title: Variability of door-to-device times at a rural tertiary care center.
abstract: OBJECTIVE
  Target door-to-device (DTD) time for ST-elevation myocardial infarction (STEMI) patients has been 90 minutes, with no distinction between urban and rural hospitals. Rural hospitals have longer DTD times for transferred patients attributed to long transportation times from referring hospitals. Longer DTD times have also been reported during after-hours. The aim of the study was to determine whether DTD times at our rural facility were impacted by arrival method, arrival time period, and season.
  
  
  METHODS
  Retrospective chart review.
  
  
  METHODS
  Rural tertiary care center in central Wisconsin.
  
  
  METHODS
  We studied 412 patients presenting with STEMI after initiation of the Rescue One program for rapid triage and transfer from October 2006 through December 2012. They were subdivided by arrival method, arrival time (ON=Monday-Friday, 8 AM-5 PM; OFF=after-hours, weekends, holidays), and season. Median DTD times and proportions below and above 90 minutes were compared.
  
  
  RESULTS
  Median DTD time for all groups, which include both directly admitted and transferred patients, was 85 minutes with 60% of patients achieving DTD times below 90 minutes while 30-day mortality was 5.3%. Median DTD time was 67 minutes for the Emergency Department (ED) (n=164), 95 minutes for Transfers (n=204), 68 minutes for Urgent Care (n=22) and 86 minutes for Field (n=22). ED had the highest proportion of patients achieving goal DTD time (81%) compared to Transfers (42%). Patients arriving by ED during OFF hours had a median DTD time 28 minutes longer than during ON hours with 21% fewer patients achieving goal DTD time, attributed to the time required to call in the catheterization team. Seasonal variability was observed due to differences in pre-hospital ambulance transportation times in the Field group.
  
  
  CONCLUSIONS
  Our data confirm that in a rural facility such as ours, ED patients arriving during after-hours and transferred patients have longer DTD times. Methods are being implemented to shorten the time to assemble the catheterization lab team during after-hours. Better performance will be seen once the first medical contact to device (FTD) time goal of 120 minutes for transferred patients is adopted at our institution. Fibrinolytic therapy should be considered at referring institutions where the FTD time is expected to exceed 120 minutes.
authors.affiliation: Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin, USA.
authors.forename: Victor A
authors.initials: VA
authors.lastname: Abrich
authors.affiliation: Department of Cardiology, Marshfield Clinic, Marshfield, Wisconsin, USA rokey.roxann@marshfieldclinic.org.
authors.forename: Roxann
authors.initials: R
authors.lastname: Rokey
authors.affiliation: Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin, USA.
authors.forename: Satya S V
authors.initials: SS
authors.lastname: Bhupathi
authors.affiliation: Department of Cardiology, Marshfield Clinic, Marshfield, Wisconsin, USA.
authors.forename: Juan E
authors.initials: JE
authors.lastname: Mesa
mesh_terms: D039602:After-Hours Care / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital; D006780:Hospitals, Rural / Q000706:statistics & numerical data*; D006801:Humans; D009203:Myocardial Infarction / Q000601:surgery*; D010360:Patient Transfer / Q000706:statistics & numerical data; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D014922:Wisconsin
keywords: Door-to-device time; ST-elevation myocardial infarction; Seasonal variability/variation; Time period/arrival time