Variability of Door-to-Device Times at a Rural Tertiary Care Center

The current best reperfusion strategy for patients presenting with an ST-elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (PCI).1 The American College of Cardiology (ACC) and American Heart Association (AHA) set a goal to attain a door-to-device (DTD) time below 90 minutes for patients with STEMI. This included patients who initially presented to facilities not equipped to perform PCI and were then transferred to hospitals that had this capability. Hospitals nationwide have managed to dramatically shorten their DTD times since the target of 90 minutes was introduced in 1999. Unfortunately, delays in inter-hospital transfer have been responsible for failing to reach this target for the majority of the transfer patient subset.1 Target DTD time is identical for both urban and rural hospitals. A hospital is considered rural if it is located in an area of low population density, compared to an urban or suburban hospital. To be considered a rural tertiary care center, the hospital must meet additional criteria outlined by the Centers for Medicare & Medicaid Services. The first criterion is that the hospital must have at least 275 beds. If this does not apply, criteria for the Medicare patient population served at the hospital may be applied and includes stipulations that at least 50% of patients must be referred from other hospitals, 60% of patients must live at least 25 miles away, and 60% of all Medicare services must be provided to patients living at least 25 miles away.2 Longer DTD times for transferred patients were reported for rural teaching hospitals compared to urban centers.3 This disparity is partially attributable to greater geographic separation of facilities leading to relatively long transportation times. In the rural setting, other factors posited for contributing to transfer delays include inadequate staffing of emergency medical services personnel, lack of 24/7 in-house cardiac catheterization laboratory team, effects of weather on transportation, and lack of experience managing STEMI at community hospitals due to relatively infrequent occurrence.4 Nevertheless, feasibility of achieving DTD times of <90 minutes in rural settings has been demonstrated, both with and without a protocol for rapid triage and transfer.5,6 The time of day a patient presents with STEMI is an important prognostic factor. In a recent study looking at the time of presentation for STEMI patients, prolonged DTD times were documented at higher frequency during after-hours compared to regular business hours. This meta-analysis reported a small increase in short-term mortality compared to regular business hours.7 The aim of the current study was to determine whether any differences exist in DTD times at our rural tertiary care center between regular business hours and after-hours, including weekends and holidays. We also examined seasonal variability for DTD times and impact on transportation time to the hospital, which have not been studied previously.