title: Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention.
abstract: BACKGROUND
  Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI. Door-in to door-out (DIDO) time, defined as the duration of time from arrival to discharge at the first or STEMI referral hospital, is a new clinical performance measure, and a DIDO time of 30 minutes or less is recommended to expedite reperfusion care.
  
  
  OBJECTIVE
  To characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less.
  
  
  METHODS
  Retrospective cohort of 14,821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry-Get With the Guidelines between January 2007 and March 2010.
  
  
  METHODS
  Factors associated with a DIDO time greater than 30 minutes, overall DTB times, and risk-adjusted in-hospital mortality.
  
  
  RESULTS
  Median DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1627 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 non-emergency 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 < .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 vs 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 < .001; adjusted odds ratio for in-hospital mortality, 1.56 [95% CI, 1.15-2.12]).
  
  
  CONCLUSIONS
  A DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA. tracy.wang@duke.edu
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
authors.forename: Shuang
authors.initials: S
authors.lastname: Li
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: James G
authors.initials: JG
authors.lastname: Jollis
authors.forename: Alice K
authors.initials: AK
authors.lastname: Jacobs
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Henry H
authors.initials: HH
authors.lastname: Ting
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data*; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000706:statistics & numerical data*; D016017:Odds Ratio; D010343:Patient Admission; D010351:Patient Discharge; D010360:Patient Transfer / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology