Association between hospital practices and door-in-door-out time in ST-segment elevation myocardial infarction

Background: Current guidelines suggest a "door-in-door-out" (DIDO) time of 30 minutes or shorter for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a STEMI referral hospital and are transferred to a STEMI-receiving center for primary percutaneous coronary intervention. Experts previously identifed 18 system practices as critical for reducing DIDO times. The objective of this study was to describe how frequently these critical practices are used and to determine whether their use was associated with shorter DIDO times. Methods: We surveyed 18 STEMI referral hospitals for 4 STEMI-receiving centers regarding their use of these 18 practices. The median number used was 14 practices (interquartile range 12-15). We then evaluated their association with DIDO times in all patients (n = 93) transferred from these STEMI referral hospitals to the 4 STEMI-receiving centers for primary percutaneous coronary intervention. Results: In univariate linear regression analyses, system-wide quality improvement programs with leaders in the emergency medical services agencies and STEMI referral hospitals were associated with shorter DIDO times (P < 0.001 for all). Overall use of system practices was not associated with DIDO times (P = 0.143). The majority (76%, 95% confdence interval: 66%-85%) of DIDO times did not meet the 30-minute goal. Conclusions: These fndings highlight the diffculty in achieving the 30-minute DIDO goal and the need for continued focus on strategies for reducing DIDO time, including system-wide quality improvement programs.