Decreasing door-to-balloon times via a streamlined referral protocol for patients requiring transport

Published:January 23, 2013DOI:



      The objective of this study was to evaluate the effectiveness of a streamlined interfacility referral protocol in reducing door-to-balloon (D2B) times for patients experiencing acute ST-segment elevation myocardial infarction (STEMI).

      Basic Procedures

      In a retrospective database review, we compared D2B times for patients requiring interfacility transfer after the implementation of a streamlined referral protocol. All patients undergoing interfacility transport with a referring diagnosis of STEMI were eligible for inclusion. Quality management databases were reviewed by trained abstractors using standardized data entry forms for D2B times from July 2009 through June 2010. Median D2B times with interquartile ranges are reported.

      Main Findings

      A total of 133 patients exhibited complete data and were included in the analysis, 54 of which were transferred via the streamlined referral protocol. Streamlined referral patients exhibited a median D2B time of 101 minutes (interquartile range, 88-128) vs a median D2B time of 122 minutes (interquartile range, 99-157) for the traditional referral group (P = .001). Door-to-balloon times of 90 minutes or less were achieved in 13% of the traditional referral patients and in 30% of the streamlined protocol group (odds ratio, 2.9; 95% confidence interval, 1.2-7).

      Principal Conclusion

      The implementation of a streamlined referral protocol has significantly reduced D2B times for patients diagnosed with STEMI that required interfacility transport for intervention.
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        • Keeley E.C.
        • Boura J.A.
        • Grines C.L.
        Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.
        Lancet. 2003; 361: 13-20
        • Grines C.L.
        • et al.
        A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in Myocardial Infarction study.
        J Am Coll Cardiol. 2002; 39: 1713-1719
        • Rathore S.S.
        • et al.
        Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study.
        BMJ. 2009; 338: b1807
        • Kushner F.G.
        • et al.
        2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2009; 120: 2271-2306
        • Nallamothu B.K.
        • et al.
        Driving times and distances to hospitals with percutaneous coronary intervention in the United States: implications for prehospital triage of patients with ST-elevation myocardial infarction.
        Circulation. 2006; 113: 1189-1195
        • Ahmed B.
        • et al.
        Consistent door-to-balloon times of less than 90 minutes for STEMI patients transferred for primary PCI.
        J Invasive Cardiol. 2009; 21: 429-433
        • Aguirre F.V.
        • et al.
        Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program.
        Circulation. 2008; 117: 1145-1152
        • Ting H.H.
        • et al.
        Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI Protocol.
        Circulation. 2007; 116: 729-736
        • Jollis J.G.
        • et al.
        Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction.
        JAMA. 2007; 298: 2371-2380
        • Henry T.D.
        • et al.
        A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction.
        Circulation. 2007; 116: 721-728
        • Blankenship J.C.
        • et al.
        Rapid triage and transport of patients with ST-elevation myocardial infarction for percutaneous coronary intervention in a rural health system.
        Am J Cardiol. 2007; 100: 944-948
        • McMullan J.
        • et al.
        Reperfusion is delayed beyond guideline recommendations in patients requiring interhospital helicopter transfer for treatment of ST-segment elevation myocardial infarction.
        Ann Emerg Med. 2010; 57: 213-220
        • Bradley E.H.
        • et al.
        Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?.
        J Am Coll Cardiol. 2005; 46: 1236-1241
        • Herrin J.
        • et al.
        National performance on door-in to door-out time among patients transferred for primary percutaneous coronary intervention.
        Arch Intern Med. 2011; 171: 1879-1886
        • McGrath C.P.
        • Rosen G.S.
        • Bechtel G.A.
        Improving bedside to departure care in air transport of ST segment elevation myocardial infarction patients: a 2-year retrospective study of performance.
        Air Med J. 2010; 29: 84-87
        • Antman E.M.
        • et al.
        ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).
        Circulation. 2004; 110: 588-636
        • Pinto D.S.
        • et al.
        Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy.
        Circulation. 2006; 114: 2019-2025