-to-drug time (door-to-electrocardiogram [ECG] and ECG-to-drug) and of door-to-balloon time (door-to-ECG, ECG-to-lab, lab-to-balloon). We sought to identify achievable subinterval times based on the experience of top performing hospitals.

Methods

We conducted a cross-sectional analysis, using data from the National Registry of Myocardial Infarction, of admissions between January 1, 2001, and December 31, 2002 (20 435 patients receiving fibrinolytic therapy in 693 hospitals, and 13 387 patients receiving percutaneous coronary intervention in 340 hospitals). Using hierarchical regression modeling, we estimated hospital-level geometric means of each subinterval, adjusted for patient clinical characteristics. We ranked hospitals based on the proportion of patients treated within 30 minutes for door-to-drug time and 90 minutes for door-to-balloon times and compared adjusted subinterval times across these groups.

Results

The higher performing hospitals (top 20%) in door-to-drug time and door-to-balloon times had significantly shorter times in nearly all subintervals compared with other hospitals, adjusted for patient clinical characteristics. Adjusted mean subinterval times in higher performing hospitals in door-to-drug time were 6.8 minutes (SD = 1.7) for door-to-ECG and 18.7 minutes (SD = 3.5) for ECG-to-drug. Adjusted mean subinterval times in higher performing hospitals in door-to-balloon time were 7.9 minutes (SD = 1.7) for door-to-ECG, 47.8 minutes (SD = 7.1) for ECG-to-lab, and 29.0 minutes (5.4) for lab-to-balloon, adjusted for patient clinical characteristics.

Conclusions

Substantial national attention is being directed at improving time to treatment of patients with STEMI. These data suggest achievable subinterval times for hospitals seeking to improve performance in this important quality indicator.

Section snippets

Study design and sample

We conducted a cross-sectional analysis of data from patients enrolled in the National Registry of Myocardial Infarction (NRMI),5 a voluntary observational database sponsored by Genentech, Inc (South San Francisco, CA). National Registry of Myocardial Infarction provides an ideal opportunity to examine hospital performance with detailed information concerning subintervals for door-to-drug and door-to-balloon times in a national sample of patients with STEMI. To establish the study sample, we

Sample characteristics

Patient characteristics for both the fibrinolytic therapy cohort and the PCI cohort are shown in Table I. At the higher performing hospitals (top 20%), the unadjusted mean door-to-drug time was 26.3 minutes (SD = 4.0) (Table II), and the proportion of patients receiving fibrinolytic therapy within 30 minutes of hospital arrival was 63.9% or more. At the lower performing hospitals (bottom 20%), the unadjusted mean overall door-to-drug time was 48.7 minutes (SD = 8.0) (Table II), and the

Discussion

Our findings reveal that hospitals vary substantially not only in their overall door-to-drug and door-to-balloon times, but also in the subintervals that comprise these overall times. The hospitals that are most successful in achieving guideline-recommended door-to-drug and door-to-balloon times significantly outperform other hospitals in the key subinterval times as well, suggesting that these higher performing hospitals have improved each of the component processes including times from

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This research was supported by the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, Md, grant R01HL072575. Dr Bradley is supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation (02-102) in Hartford, Conn, and the Claude D. Pepper Older Americans Independence Center at Yale (P30AG21342).

Genentech supports the NRMI database, provided access to the database, and approved the study; however, Genentech did not provide any direct support for the study. Except for Dr Blaney, who is a Genentech employee, none of the authors is financially associated with Genentech or any other organization in a way that could be construed as a conflict of interest in connection with the submitted article.

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