title: Transfer of patients with ST-elevation myocardial infarction for primary percutaneous coronary intervention: a province-wide evaluation of "door-in to door-out" delays at the first hospital.
abstract: BACKGROUND
  Interhospital transfer of patients with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PPCI) is associated with longer delays to reperfusion, related in part to turnaround ("door in" to "door out," or DIDO) time at the initial hospital. As part of a systematic, province-wide evaluation of STEMI care, we examined DIDO times and associations with patient, hospital, and process-of-care factors.
  
  
  RESULTS
  We performed medical chart review for STEMI patients transferred for PPCI during a 6-month period (October 1, 2008, through March 31, 2009) and linked these data to ambulance service databases. Two core laboratory cardiologists reviewed presenting ECGs to identify left bundle-branch block and, in the absence of left bundle-branch block, definite STEMI (according to both cardiologists) or an ambiguous reading. Median DIDO time was 51 minutes (25th to 75th percentile: 35-82 minutes); 14.1% of the 988 patients had a timely DIDO interval (≤30 minutes as recommended by guidelines). The data-to-decision delay was the major contributor to DIDO time. Female sex, more comorbidities, longer symptom duration, arrival by means other than ambulance, arrival at a hospital not exclusively transferring for PPCI, arrival at a center with a low STEMI volume, and an ambiguous ECG were independently associated with longer DIDO time. When turnaround was timely, 70% of patients received timely PPCI (door-to-device time ≤90 minutes) versus 14% if turnaround was not timely (P<0.0001).
  
  
  CONCLUSIONS
  Benchmark DIDO times for STEMI patients transferred for PPCI were rarely achieved. Interventions aimed at facilitating the transfer decision, particularly in cases of ECGs that are difficult to interpret, are likely to have the best impact on reducing delay to reperfusion.
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.). laurie.lambert@inesss.qc.ca.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Lambert
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Brown
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Lucy J
authors.initials: LJ
authors.lastname: Boothroyd
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Eli
authors.initials: E
authors.lastname: Segal
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Sébastien
authors.initials: S
authors.lastname: Maire
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Simon
authors.initials: S
authors.lastname: Kouz
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Dave
authors.initials: D
authors.lastname: Ross
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Richard
authors.initials: R
authors.lastname: Harvey
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Stéphane
authors.initials: S
authors.lastname: Rinfret
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Yongling
authors.initials: Y
authors.lastname: Xiao
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: James
authors.initials: J
authors.lastname: Nasmith
authors.affiliation: From the Cardiology Evaluation Unit, Institut national d'excellence en santé et en services sociaux (INESSS), Montreal, Quebec, Canada (L.J.L., K.A.B., L.J.B., Y.X., P.B.); Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada (E.S.); Corporation d'Urgences-santé, Montreal, Quebec, Canada (E.S., D.R.); Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Quebec, Canada (S.M.); Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada (S.K.); Services préhospitaliers d'urgence en Montérégie, Longueuil, Quebec, Canada (D.R.); Département de médecine préhospitalière, Hôpital Sacré-Cœur de Montréal, Montreal, Quebec, Canada (D.R.); Université de Sherbrooke, Sherbrooke, Quebec, Canada (R.H.); Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada (S.R., P.B.); and St. Paul's Hospital, Vancouver, British Columbia, Canada (J.N.).
authors.forename: Peter
authors.initials: P
authors.lastname: Bogaty
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002037:Bundle-Branch Block / Q000503:physiopathology; D004562:Electrocardiography; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D010360:Patient Transfer / Q000706:statistics & numerical data*; D062645:Percutaneous Coronary Intervention; D011792:Quebec; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D055815:Young Adult
keywords: emergency medical services; guideline adherence; myocardial infarction; quality of health care