Time Delay in The Emergency Management of ST-Segment Elevation Myocardial Infarction in A Tertiary Care Hospital in New Delhi, India: A Prospective Study

Anita Rawat1, Surjeet Acharya2* and Kishalay Datta3

1Senior Consultant, Emergency Medicine, Max Super Speciality Hospital, Shalimar Bagh, Delhi

2Post Graduate trainee, Emergency Medicine, Max Superspeciality Hospital, Shalimar Bagh, Delhi

3Director and HOD, Emergency Medicine, Max Super Speciality Hospital, Shalimar Bagh, Delhi

*Corresponding Author: Acharya S, Post Graduate trainee, Emergency Medicine, Max Superspeciality Hospital, Shalimar Bagh, Delhi. E-mail: drsa2495@gmail.com

Citation: Rawat A, Acharya S, Datta K. Time Delay in The Emergency Management of St Segment Elevation Mi in A Tertiary Care Hospital in New Delhi, India: A Prospective Study. Journal of Current Emergency Medicine Reports. 2022;2(1):1-3.

Copyright: © 2022 Acharya S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received On: 19th January,2022     Accepted On: 8th April,2022    Published On: 18th April,2022

Abstract

Time delay in STEMI works as an indicator for performance assessment and marker of quality of care. The door to balloon time (D2BT) works as an in-hospital performance manager. There is a minimum time delay in moving of patients from the ER (Emergency room) to the Cath lab (catheterisation lab) in the tertiary care hospital within-hospital cardiology team. But we sometimes face time delays and, in this study, we will look at the causes of the time delays and will try to find solutions to them over a period of 10 months.

Keywords: ST segment elevation Myocardial infarction (STEMI), coronary artery disease, catheterisation, thrombolytics, door to balloon time

Introduction

STEMI stands for ST elevation Myocardial infarction. Probably, the early treatment of ischaemia of the heart is the most important step in interventional cardiology. Performing immediate angiography in patients with acute coronary syndrome (ACS), specifically with ST elevation in the 12-lead ECG (STEMI), followed by percutaneous coronary intervention (PCI) to restart the blood flow in blocked coronary arteries has proven to save lives [1, 2, 3]. There is no universal definition for (FMC) first medical contact, as in Figure 1 [4].  Thus, by improving the logistics around all these procedures, better outcomes can be accomplished in all STEMI patients. This involves many steps ranging from ambulance services, prehospital triage and treatment strategies, dedicated cardiac units, skilled paramedic personnel’s and many other additional measures. Also, nowadays it is well recognised that an experienced team handling myocardial ischemic patients performs better [5, 6]. The door to the balloon time in a STEMI patient is 90 minutes as per the American Heart Association (AHA) criteria.

Figure 1: Field triage for PPCI

The most effective parameters for good STEMI outcomes are the time from symptom onset till effective reperfusion (total ischaemic time) and the door-to-balloon time (D2BT), the latter supposed to represent the in-hospital performance. Besides, the door-to-balloon time can easily be determined and it was introduced as a measure of quality of care in patients with STEMI. In this study, we try to find out the most common reasons for delay in early intervention for STEMI patients in a tertiary care hospital in Delhi. This study data will help to improve the healthcare performance and the ability to monitor all the aspects of this complicated chain of medical care and to thus, find ways for improvement for not only PCI procedure itself, but also its supportive logistics. The determination of treatment and patient delay is based on information regarding symptom onset, which may be uncertain because of recall bias and because the onset of acute myocardial infarction which may have been preceded by hours of unstable angina. Thus, it is impossible to establish the exact time of onset of the AMI. To study these effects of delayed intervention therapy on mortality, it will be more relevant to focus on a parameter which is not hampered by recall bias and is less prone to confounding, selection bias, information bias. Various studies have been done which has focused on the association between door-to-balloon delay and outcome, whereas the total health care system delay, defined as the time from first contact with the health care system to initiation of reperfusion therapy.

Methodology

In this study, we review the data stored over the network system of our tertiary care hospital in Delhi. We have included the time period from March 2021 to December 2021.

Results

The total number of patients sent to Cath lab from the ER (for CAG followed by PCI) for the following months and delay:

Table 2: The total number of patients sent to Cath lab from the ER (for CAG followed by PCI) for the following months and delay.

The main reasons for delay as seen below is due to the decision making by the patient relatives and the rest follows.

Figure 2: Pictorial representation of decision making by patients for the delay

Discussion

To our knowledge, this study is the first study to be carried out in our institute regarding the major factors contributing to the delay in shifting of ST elevation Myocardial infarction patients from the emergency room to the Cath lab. The major factor in patient delay is the time taken by the patient or patient attendant in accepting the diagnosis and decision making for coronary angiography and further treatment in patients going to cath-lab. This is a preventable modifiable risk factor in patient delay and also lowering of the mortality. Educating the patients and attendants about the disease process and its outcome and need for urgent intervention must be explained to the patient and attendants and the decision should be made quickly without much delay as the delay can lead to increase in mortality and morbidity. The pattern of knowledge retention and the effectiveness of repeated educational interventions require additional investigation. To get the best results from the educational interventions, there should be evidence that shows that there is a knowledge gap that exists among the target group for the observed defect, and that can be corrected and sustained with an educational intervention [7].

        The cornerstone in treatment of patients with ST elevation Myocardial infarction is to minimize the time from symptom onset to reperfusion therapy (door to balloon time –  D2BT). D2BT is 90 minutes as per the AHA guidelines. Better outcomes have been observed in early D2BT. Decision making delay time remains one of the longest portions of the total delay time. Educational interventions imparted to the common public have not been much successful to date. Perhaps, this area of interventional cardiology needs more innovative and disruptive strategies used by marketing firms to understand and influence patient and their relative’s behaviour to change the inertia decision making process.

Conclusion

From the results obtained from above, the main reason for delay in shifting of ST elevation MI patients from ER to the Cath lab was the delay caused by patient or attendant in making decision. The next major reason for the delay for shifting of patients from ER to Cath lab was due to non-availability of a doctor (cardiologist) at that point of time. Surprisingly, even with a busy ER in our tertiary care hospital, there was no delay due to lack of in-coordination between the ER team. Registration and admission process from the admission unit and other financial units also had a very minimal role in the delay of shifting of patients from ER to Cath lab. Proper education of the patient and relatives must be done by experts for helping them make immediate, correct decisions for the betterment of the patient.

This study is limited to the data collected over the time period of ten months stored over the network system of our hospital and further studies are required to get more clear and appropriate details about the same.

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