Patients Requiring Transfer to Another Facility for Percutaneous Coronary Intervention Rarely Meet Recommended Guidelines for Transfer to Treatment Times

Among patients requiring transfer to another hospital for percutaneous coronary intervention (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries), the estimated time from arrival to transfer rarely meets recommended guidelines of 30 minutes or less, according to a report in the November 28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.1

“Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction [STEMI] who must be transferred to another hospital for percutaneous coronary intervention,” the authors write as background information in the article. “Experts have recommended that door-in to door-out (DIDO) time (i.e., time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes.”

Jeph Herrin, Ph.D., of Yale University School of Medicine, New Haven, Conn., and colleagues examined national DIDO times for patients who presented at an emergency department with STEMI and who required transfer to another hospital for PCI. The authors examined data on all patients reported by hospitals with five or more eligible transfer patients between January 1, and December 31, 2009.

Of the 13,776 patients from 1,034 hospitals included in the analysis, 1,343 patients (9.7 percent) had a DIDO time within 30 minutes while DIDO time exceeded 90 minutes for 4,267 patients (31 percent). After adjusting for patient and hospital characteristics, women had a mean (average) estimated time 8.9 minutes longer than men; African Americans had an estimated time 9.1 minutes longer than those patients reported as white; patients age 18 to 35 years had an estimated time significantly longer than that for all patients except those older than 75 years of age, with a time 18.3 minutes longer relative to patients age 46 to 55 years.

“Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes,” the authors conclude. “DIDO time may be a key component of treatment delays in patients with STEMI who are transferred for PCI; improvement efforts should focus on understanding and reducing this delay.”

Additionally, in a research letter published Online First, Eric A. Secemsky, M.D., of the University of California, San Francisco, and colleagues examined whether creation of a 24-hour cardiac catheterization laboratory (CCL) was associated with improved revascularization times among patients with STEMI presenting at a public hospital previously reliant on transferring patients for PCI.

The authors enrolled patients between April 2005 and October 2008 with a clinical diagnosis of STEMI, successful transfer for angiography and available data for all time intervals. The authors found that among transfer patients, median (midpoint) door-to-catheterization (DTC) and door-to-balloon (DTB) times were 184 minutes and 200 minutes, respectively, with no patients revascularized in less than 90 minutes. Among patients treated after creation of the 24-hour PCI facility, median DTC and DTB times decreased to 50 minutes and 84 minutes, respectively, with 65 percent of patients revascularized in less than 90 minutes.

“Creation of a CCL successfully improved median DTB times to less than 90 minutes, and currently, nearly 90 percent of patients with STEMI are revascularized in less than 90 minutes,” the authors conclude.

In an editorial published Online First2, Archives editor Rita F. Redberg, M.D., M.Sc., of the University of California, San Francisco, writes, “primary PCI [pPCI] is resource intensive and therefore not widely available. Of the nearly 5,000 acute care hospitals in the United States, less than one-fourth have PCI capability and even less can provide 24-hours-a-day, 7-days-per-week (24/7) PCI.”

“Despite years of hard work and noble efforts by many individuals and professional organizations... to enable hospitals to either provide pPCI or reduce door-in to door-out (DIDO) time in transferring to a facility that does, results have been disappointing,” writes Dr. Redberg. “After years of well-intentioned arduous efforts to decrease DIDO time, it is time to consider other strategies.”

“The reports by Herrin et al and Wang et al show us that DIDO time remains much slower than benchmarks,” Dr. Redberg concludes. “For low- and intermediate-risk patients, there is no mortality advantage to pPCI over thrombolytic therapy…It is time to reconsider transferring patients with STEMI for pPCI. Timely reperfusion by thrombolytics, not late pPCI via transfer, will save lives.”


1. (Arch Intern Med. 2011;171[21]:1879-1886; doi:10.1001/archinternmed.2011.564.

2. (Arch Intern Med. Published online November 28, 2011. doi:10.1001/archinternmed.2011.566.