A hospital-wide system to ensure rapid treatment time across the entire spectrum of emergency percutaneous intervention.

OBJECTIVES: This study's aim was to describe a hospital-wide system to deliver rapid door-to-balloon time across the entire spectrum of emergency percutaneous intervention. BACKGROUND: Many patients needing emergency PCI are excluded from door-to-balloon public reporting metric; these groups do not achieve door-to-balloon times ≤90 min and have increased mortality rates. METHODS: We prospectively implemented a protocol for patients with STEMI or other emergency indication for catheterization mandating (1) emergency department physician or cardiologist activation of the catheterization lab and (2) immediate patient transfer to an immediately available catheterization lab by an in-house nursing transfer team. RESULTS: From September 1, 2005 to December 31, 2008, 526 consecutive patients underwent emergency PCI. Median door-to-balloon time was 68 min with 85.7% ≤90 min overall. Important subgroups included primary emergency department (62.5 min), cardiorespiratory arrest (71 min), cardiogenic shock (68 min), need for temporary pacemaker or balloon pump (67 min), initial ECG without ST-elevation (66.5 min), transfer from another ED (84 min), in-hospital (70 min), and activation indications other than STEMI (68 min). Patients presenting to primary ED and in transfer were compared to historical controls. Treatment ≤90 min increased (28%-85%, P < 0.0001). Mean infarct size decreased, as did hospital length-of-stay and admission total hospital costs. Acute myocardial infarction all-cause 30-day unadjusted mortality and risk-standardized mortality ratios were substantially lower than national averages. CONCLUSION: A hospital-wide systems approach applied across the entire spectrum of emergency PCI leads to rapid door-to-balloon time, reduced infarct size and hospitals costs, and low myocardial infarction 30-day all-cause mortality. © 2015 Wiley Periodicals, Inc.

Financial impact of reducing door-to-balloon time in ST-elevation myocardial infarction: a single hospital experience.

BACKGROUND: The impact of reducing door-to-balloon time on hospital revenues, costs, and net income is unknown. METHODS: We prospectively determined the impact on hospital finances of (1) emergency department physician activation of the catheterization lab and (2) immediate transfer of the patient to an immediately available catheterization lab by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected financial data for 52 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention from October 1, 2004-August 31, 2005 and compared this group to 80 consecutive ST-elevation myocardial infarction patients from September 1, 2005-June 26, 2006 after protocol implementation. RESULTS: Per hospital admission, insurance payments (hospital revenue) decreased ($35,043 +/- $36,670 vs. $25,329 +/- $16,185, P = 0.039) along with total hospital costs ($28,082 +/- $31,453 vs. $18,195 +/- $9,242, P = 0.009). Hospital net income per admission was unchanged ($6962 vs. $7134, P = 0.95) as the drop in hospital revenue equaled the drop in costs. For every $1000 reduction in total hospital costs, insurance payments (hospital revenue) dropped $1077 for private payers and $1199 for Medicare/Medicaid. A decrease in hospital charges ($70,430 +/- $74,033 vs. $53,514 +/- $23,378, P = 0.059), diagnosis related group relative weight (3.7479 +/- 2.6731 vs. 2.9729 +/- 0.8545, P = 0.017) and outlier payments with hospital revenue>$100,000 (7.7% vs. 0%, P = 0.022) all contributed to decreasing ST-elevation myocardial infarction hospitalization revenue. One-year post-discharge financial follow-up revealed similar results: Insurance payments: $49,959 +/- $53,741 vs. $35,937 +/- $23,125, P = 0.044; Total hospital costs: $39,974 +/- $37,434 vs. $26,778 +/- $15,561, P = 0.007; Net Income: $9984 vs. $9159, P = 0.855. CONCLUSION: All of the financial benefits of reducing door-to-balloon time in ST-elevation myocardial infarction go to payers both during initial hospitalization and after one-year follow-up. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT00800163.

Emergency department physician activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction.

