Transfer in D2B. Scott D Friedman, MD FACC Medical Director, Cardiology Services Shore Health System of Maryland. The Problem

Transcription

1 Transfer in D2B Scott D Friedman, MD FACC Medical Director, Cardiology Services Shore Health System of Maryland The Problem NRMI-5: North Carolina, July June 2004 NC Nation Guidelines N 2,738 79,927 % eligible treated 81% 80% Door-balloon 101 min 100 min <90 min 11PM to 7AM Weekend Transfer 107 min 105 min 1 st door balloon 191 min 165 min <90 min 1 st d-b <90 min 0.8% 5.5% 100% 1

2 Transfer Times and Delay: STEMI Patients Transferred to Another Hospital and Received Primary PCI NRMI 2 NRMI 3 NRMI 4 NRMI Door to Balloon Hours (Median) Door to Door Year of Discharge Transfer for Consideration of Primary PCI 192/519 (37%) transferred for consideration for PPCI Time from non-pci ED arrival to non-pci ED departure median 89 minutes State NRMI First door to balloon inflation in transfer-in Patients n=376 median 156 minutes(2:05,3:40) Only 2.9% of NC transfer-in patients make balloon up in < 90 minutes! 2

3 Reperfusion in AMI in Carolina Emergency Departments A Systems Approach To Improve Survival of Patients with Myocardial Infarction In North Carolina Through Improved Application of Reperfusion Therapy Door-to-Balloon & 30-d Mortality 6% P= day Mortality 4% 2% % < >120 Door-Balloon Times (minutes) Hudson ACC

4 STEMI Primary PCI Results DTB Benchmarks for Transfer-In Patients 1 st Door to Balloon < 90 Minutes 1 st Door to Balloon < 120 Minutes ACTION Registry-GWTG DATA: January 01, December 31, 2011 STEMI Door to Balloon and Door to Needle Times Cumulative 12 Month Data DTB = 1 st Door to Balloon for Primary PCI DTN = Door to Needle for Lytics ACTION Registry-GWTG DATA: January 01, December 31,

5 STEMI Door-to-Balloon Times Median Times for Transfer In and Non-Transfer In Patients Time (min) Transfer in DTB Times Non-Transfer in DTB Times ACTION Registry-GWTG DATA: January 01, December 31,

6 Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary InterventionFREE Tracy Y. Wang, MD, MHS, MSc; BrahmajeeK. Nallamothu, MD, MPH; Harlan M. Krumholz, MD, ObjectiveTo characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less. Design, Setting, and PatientsRetrospective cohort of patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry Get With the Guidelines between January 2007 and March ResultsMedian DIDO time was 68 minutes (interquartile range, minutes), and only 1627 patients (11%) had DIDO times of 30 minutes or less. Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and non emergency medical services transport to the first hospital. Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60% [95% confidence interval {CI}, 57%-62%] vs13% [95% CI, 12%-13%]; P<.001). Among patients with DIDO times greater than 30 minutes, only 0.6% (95% CI, 0.5%-0.8%) had an absolute contraindication to fibrinolysis. Observed in-hospital mortality was significantly higher among patients with DIDO times greater than 30 minutes vspatients with DIDO times of 30 minutes or less (5.9% [95% CI, 5.5%-6.3%] vs2.7% [95% CI, 1.9%-3.5%]; P<.001; adjusted odds ratio for in-hospital mortality, 1.56 [95% CI, ]). ConclusionA DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality. From: Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention JAMA. 2011;305(24): doi: /jama Figure Legend: Each bar represents the percentage of patients among the overall transferred patients with ST-elevation myocardial infarction (STEMI) who had a door-in to door-out (DIDO) time within the specified time frame. Date of download: 10/14/2012 Copyright 2012 American Medical Association. All rights reserved. 6

7 From: Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention JAMA. 2011;305(24): doi: /jama Figure Legend: For each door-in to door-out (DIDO) time group, the unadjusted mortality rate is presented, as well as the adjusted odds ratio and 95% confidence interval (CI; error bars) for each group, with DIDO time greater than 90 minutes as the reference group. Date of download: 10/14/2012 Copyright 2012 American Medical Association. All rights reserved. Our results underscore the importance of optimizing regional and statewide networks for STEMI systems of care. DIDO time is a performance measure that informs how efficiently the STEMI referral hospital coordinates care and transfer, and achieving a DIDO time of 30 minutes or less was strongly associated with an overall DTB time of 90 minutes or less. Thus, DIDO can be used to inform the choice of reperfusion therapy. However, the ultimate choice of reperfusion therapy (fibrinolysisvsprimary PCI) at STEMI referral hospitals should be individualized based on several factors, such as the patient's mortality and bleeding risks and duration of symptoms, in addition to the time needed to transfer to a PCI-capable hospital. 27 7

8 Recent Data Q median data MD DIDO 51 MD D2B 111 National 105 Race 103 Original Talbot County plan 8

9 Revised Talbot County plan DRIVETIME DATA TO CIC CENTERS North/South Zone: Primary -Drive Time less than 45 minutes to CIC Western Zone: Primary Fly Checklist Local ED Unstable Local ED Drive to CIC AAMC PRMC Either Facility Approved Drive Time to CIC 9

10 Pre-Intervention Data Hospital Arrival Mode 42% 57% n=515 EMS Self Transport From: 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction J Am Coll Cardiol. 2008;51(2): doi: /j.jacc Date of download: 10/2/2012 Figure Legend: Copyright The American College of Cardiology. All rights reserved. 10

11 STEMI guideline update Transfer AMI Trial August 4, 2009 Authors: Cantor WJ, Fitchett D, Borgundvaag B, et al., on behalf of the TRANSFER- AMI Trial Investigators. Citation: N Engl J Med 2009;360: Print Methods: A total of 1,059 high-risk patients who had a myocardial infarction (MI) with ST-segment elevation and were given fibrinolytictherapy at centers that did not have the capability of performing PCI were enrolled in the TRANSFER-AMI trial. They were randomized to either standard treatment (including rescue PCI for lyticfailure or hemodynamic compromise, or delayed angiography) or a strategy of immediate transfer to another hospital and PCI within 6 hours after fibrinolysis. Randomization was stratified by referring site and age 75 years. All patients received aspirin, tenecteplase, and heparin or enoxaparin; concomitant clopidogrelwas recommended. The primary endpoint was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days. Results: There was no between-group difference for the following: median age of ~56, ~9% were older than 75 years, 20% female, prior MI 10%, anterior MI about 50%, Killipclass of which 90% were class I, or median time from symptoms to lytictherapy. Cardiac catheterization was performed in 88.7% of the patients assigned to standard treatment a median of 32.5 hours after randomization, and in 98.5% of the patients assigned to routine early PCI, a median of 2.8 hours after randomization. At 30 days, the primary endpoint occurred in 11.0% of the patients who were assigned to routine early PCI and in 17.2% of the patients assigned to standard treatment (relative risk with early PCI, 0.64; 95% confidence interval, ; p = 0.004). More than 97% of patients in both groups received stents, three-quarters of which were bare-metal. The only significant treatment difference between groups was the use of clopidogrelbefore admission or within 6 hours and at discharge. There were no significant differences between the groups in the incidence of major bleeding. Conclusions: Among high-risk patients who had an MI with ST-segment elevation and who were treated with fibrinolysis, transfer for PCI within 6 hours after fibrinolysiswas associated with significantly fewer ischemic complications than was standard treatment. 11