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Transfer times for patients requiring PCI often exceeded recommendations

Issue: January 2012

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Patients with STEMI who require transfer to another hospital for percutaneous coronary intervention are rarely discharged from the first hospital within the recommended 30-minute period, according to study results.

Using CMS reporting data, researchers examined time-to-transfer data on 13,776 patients with STEMI who presented to the EDs of 1,034 hospitals and required transfer for PCI. They defined door-in to door-out time as the period between the patient’s arrival in the ED to discharge for transfer to another hospital for primary PCI.

Results showed that only 9.7% (n=1,343) were discharged within 30 minutes of presentation to the ED. For 31% of patients, door-in to door-out time exceeded 90 minutes. Researchers also found that only 1.3% (n=13) of hospitals included in the study met the recommended door-in to door-out time of 30 minutes or less. In fact, the median door-in to door-out period for all hospitals was 68 minutes, the researchers said.

After adjusting for patient and hospital characteristics, a multivariable analysis showed transfer times were:

• 8.9 minutes longer for women (95% CI, 5.6-12.2).
• 9.1 minutes longer for black patients (95% CI, 2.7-16).
• 6.9 minutes longer for patients with contraindications to fibrinolytic therapy (95% CI, 1.6-11.9).
• 15.3 minutes longer for rural hospitals (95% CI, 7.3-23.5).
• 14.4 minutes longer for hospitals with nine or fewer transfers vs. those with 15 transfers or more in 2009.

When compared with all other age groups, except for patients aged older than 75 years, those aged 18 to 35 years also had longer transfer times.

The fact that primary PCI is not widely available may be contributing to the problem, according to Rita F. Redberg, MD, MSc, of the department of medicine at the University of California, San Francisco.

“Of the nearly 5,000 acute care hospitals in the United States, less than one-fourth have PCI capability and even less can provide 24-hours-a-day, 7-days-per-week PCI,” she wrote in an accompanying editorial. “Although transfer from a non-primary PCI-performing hospital to one that does perform this procedure is possible, it is very difficult to organize and coordinate these transfers in a timely way.”

During their analysis, the researchers also found that many patients benefited from fibrinolytic therapy after transfer vs. primary PCI. Therefore, Redberg said physicians should reconsider treatment strategies.

“For low- and intermediate-risk patients, there is no mortality advantage to primary PCI over thrombolytic therapy,” she wrote. “Even for high-risk patients with STEMI, the mortality benefit of primary PCI is frequently lost due to routine delays of 1 to 3 hours by transfer. It is time to reconsider transferring patients with STEMI for primary PCI. Timely reperfusion by thrombolytics, not late primary PCI via transfer, will save lives.”

For more information:

• Herrin J. Arch Intern Med. 2011;171:1879-1886.
• Redberg R. Arch Intern Med. 2011;doi:10.1001/archinternmed.2011.566.

Disclosure: One researcher reports serving on the advisory board of UnitedHealthcare and receiving a research grant from Medtronic. Dr. Redberg reports no relevant financial disclosures.

This is a broad sample of more than 14,000 patients at nearly 1,000 hospitals showing that less than 10% met that 30-minute recommendation. In another study of the ACTION registry, the same group found similar results - we just don't go very well in non-PCI hospitals at getting these patients out the door in the recommended 30 minutes or less. We need to emphasize protocols and rapid turnaround of these patients. If it is not feasible to do that, then we need to think about the pharmacological treatment of these patients, which Redberg suggested in her accompanying editorial.

– R. David Anderson, MD, MS, FACC, FSCAI
Associate Professor of Medicine
Director of Interventional Cardiology
University of Florida - Shands Healthcare

Disclosure: Dr. Anderson reports no relevant financial disclosures.

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