Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective: To determine th...Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective: To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. Design, Setting, and Participants: Cohort study of 68 439 patients with ST-segment elevation myocardial infarction(STEMI) treated with fibrinolytic therapy and 33 647 treated with percutaneous coronary intervention(PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours(weekdays, 7 AM-5 PM) and off-hours(weekdays 5 PM-7 AM and weekends). Main Outcome Measures: Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics. Results: Most fibrinolytic therapy(67.9%) and PCI patients(54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours(34.3 minutes) than regular hours(33.2 minutes; difference, 1.0 minute; 95%confidence interval[CI], 0.7-1.4; P< .001). In contrast, door-to-balloon times were substantially longer during off-hours(116.1 minutes) than regular hours(94.8 minutes; difference, 21.3 minutes; 95%CI, 20.5-22.2; P< .001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours(25.7%) than regular hours(47%; P< .001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours(41.5%) than regular hours(27.7%; P< .001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory(off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P< .001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours(odds ratio, 1.07; 95%CI, 1.01-1.14; P=.02). Conclusions: Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.展开更多
文摘Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective: To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. Design, Setting, and Participants: Cohort study of 68 439 patients with ST-segment elevation myocardial infarction(STEMI) treated with fibrinolytic therapy and 33 647 treated with percutaneous coronary intervention(PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours(weekdays, 7 AM-5 PM) and off-hours(weekdays 5 PM-7 AM and weekends). Main Outcome Measures: Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics. Results: Most fibrinolytic therapy(67.9%) and PCI patients(54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours(34.3 minutes) than regular hours(33.2 minutes; difference, 1.0 minute; 95%confidence interval[CI], 0.7-1.4; P< .001). In contrast, door-to-balloon times were substantially longer during off-hours(116.1 minutes) than regular hours(94.8 minutes; difference, 21.3 minutes; 95%CI, 20.5-22.2; P< .001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours(25.7%) than regular hours(47%; P< .001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours(41.5%) than regular hours(27.7%; P< .001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory(off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P< .001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours(odds ratio, 1.07; 95%CI, 1.01-1.14; P=.02). Conclusions: Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.
