Meeting Guideline Goals For Stemi PCI Is Related To Transport Time And Speed Of Treating Interventionist C. Randolph Hubbard, James C Blankenship, Marie Sledgen, Kimberly A Skelding, Thomas D Scott, Peter B Berger, Michael A Donegan, G Craig Wood, Frank J Menapace

Background National Registry for Myocardial Infarction --15% of transferred patients had D2B < 120 minutes -- D2B for transferred patients transferred to rural teaching hospital were 73 minutes slower than their urban counterparts

Background January 2005 GMC started Level 1 STEMI -- Database dating to 1/1/04 -- One call to GMC ED doc dispatches helicopter -- GMC ED doc calls cath doc who calls cath lab -- Patient goes from copter to cath lab -- Visits and protocols to referring hospitals

Background Geisinger Medical Center 437-bed tertiary care hospital in rural central PA. Serves 37 counties, 2.4 million people. Lifeflight: 5 helicopters operated by GHS -- Flies for 98% of all requests for transports referring hospitals within 25 minutes flight PCI Program -- 4 interventionists, 1000 PCI/year --GMC provided direct PCI for STEMI since of 4 docs lives within 7 minutes

Blue = 30 miles- 15 min flight time (each way) Red= 60 miles- 23 min flight time (each way)

Background D2B for transferred STEMI patients Henry et al and Ting et al: 95 – 116 minutes (Circulation 2007) Geisinger Medical Center data: 105 – 113 min

Hypotheses It is possible to identify predictors of shorter D2B time Some predictors may be modifiable

METHODS Inclusion: All STEMI pts transferred to GMC in

Database with prospectively recorded milestones -Presentation to the community hospital -EKG time -Helicopter Dispatch -Helicopter arrival and departure -Arrival at GMC, arrival at Cath Lab -Wire crossing, device activation NCDR database for each patient

Statistical Analyses Identified univariate predictors of overall D2B and of time for each interval Multiple regression analysis to identify independent predictors of overall D2B and for each time interval

Results Patients Transferred to GMC 2004 (n = 110) 2005 (n = 134) 2006 (n = 143) 2007 (n = 63) D2B (Minutes)

Results 2005 – 2006: n = 254 STEMI transfers for PCI. Age (yrs, mean +/- SD)60 +/- 13 Male76% Weight (kg, mean +/- SD)87 +/- 21 Smoker42% Diabetes8% Hypertension33% Hypercholesterolemia35% Prior PCI5% Prior CABG2% Prior CHF1%

Correlates of Shorter Overall D2B (all p < 0.05) Referring hospital (independent of flight time) Flight times (distance) Current smoker Diabetic Weekday D2B = 97 minutes; After-hours/weekend D2B = 94 minutes (p = NS).

Results Patients Transferred to GMC HospitalD2BFlight Time D2B – Flight Time A83677 B83677 C85778 D E Others105--

Results Components of D2B (minutes) Presentation to EKG6 EKG – to - dispatch17 Dispatch-to-arrival15 Touchdown to LIftoff18 Liftoff to GMC arrival11 GMC arrival to wire cross27 Total D2B109

Correlate of Presentation-to-EKG Time (p < 0.05) 22 minutes with prior CABG 8 minutes without prior CABG P < 0.05

Correlates of EKG-to-Dispatch Time (p < 0.05) referring hospital (15 minutes fastest, 25 minutes slowest), culprit artery (RCA 16 minutes fastest, LAD 21 minutes slowest) shock (13 minutes with versus 18 minutes without)

Correlates of Dispatch-to-Arrival at GMC Time (p < 0.05) Flight time (range 6 minutes to 25 minutes)

Correlates of Cath Lab Arrival-to-Wire Time (p < 0.05) culprit artery (RCA 17 minutes, LCx 20 min) interventionist (15 minutes fastest versus 24 minutes slowest).

Correlates of Cath Lab Arrival-to-Wire Time (p < 0.05) Dr ADr BDr CDr Dp Cath Lab Arrival to Wire <.05 Overall D2B NS

Conclusion (1) The major modifiable correlate of D2B for STEMI patients transferred for PCI is the referring hospital, with a 10 minute difference between slowest and fastest (2)Variation in speed of interventionists results in 10 minute differences in median cath lab arrival-to- balloon time, but did not correlate with overall D2B. (3)RCA STEMI may be easier to recognize and treat than STEMI caused by LCx or LAD lesions

Limitations Small number of patients Evolution of treatment protocol over time Large variation in times among patients Difficult to quantify enthusiasm

Future Improvements Inform interventionists and referring hospitals Identify best practices and spread them Encourage healthy competition