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Patients with ST-elevation myocardial infarction (STEMI) who go to hospitals on off-hours (weekdays between 5 p.m. and 7 a.m. or weekends) wait longer for treatment with percutaneous coronary intervention (PCI) or fibrinolytic drug therapy than patients who arrive during regular hours, according to a study of more than 68,000 patients. The delay in care could be fatal.


Patients with a STEMI who arrive at hospitals after hours waited an average of 116 minutes for PCI and 34 minutes for fibrinolytic therapy. Patients who visited during regular business hours waited about 95 minutes for PCI and about 33 minutes for fibrinolytic therapy.


According to American Heart Association guidelines, the time from arrival in the ED until PCI (door-to-balloon time) should be less than 90 minutes. The time from arrival to fibrinolytic therapy (door-to-drug time) should be less than 30 minutes. Less than 26% of patients treated after hours met the 90-minute guideline for PCI, compared with 47% who met the guideline during regular hours. Delays increased the risk of death by about 7%.


Patients who needed fibrinolytic therapy fared better-those who arrived at the ED after hours waited only 1 minute longer for fibrinolytic drug therapy than patients who visited during regular hours. This is probably because fibrinolytic drugs are easily administered in the ED, which is always staffed. In contrast, most hospitals don't staff PCI labs 24 hours a day.


Hospitals that had the shortest wait times for after-hours care required PCI staff to live nearby and respond quickly to pagers. And at the end of the regular workday, the staff set up the lab for the next patients. One hospital allowed ED physicians to call in the PCI team without approval from a cardiologist, which saved an estimated 30 minutes.


Two-thirds of heart attack patients arrive at EDs after hours. Researchers conclude that continuous staffing of PCI labs, while costly, could save lives.




Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction, JAMA, DJ Magid, et al., August 17, 2005.