This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (86)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in JAMA  Topic Collections  • Cardiovascular System  • Cardiovascular Disease/ Myocardial Infarction  • Alert me on articles by topic  Social Bookmarking   What's this?

David J. Magid, MD, MPH; Yongfei Wang, MS; Jeph Herrin, PhD; Robert L. McNamara, MD, MHS; Elizabeth H. Bradley, PhD; Jeptha P. Curtis, MD; Charles V. Pollack, Jr, MD; William J. French, MD; Martha E. Blaney, PharmD; Harlan M. Krumholz, MD, SM

JAMA. 2005;294:803-812.

Context  Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy.

Objective  To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality.

Design, Setting, and Participants  Cohort study of 68 439 patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy and 33 647 treated with percutaneous coronary intervention (PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours (weekdays, 7 AM-5 PM) and off-hours (weekdays 5 PM-7 AM and weekends).

Main Outcome Measures  Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics.

Results  Most fibrinolytic therapy (67.9%) and PCI patients (54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours (34.3 minutes) than regular hours (33.2 minutes; difference, 1.0 minute; 95% confidence interval [CI], 0.7-1.4; P<.001). In contrast, door-to-balloon times were substantially longer during off-hours (116.1 minutes) than regular hours (94.8 minutes; difference, 21.3 minutes; 95% CI, 20.5-22.2; P<.001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours (25.7%) than regular hours (47%; P<.001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours (41.5%) than regular hours (27.7%; P<.001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory (off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P<.001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours (odds ratio, 1.07; 95% CI, 1.01-1.14; P = .02).

Conclusions  Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.

Author Affiliations: Clinical Research Unit, Kaiser Permanente, Denver (Dr Magid) and Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver (Dr Magid); Department of Internal Medicine, Section of Cardiovascular Medicine (Drs Herrin, McNamara, Curtis, Krumholz, and Wang), Division of Health Policy and Administration, Department of Epidemiology and Public Health (Drs Bradley and Krumholz), and Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, and Center for Outcomes Research and Evaluation, Yale–New Haven Health, New Haven, Conn (Drs Krumholz and Bradley); Pennsylvania Hospital, Philadelphia (Dr Pollack); Harbor/University of California Los Angeles Medical Center, Torrance (Dr French); and Genentech, South San Francisco, Calif (Dr Blaney).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

RELATED LETTERS

Circadian Rhythms and Reperfusion in Patients With Acute ST-Segment Elevation Myocardial Infarction
Roberto Manfredini, Benedetta Boari, Raffaella Salmi, Anna Maria Malagoni, and Fabio Manfredini
JAMA. 2005;294(22):2846-2847.
EXTRACT | FULL TEXT  

Circadian Rhythms and Reperfusion in Patients With Acute ST-Segment Elevation Myocardial Infarction—Reply
David J. Magid, Elizabeth H. Bradley, and Harlan M. Krumholz
JAMA. 2005;294(22):2847.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Long-Term Prognosis in an ST-Segment Elevation Myocardial Infarction Population Treated With Routine Primary Percutaneous Coronary Intervention: From Clinical Trial to Real-Life Experience
Pedersen et al.
Circ Cardiovasc Interv 2009;2:392-400.
ABSTRACT | FULL TEXT  

The Prevalence of Weekly Angina Among Patients With Chronic Stable Angina in Primary Care Practices: The Coronary Artery Disease in General Practice (CADENCE) Study
Beltrame et al.
Arch Intern Med 2009;169:1491-1499.
ABSTRACT | FULL TEXT  

Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction: Bayesian Hierarchical Meta-Analyses of Randomized Controlled Trials and Observational Studies
Huynh et al.
Circulation 2009;119:3101-3109.
ABSTRACT | FULL TEXT  

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital
Pelletier
Crit Care Nurse 2009;29:54-64.
FULL TEXT  

Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial Infarction Receiving Center (SRC) Networks: Impact on Door-to-Balloon Times Across 10 Independent Regions
Rokos et al.
J Am Coll Cardiol Intv 2009;2:339-346.
ABSTRACT | FULL TEXT  

Systems-Based Improvement in Door-to-Balloon Times at a Large Urban Teaching Hospital: A Follow-Up Study From Parkland Health and Hospital System
Parikh et al.
Circ Cardiovasc Qual Outcomes 2009;2:116-122.
ABSTRACT | FULL TEXT  

Primary PCI as the preferred reperfusion therapy in STEMI: it is a matter of time
Terkelsen et al.
Heart 2009;95:362-369.
ABSTRACT | FULL TEXT  

Off-Hour Admission and In-Hospital Stroke Case Fatality in the Get With The Guidelines-Stroke Program
Reeves et al.
Stroke 2009;40:569-576.
ABSTRACT | FULL TEXT  

Long-term effectiveness of early administration of glycoprotein IIb/IIIa agents to real-world patients undergoing primary percutaneous interventions: results of a registry study in an ST-elevation myocardial infarction network
Ortolani et al.
Eur Heart J 2009;30:33-43.
ABSTRACT | FULL TEXT  

Factors Associated With Poorer Prognosis for Patients Undergoing Primary Percutaneous Coronary Intervention During Off-Hours: Biology or Systems Failure?
Glaser et al.
J Am Coll Cardiol Intv 2008;1:681-688.
ABSTRACT | FULL TEXT  

Physicians ... Wake Up!
Shah and French
J Am Coll Cardiol Intv 2008;1:689-691.
FULL TEXT  

