title: Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction.
abstract: OBJECTIVE
  Most US hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion, and referring emergency departments (EDs) are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs.
  
  
  METHODS
  We retrospectively analyzed a secondary data set used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), periods that comprised DIDO (door to electrocardiogram [EKG], EKG-to-PCI activation, and PCI activation to exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval).
  
  
  RESULTS
  We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (interquartile range [IQR] 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was composed of door to EKG, 5 minutes (IQR 2,11); EKG-to-PCI activation, 18 minutes (IQR 7,37); and PCI activation to exit, 44 minutes (IQR 34,56). Door-in door-out accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability, 1.37) of these intervals.
  
  
  CONCLUSIONS
  In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision making and transportation coordination after PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.
authors.affiliation: Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232. Electronic address: mward04@gmail.com.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Ward
authors.affiliation: Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232.
authors.forename: Sunil
authors.initials: S
authors.lastname: Kripalani
authors.affiliation: Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232.
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232.
authors.forename: Dandan
authors.initials: D
authors.lastname: Liu
authors.affiliation: Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN.
authors.forename: Theodore
authors.initials: T
authors.lastname: Speroff
authors.affiliation: Departments of Biomedical Informatics and Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN.
authors.forename: Michael
authors.initials: M
authors.lastname: Matheny
authors.affiliation: Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Thomassee
authors.affiliation: Owen Graduate School of Management, Vanderbilt University, Nashville, TN.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Vogus
authors.affiliation: Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: Daniel
authors.initials: D
authors.lastname: Munoz
authors.affiliation: Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: Carol
authors.initials: C
authors.lastname: Scott
authors.affiliation: Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Fredi
authors.affiliation: Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Dittus
mesh_terms: D000368:Aged; D002300:Cardiac Care Facilities; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000628:therapy*; D010360:Patient Transfer / Q000706:statistics & numerical data*; D062645:Percutaneous Coronary Intervention; D012189:Retrospective Studies; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*