1. Home>
2. Specialties>
3. Emergency Medicine>
4. Summary and Comment

Emergency Physician Activation of the Cardiac Cath Lab

Door-to-balloon time decreased significantly, with few false positives.

Time from presentation to revascularization influences infarct size and mortality in ST-segment–elevation myocardial infarction (STEMI). These authors prospectively assessed door-to-balloon times before and after implementation of a protocol mandating that emergency physicians (EPs) activate the cath lab without cardiology consultation and that a team of three registered nurses immediately transfer each patient from the emergency department to the cath lab.

Sixty consecutive STEMI patients were catheterized during the 11 months before implementation of the protocol, and 86 were catheterized during the 10 months after. Median door-to-balloon time decreased significantly overall (113.5 vs. 75.5 minutes), during regular hours (83.5 vs. 64.5 minutes), during off-hours (123.5 vs. 77.5 minutes), and in cases transferred from an outside affiliated ED (147 vs. 85 minutes). Mean infarct size decreased significantly (peak creatinine kinase during first 24 hours, 2623 vs. 1517 IU/L), as did mean hospital stay (5 vs. 3 days) and total hospital costs per admission (US$26,826 vs. $18,280). Mortality rates did not differ significantly (7.4% vs. 5.2%). One patient was misrouted to the cath lab rather than to the critical care unit because of a communication error between the EP and the cardiologist.

Comment: This study is one of several demonstrating that door-to-balloon time is improved when EPs, not cardiologists, activate the cath lab (Journal Watch Emergency Medicine Nov 17 2006). The observed decreases in length of stay and cost seem too good to be true, and the authors provide insufficient detail to determine whether they fully accounted for the cost of the three nurses for patient transfer. Nonetheless, even if the authors overestimated the benefits, the only reason to require cardiologists to activate the lab would be if EPs did so unnecessarily, which didn’t happen in this study. If this finding is generalizable to other hospitals, we can conclude that qualified EPs, not cardiologists, should activate the cath lab for ED STEMI patients.

— Daniel J. Pallin, MD, MPH

Dr. Pallin is an attending physician in the Department of Emergency Medicine at Brigham and Women’s Hospital in Boston and in the Division of Emergency Medicine at Children’s Hospital Boston. He is also an Assistant Professor in Medicine (Emergency Medicine) at Harvard Medical School.

Published in Journal Watch Emergency Medicine August 17, 2007

Citation(s):

Khot UN et al. 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. Circulation 2007 Jul 3; 116:67-76.

• Original article (Subscription may be required)
• Medline abstract (Free)