Doorto Needie Time minutes

Fig. 4. NRMI-2: Thrombolysis—door-to-needle time vs mortality.

Fig. 5. NRMI-2: Thrombolysis—door-to-needle time vs. mortality.

Door-to-Needle Time (minutes)

Fig. 5. NRMI-2: Thrombolysis—door-to-needle time vs. mortality.

Second NRMI, from 1994 to 1998 in 661 community and tertiary care hospitals in the United States. The median time from the onset of chest pain to hospital arrival was 1.6 h, and the median time from onset of chest pain to primary angioplasty was 3.9 h. Unadjusted mortality was higher in the patients treated later, but the multivari-ate-adjusted odds of in-hospital mortality did not increase over the 24-h period (Figs. 6 and 7). The door-to-balloon time, however, showed that the adjusted odds of mortality were significantly increased by 41-62% for patients with door-to-balloon times longer than 2 h (present in nearly 50% of the cohort) (36) (Figs. 8 and 9).

Thus, both door-to-needle and door-to balloon times appear to be important quality of care indicators, and efforts to improve processes of care to achieve these optimal treatment times should rigorously continue. Furthermore, door-to-balloon times should be considered when choosing between thrombolysis and primary percutaneous coronary intervention (36).

Fig. 6. NRMI-2: Primary PCI—time-to-treatment vs mortality.

Door-to-Balloon Time (minutes)

Fig. 6. NRMI-2: Primary PCI—time-to-treatment vs mortality.

Fig. 7. NRMI-2: Primary PCI—time-to-treatment vs mortality.

Treatment (hours)

Fig. 7. NRMI-2: Primary PCI—time-to-treatment vs mortality.

It is very clear that reductions in delay can only occur if times are recorded consistently on every patient, and door-to-drug time trends are monitored by quarterly analysis of these data. Significant reductions in door-to-drug times may drift back to unacceptable levels should a multidisciplinary quality improvement team not meet on a regular basis to review times to diagnosis and treatment for the purpose of improving the process. Feedback of these times to participating physicians, nurses, and technologists is critical in improving performance and outcomes. In the NRMI, median door-to-drug time has fallen from 60 min in 1990, when the Registry was initiated, to 34 min in 1999 (37) (Fig. 10). The Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) reported that between 1994 and 1995, the median time from emergency department arrival to thrombolytic therapy was 46 min, and by the 1998 to 1999 time period, the median time had decreased to 39 min (38). This is a result of continuing surveillance and feedback of these data to the team involved in caring for these patients.

Fig. 8. NRMI-2: Primary PCI—door-to-balloon time vs mortality.

Fig. 9. NRMI-2: Primary PCI—door-to-balloon time vs mortality.

-Balloon Time (minutes)

Fig. 9. NRMI-2: Primary PCI—door-to-balloon time vs mortality.

Fig. 10. National trends in AMI management: door-to-drug time with thrombolysis.
1994 1995 1996 1997 1998 1999 Fig. 11. National trends in AMI management: door-to-balloon time in PPTCA.

The NRMI reported a reduction in median door-to-balloon time for PTCA from 116 min in 1994 to 108 min in 1999 (37) (Fig. 11). The Health Care Financing Administration reported that between 1994 and 1995, the median time from hospital arrival to primary angioplasty was 120 min, and by 1998 to 1999, the median time had decreased to 108 min (38). If patients arrive at a hospital without angioplasty capability, there can be no justification on the basis of studies of effectiveness in the community for the delay in reperfusion incurred by the transfer of such patients to angioplasty-capable hospitals. These patients, if they cannot be dilated within 90 min or less (±30 min) as recommended by the most recent American College of Cardiology (ACC) American Heart Association (AHA) Guidelines (39), should be treated with thrombolytics at the receiving hospital.

Currently, there are more than 1200 chest pain centers in the United States (40). The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations to assist emergency physicians in emergency departments (including those with chest pain centers) in providing comprehensive management of patients with acute coronary syndromes (20).

They cited three distinct types of programs in chest pain centers:

1. A heart attack program for the rapid treatment of acute MI in patients with ST-segment elevation on the 12-lead ECG.

2. A diagnostic (observational) program to exclude the diagnosis of acute MI or unstable angina in patients with a low-to-moderate probability of having these conditions.

3. An outreach program to educate patients in the chest pain center and in the broader community about early evaluation for chest pain or related symptoms of a heart attack and the importance of risk factor identification and control.

The task force recommended certain points that should be kept in mind when developing chest pain centers or programs to evaluate patients with symptoms of acute coronary syndromes. These recommendations are shown in Table 1. The authors concluded that in the final analysis the criteria for all approaches and strategies must be the optimal care and clinical outcomes of patients. The organization and designation of a separate chest pain center are worthwhile only to the extent the center demonstrably furthers that goal. It is not the name "chest pain center" that counts, but the program of care in place (20).

Table 1

National Heart Attack Alert Program Recommendations for Chest Pain Centers and Programs

• Address the need to identify accurately and efficiently patients with acute cardiac ischemia (ACI) among the large, and likely increasing, numbers of patients presenting to emergency departments with symptoms suggestive of ACI.

• Make clear to the public, patients, and providers that the goal is to provide prompt evaluation and effective care to all patients with symptoms that may represent ACI: chest pain or discomfort, shortness of breath, nausea, dizziness/fainting, or abdominal pain; a focus only on chest pain is potentially misleading, since as many as 25% of patients presenting with ACI will not have chest pain.

• In outreach efforts, emphasize the general principles of patient response to important symptoms and not direct patients to a particular hospital during an acute episode; instead, encourage them to call 9-1-1 to seek rapid treatment.

• Base care, as much as possible, on the use of approaches and technologies for which evidence supports safety and effectiveness, such as those supported in the NHAAP ACI Diagnostic Technologies Working Group report, its update, or by subsequently published prospective evaluations.

• Use operational processes that facilitate care of all presenting patients, incorporating attention to the "4 Ds" (to reduce door-to-drug time with reperfusion therapies) (12) and treatment particularly for those needing reperfusion and anti-ischemic therapy.

• In a continuous quality improvement program, monitor process indicators (measures of appropriateness of emergency department triage, treatment, and outcomes) using forms and systems such as those utilized by continuous improvement cycles.

• Coordinate the care of patients, particularly those discharged without a diagnosis of ACI, to ensure that test results are communicated to the patient's primary care or follow-up physician.

Reprinted from ref. 20.

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