BACKGROUND: Consensus guidelines and hospital quality-of-care programs recommend that ST-elevation myocardial infarction patients achieve a door-to-balloon time of < or = 90 minutes. However, there are limited prospective data on specific measures to significantly reduce door-to-balloon time. METHODS AND RESULTS: We prospectively determined the impact on median door-to-balloon time of a protocol mandating (1) emergency department physician activation of the catheterization laboratory and (2) immediate transfer of the patient to an immediately available catheterization laboratory by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected door-to-balloon time for 60 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention within 24 hours of presentation from October 1, 2004, through August 31, 2005, and compared this group with 86 consecutive ST-elevation myocardial infarction patients from September 1, 2005, through June 26, 2006, after protocol implementation. Median door-to-balloon time decreased overall (113.5 versus 75.5 minutes; P<0.0001), during regular hours (83.5 versus 64.5 minutes; P=0.005), during off-hours (123.5 versus 77.5 minutes; P<0.0001), and with transfer from an outside affiliated emergency department (147 versus 85 minutes; P=0.0006). Treatment within 90 minutes increased from 28% to 71% (P<0.0001). Mean infarct size decreased (peak creatinine kinase, 2623+/-3329 versus 1517+/-1556 IU/L; P=0.0089), as did hospital length of stay (5+/-7 versus 3+/-2 days; P=0.0097) and total hospital costs per admission ($26,826+/-29,497 versus $18,280+/-8943; P=0.0125). CONCLUSIONS: Emergency department physician activation of the catheterization laboratory and immediate transfer of the patient to an immediately available catheterization laboratory reduce door-to-balloon time, leading to a reduction in myocardial infarct size, hospital length of stay, and total hospital costs.

Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: the enduring value of Killip classification.

CONTEXT: In acute myocardial infarction, the presence and severity of heart failure at the time of initial presentation have been formally categorized by the Killip classification. Although well studied in ST-elevation myocardial infarction, the prognostic importance of Killip classification in non-ST-elevation acute coronary syndromes is not well established. OBJECTIVES: To determine the prognostic importance of physical examination for heart failure analyzed according to Killip classification in non-ST-elevation acute coronary syndromes and to understand its predictive value relative to other variables. DESIGN, SETTING, AND PATIENTS: From April 2001 to September 2003, We analyzed information from 26 090 patients with non-ST-elevation acute coronary syndromes enrolled in the GUSTO IIb, PURSUIT, PARAGON A, and PARAGON B trials. Demographic information was categorized by Killip class. Killip classes III and IV were combined into 1 category. Multivariate Cox proportional hazard models were developed to determine the prognostic importance of Killip classification in comparison with other variables. MAIN OUTCOME MEASURE: Association between Killip classification and all-cause mortality at 30 days and 6 months. RESULTS: Patients in Killip class II (n = 2513) and III/IV (n = 390) were older than those in Killip class I (n = 23 187), with higher rates of diabetes, prior myocardial infarction, ST depression, and elevated cardiac enzymes (all P<.001). Higher Killip class was associated with higher mortality at 30 days (2.8% in Killip class I vs 8.8% in class II vs 14.4% in class III/IV; P<.001) and 6 months (5.0% vs 14.7% vs 23.0%, respectively; P<.001). Patients with Killip class II, III, or IV constituted 11% of the overall population but accounted for approximately 30% of the deaths at both time points. In multivariate analysis, Killip class III/IV was the most powerful predictor of mortality at 30 days (hazard ratio [HR], 2.35; 95% confidence interval [CI], 1.69-3.26; P<.001) and 6 months (HR, 2.12; 95% CI, 1.63-2.75; P<.001). Killip class II was predictive of mortality at 30 days (HR, 1.73; 95% CI, 1.44-2.09; P<.001) and 6 months (HR, 1.52; 95% CI, 1.31-1.76; P<.001). Five factors-age, Killip classification, heart rate, systolic blood pressure, and ST depression-provided more than 70% of the prognostic information for 30-day and 6-month mortality. CONCLUSIONS: Killip classification is a powerful independent predictor of all-cause mortality in patients with non-ST-elevation acute coronary syndromes. Age, Killip classification, heart rate, systolic blood pressure, and ST depression should receive particular attention in the initial assessment of these patients.

Prevalence of conventional risk factors in patients with coronary heart disease.