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome: A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology
Ting et al.
Circulation 2008;118:1066-1079.
FULL TEXT  

A Delicate Balance: Physician Work Hours, Patient Safety, and Organizational Efficiency
Volpp
Circulation 2008;117:2580-2582.
FULL TEXT  

Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction
Jneid et al.
Circulation 2008;117:2502-2509.
ABSTRACT | FULL TEXT  

Factors Associated With Longer Time From Symptom Onset to Hospital Presentation for Patients With ST-Elevation Myocardial Infarction
Ting et al.
Arch Intern Med 2008;168:959-968.
ABSTRACT | FULL TEXT  

Response to Letter Regarding Article, "A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction"
Henry et al.
Circulation 2008;117:e329-e329.
FULL TEXT  

Day of Admission and Clinical Outcomes for Patients Hospitalized for Heart Failure: Findings From the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF)
Fonarow et al.
Circ Heart Fail 2008;1:50-57.
ABSTRACT | FULL TEXT  

Treatment delays in ST elevation myocardial infarction
Terkelsen and Lassen
BMJ 2008;336:401-402.
FULL TEXT  

Systems of Care to Improve Timeliness of Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction During Off Hours The Mayo Clinic STEMI Protocol.
Holmes et al.
J Am Coll Cardiol Intv 2008;1:88-96.
ABSTRACT | FULL TEXT  

Time to Treatment in Primary Percutaneous Coronary Intervention
Nallamothu et al.
NEJM 2007;357:1631-1638.
FULL TEXT  

Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome
Carstensen et al.
Eur Heart J 2007;28:2313-2319.
ABSTRACT | FULL TEXT  

Time delay in primary angioplasty: how relevant is it?
Dudek et al.
Heart 2007;93:1164-1166.
FULL TEXT  

Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Review of Contemporary Management Options
Boden et al.
J Am Coll Cardiol 2007;50:917-929.
ABSTRACT | FULL TEXT  

ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) Trial
Dhruva et al.
J Am Coll Cardiol 2007;50:509-513.
ABSTRACT | FULL TEXT  

Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week
Afolabi et al.
Emerg. Med. J. 2007;24:588-591.
ABSTRACT | FULL TEXT  

Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: Executive Summary
Jacobs et al.
Circulation 2007;116:217-230.
FULL TEXT  

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
Khot et al.
Circulation 2007;116:67-76.
ABSTRACT | FULL TEXT  

Facilitated percutaneous coronary intervention: current concepts, promises, and pitfalls
Kiernan et al.
Eur Heart J 2007;28:1545-1553.
ABSTRACT | FULL TEXT  

Door-to-Balloon Time in Acute Myocardial Infarction
Dalby et al.
NEJM 2007;356:1475-1479.
FULL TEXT  

Weekend versus Weekday Admission and Mortality from Myocardial Infarction
Kostis et al.
NEJM 2007;356:1099-1109.
ABSTRACT | FULL TEXT  

Weekend Worriers
Redelmeier and Bell
NEJM 2007;356:1164-1165.
FULL TEXT  

Total Liquid Ventilation Provides Ultra-Fast Cardioprotective Cooling
Tissier et al.
J Am Coll Cardiol 2007;49:601-605.
ABSTRACT | FULL TEXT  

The optimum reperfusion pathway for ST elevation acute myocardial infarction: development of a decision framework
Kendall
Emerg. Med. J. 2007;24:52-56.
ABSTRACT | FULL TEXT  

The Year in Epidemiology, Health Services Research, and Outcomes Research
Krumholz and Masoudi
J Am Coll Cardiol 2006;48:1886-1895.
FULL TEXT  

Narrative review: reperfusion strategies for ST-segment elevation myocardial infarction.
Ting et al.
ANN INTERN MED 2006;145:610-617.
ABSTRACT | FULL TEXT  

Hubris Versus Evidence
Wharton
J Am Coll Cardiol 2006;48:415-416.
FULL TEXT  

Recommendation to Develop Strategies to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention
The American Heart Association's Acute Myocardial et al.
Circulation 2006;113:2152-2163.
ABSTRACT | FULL TEXT  

The Year in Interventional Cardiology
Dixon et al.
J Am Coll Cardiol 2006;47:1689-1706.
FULL TEXT  

Regionalization of ST-Segment Elevation Acute Coronary Syndromes Care: Putting a National Policy in Proper Perspective
Rathore et al.
J Am Coll Cardiol 2006;47:1346-1349.
ABSTRACT | FULL TEXT  

Door-to-Balloon Time in Primary Percutaneous Coronary Intervention: Is the 90-Minute Gold Standard an Unreachable Chimera?
Moscucci and Eagle
Circulation 2006;113:1048-1050.
FULL TEXT  

Circadian Rhythms and Reperfusion in Patients With Acute ST-Segment Elevation Myocardial Infarction
Manfredini et al.
JAMA 2005;294:2846-2847.
FULL TEXT  

The Case for Community Hospital Angioplasty
Wharton et al.
Circulation 2005;112:3509-3534.
FULL TEXT  

JournalScan
Malik
Heart 2005;91:1503-1504.
FULL TEXT  

PCI Faster During Business Hours
JWatch Emergency Med. 2005;2005:9-9.
FULL TEXT  

How Timely Is PCI During Off Hours?
Journal Watch Cardiology 2005;2005:1-1.
FULL TEXT