Median time for patients transferred from an emergency department to another hospital for percutaneous coronary intervention (PCI) was double the recommended 30 minutes, according to a study published Nov. 28 in the Annals of Internal Medicine. The researchers noted a great deal of variability between hospital characteristics, patient demographics and geographic locations.

Previous studies have shown that reducing in-hospital delays in the door-to-balloon (D2B) time for patients who present with ST-segment elevation acute myocardial infarction (STEMI) or left bundle branch block myocardial infarction (MI) improves outcomes and mortality. Patients admitted to hospitals that do not provide primary PCI must be transferred, though, making timeliness in that process critical. The American College of Cardiology consequently has recommended that the time between patient presentation and patient discharge (door-in-door-out, or DIDO) should not exceed 30 minutes.

But the frequency of meeting that goal is unknown, Jeph Herrin, PhD, of the Yale School of Medicine in New Haven, Conn., and colleagues wrote. In order to assess the national DIDO performance of hospitals that transfer patients for PCI care, they used a time-to-transfer performance measure developed by the Centers for Medicare & Medicaid Services (CMS) that captures DIDO data for all hospitals that participate in the Outpatient Prospective Payment System program. That data included reports on patients 18 years and older who were admitted to the emergency department with a STEMI or left bundle branch block MI diagnosis and then transferred to another hospital for PCI.

The retrospective, observational study included data submitted in 2009 on 13,776 patients at 1,034 hospitals. The researchers assessed patient data for age, sex, race, time and date of arrival at the emergency department, and reasons, if any for administering fibrinolytic therapy. Hospitals also were assessed by number of beds, census region, ownership, location and the number of transfers reported to CMS. The outcome was DIDO.

They found that 9.7 percent of hospitals met the 30-minute threshold for DIDO time and DIDO time exceeded 90 minutes in 31 percent of hospitals. A calculation of interquartile range showed that the mean DIDO time for hospitals with more than five transfers in the period was 68 minutes. Only 1.3 percent of hospitals had a median DIDO time of 30 minutes or less.

“A previous study has shown that times longer than 30 minutes are associated with a much higher risk of in-hospital mortality,” Herrin and colleagues wrote. “Our analysis of CMS data provides strong evidence for the need to improve this aspect of care based on a comprehensive national assessment.”

Their research also revealed that DIDO times were highly variable. The mean estimated DIDO time for women was 8.9 minutes longer than for men; 9.1 minutes longer for blacks than for whites; and 18.3 minutes longer for patients between 18 and 35 years old compared with patients age 46 to 55. Patients reported with contraindications for fibrinolytic therapy had an estimated wait of 6.9 minutes longer than patients without contraindications.

“We showed marked patterns of delays by age, sex and race,” the authors wrote. “Although these findings could result from differences in presentation or other clinical factors, we cannot exclude the possibility that quality of care varies by these patient characteristics.”

Estimated DIDO times were 15.3 minutes longer in rural hospitals compared with urban hospitals and 8.1 minutes longer in government-owned hospitals compared with private, for-profit hospitals. Hospitals in the East and West North Central regions had shorter DIDO times than did those in the New England region, and hospitals that transferred 15 or more patients in the study period had a 14.4-minute shorter DIDO time than did hospitals with five to nine patients. The authors highlighted North Carolina’s Reperfusion of Acute Myocardial Infarction in Carolina Emergency Department initiative as an effective statewide effort for reducing DIDO times.

They acknowledged limitations, including being unable to evaluate factors for DIDO delays and the use of self-reported data.

They argued that their analyses showed that achieving the recommended the 30-minute DIDO time was a rarity, and that DIDO times varied. “DIDO time may be a key component of treatment delays in patients with STEMI who are transferred for PCI; improvement efforts should focus on understanding and reducing this delay,” they concluded.