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Circ Cardiovasc Qual Outcomes. 2011 Jul;4(4):382-8. doi: 10.1161/CIRCOUTCOMES.110.959643. Epub 2011 Jun 28.

Care processes associated with quicker door-in-door-out times for patients with ST-elevation-myocardial infarction requiring transfer: results from a statewide regionalization program.

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Duke Clinical Research Institute and Department of Medicine, Duke University School of Medicine, 170 Manning Drive, Durham, NC 27599, USA.



The ability to rapidly identify patients with ST-segment elevation-myocardial infarction (STEMI) at hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department (ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with door-in-door-out times at non-PCI hospitals.


Door-in-door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED, and hospital settings) with door-in-door-out times was determined using multivariable linear regression. Median door-in-door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes; after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P<0.0001). Hospital, ED, and EMS care processes were each independently associated with shorter door-in-door-out times (-17.7 [95% confidence interval, -27.5 to -7.9]; -10.1 [95% confidence interval, -19.0 to -1.1], and -7.3 [95% confidence interval, -13.0 to -1.5] minutes for each additional hospital, ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none).


Prehospital, ED, and hospital processes of care were independently associated with shorter door-in-door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.

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