Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention

Study Questions:

What is the relationship between a door-in to door-out (DIDO) time of 30 minutes or less, time to reperfusion, and patient outcomes?

Methods:

This was a retrospective cohort study of 14,821 patients with ST-segment elevation myocardial infarction (STEMI) transferred to 298 STEMI receiving centers for primary percutaneous coronary intervention (PCI) in the NCDR® ACTION Registry®–GWTG™ between January 2007 and March 2010. The main outcome measures were factors associated with a DIDO time greater than 30 minutes, overall door-to-balloon (DTB) times, and risk-adjusted in-hospital mortality.

Results:

Median DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1,627 patients (11%) had DIDO times of 30 minutes or less. Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and nonemergency medical services transport to the first hospital. Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60%; 95% confidence interval [CI], 57%-62% vs. 13%, 95% CI, 12%-13%; p < 0.001). Among patients with DIDO times greater than 30 minutes, only 0.6% (95% CI, 0.5%-0.8%) had an absolute contraindication to fibrinolysis. Observed in-hospital mortality was significantly higher among patients with DIDO times greater than 30 minutes versus patients with DIDO times of 30 minutes or less (5.9%; 95% CI, 5.5%-6.3% vs. 2.7%; 95% CI, 1.9%-3.5%; p < 0.001; adjusted odds ratio for in-hospital mortality, 1.56; 95% CI, 1.15-2.12).

Conclusions:

The authors concluded that a DIDO time of 30 minutes or less was associated with shorter reperfusion delays and lower in-hospital mortality.

Perspective:

DIDO time is a new performance measure that assesses the timeliness and quality of initial care for patients who require interhospital transfer for primary PCI. The authors found that only 11% of transferred patients with STEMI met the recommended benchmark of a DIDO time of 30 minutes or less. Furthermore, the study shows that patients with a DIDO time of 30 minutes or less are more likely to achieve an overall DTB time of less than 90 minutes, and are associated with lower risk-adjusted mortality compared with patients who had a DIDO time greater than 30 minutes. Overall, the study suggests that attention and improvement of this performance measure will likely translate into improvement in the timeliness of primary PCI and clinical outcomes for transferred STEMI patients.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Outcome Assessment (Health Care), Patient Transfer, Myocardial Infarction, Hospital Mortality, Diabetes Mellitus, Percutaneous Coronary Intervention


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