CONTEXT: It is commonly suggested that more than 50% of patients with coronary heart disease (CHD) lack any of the conventional risk factors (cigarette smoking, diabetes, hyperlipidemia, and hypertension). This claim implies that other factors play a significant role in CHD and has led to considerable interest in nontraditional risk factors and genetic causes of CHD. OBJECTIVE: To determine the prevalence of the 4 conventional risk factors among patients with CHD. DESIGN, SETTING, AND PATIENTS: In 2002-2003, we analyzed data for 122458 patients enrolled in 14 international randomized clinical trials of CHD conducted during the prior decade. Patients included 76716 with ST-elevation myocardial infarction, 35527 with unstable angina/non-ST-elevation myocardial infarction, and 10215 undergoing percutaneous coronary intervention. MAIN OUTCOME MEASURES: Prevalence of each conventional risk factor and number of conventional risk factors present among patients with CHD, compared between men and women and by age at trial entry. RESULTS: Among patients with CHD, at least 1 of the 4 conventional risk factors was present in 84.6% of women and 80.6% of men. In younger patients (men < or =55 years and women < or =65 years) and most patients presenting either with unstable angina or for percutaneous coronary intervention, only 10% to 15% of patients lacked any of the 4 conventional risk factors. This pattern was largely independent of sex, geographic region, trial entry criteria, or prior CHD. Premature CHD was related to cigarette smoking in men and cigarette smoking and diabetes in women. Smoking decreased the age at the time of CHD event (at trial entry) by nearly 1 decade in all risk factor combinations. CONCLUSIONS: In direct contrast with conventional thinking, 80% to 90% of patients with CHD have conventional risk factors. Although research on nontraditional risk factors and genetic causes of heart disease is important, clinical medicine, public health policies, and research efforts should place significant emphasis on the 4 conventional risk factors and the lifestyle behaviors causing them to reduce the epidemic of CHD.

Thermal diffusion probe analysis of perfusion changes in vascular occlusions of rabbit pedicle flaps.

BACKGROUND: The purpose of this study was to show the efficacy of a novel tissue blood flow measuring device in an animal model. Thermal diffusion technology evaluates changes in perfusion in small volumes of tissue. METHODS: The thermal diffusion probe device is a long, 0.9-mm-diameter flexible catheter with two thermistors, which are placed directly into the tissue; it excites an active thermistor to a constant temperature slightly above the tissue baseline and collects data on the power dissipated in the active thermistor. It also continuously monitors the baseline tissue temperature using an additional passive thermistor placed outside the heated field. In this study, rabbit epigastric pedicle flaps were instrumented with two thermal diffusion probes (peripheral and deep) to continuously monitor flap perfusion. RESULTS: Twenty-five vascular occlusion studies were performed in 16 flaps. Blood vessel occlusions (arterial, venous, and arteriovenous) were easily detectable with this system. Waveforms for arterial and arteriovenous occlusions differed from those for venous occlusions. Probes in both peripheral and deep tissue locations were sensitive to changes in tissue perfusion. CONCLUSION: Thermal diffusion probes may provide a useful clinical method for monitoring flap perfusion.

Continuous and real-time blood perfusion monitoring in prefabricated flaps.

The Thermal Diffusion Probe (TDP) System allows continuous real-time measurement of tissue perfusion in flaps. The authors used a TDP with two thermistors, one active, the other passive, embedded in a 0.9-mm diameter catheter to measure continuous tissue perfusion in rabbit epigastric flaps. The distal thermistor is heated to 2 degrees C above the tissue baseline temperature. The power required to maintain this temperature difference is mathematically related to the tissue perfusion in the volume surrounding the probe tip. Central and peripheral TDPs were placed. The TDP effectiveness in detecting and measuring daily tissue perfusion in buried epigastric flaps was tested. Contralateral epigastric pedicles were transposed into the flaps prior to ligation of the original pedicle. Flaps with transposed pedicles showed a progressive and significant increase in tissue perfusion during the initial 3 weeks of the experiment, compared to flaps without the pedicle transfer. The TDP System is a useful experimental method for the continuous and real-time quantification of flap perfusion and may be helpful in making clinical decisions about prefabricated flap transfer.