Timely care for off-hours STEMI still lags in hospitals

Initiatives to provide timely treatment for patients with acute MI overall appear to making an impact but hospitals still have room to improve in their care of patients who present off-hours, an analysis published online July 29 in Circulation: Cardiovascular Quality and Outcomes suggests.

Tarun W. Dasari, MD, MPH, of the University of Oklahoma Health Science Center in Oklahoma City, and colleagues looked at data submitted to the Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG) registry on 43,242 patients with STEMI to compare outcomes based on time of presentation. Quality improvement initiatives stress the need to provide swift treatment no matter when the patient presents but in practice the goals may be a challenge to meet.

Dasari et al assessed performance measures for patients treated on-hours (weekday business hours) or off-hours (nights, weekends and holidays). The measures included aspirin use within 24 hours; door-to-electrocardiogram (ECG) time of 10 minutes or less; door-to-balloon time of 90 minutes or less; and door-to-needle time of 30 minutes or less. They also evaluated in-hospital death.  

Of the full cohort, 63 percent of patients presented off-hours. The off-hour patients were younger (59 years old vs. 61 years old for on-hour patients) but there were no other significant differences between the groups.

The majority of patients in both groups received aspirin within 24 hours (99.1 percent on-hours and 98.9 percent off-hours. A larger proportion of off-hours patients received unfractionated heparin use (76.3 percent vs. 72.1 percent).

Median door-to-ECG times totaled six minutes in both groups but a gap emerged with door-to-balloon times. Off-hours patients had a median door-to-balloon time of 72 minutes vs. 56 minutes for on-hours patients. They also were less likely meet the 90-minute window (79.2 percent vs. 87.8 percent). Median door-to-needle times of less than 30 minutes for both groups was 58.7 percent for off-hours and 62.3 percent for on-hours.

Dasari et al reported all-cause mortality for both groups of 4.2 percent yet adjusted all-cause in-hospital mortality was higher during off-hours.

Off-hour results in their analyses show improvements from previous studies, they noted. Also, the 4.2 percent mortality rate in both groups was lower than other reports. Nonetheless, proportion the median door-to-balloon time was 16 minutes longer in the off-hours group, risk-adjusted mortality was 13 percent higher during off-hours and the door-to-needle finding “was still less than optimal both during on-hours and off-hours.”

They speculated that off-hour staffing in the catheterization laboratory may explain the difference for door-to-balloon times while improvement in care may have contributed to lower in-hospital mortality.