Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore

doi:10.5847/wjem.j.1920-8642.2015.04.005

Abstract

Abstract:

BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction (STEMI) improves outcomes. System delay is that between first medical contact and reperfusion therapy, comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.
METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services (EMS), ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.
RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5 minutes (interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes (IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes (IQR=1.30, 22.13); between arrival-at- and departure-from-patient-location was 13.12 minutes (IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes (IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulance-dispatch and arrival-at-patient-location was shorter (5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter (10.78 vs. 14.37 minutes, P<0.01).
CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

Key words: Myocardial infarction, Emergency medical services, Delay, First medical contact, Door to balloon

Andrew Fu Wah Ho, Pin Pin Pek, Stephanie Fook-Chong, Ting Hway Wong, Yih Yng Ng, Aaron Sung Lung Wong, Marcus Eng Hock Ong. Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore[J]. World Journal of Emergency Medicine, 2015, 6(4): 277-282.

Figures/Tables 3

Figure 1.

Table 1

Correlates of pre-hospital system delay (first medical contact to door time)

Variables	All (n=52)	FC2D<35.5 minutes (n=26)	FC2D>35.5 minutes (n=26)	P value
Demographics
Age, median (range), years	56.0 (36.0-79.0)	54.0 (41.0-74.0)	58.0 (36.0-79.0)	0.213
Gender (n, %)				0.714
Male	43 (82.7)	21 (80.8)	22 (84.6)
Female	9 (17.3)	5 (19.2)	4 (15.4)
Race (n, %)				0.629
Chinese	31 (59.6)	17 (65.4)	14 (53.8)
Malay	9 (17.3)	5 (19.2)	4 (15.4)
Indian	9 (17.3)	6 (23.1)	3 (11.5)
Others	3 (5.8)	1 (3.8)	2 (7.7)
Presenting circumstances
Chest pain/discomfort (n, %)	45 (86.5)	23 (88.5)	22 (84.6)	0.685
Incident location (n, %)				0.780
Residential	29 (55.8)	14 (53.8)	15 (57.7)
Non-residential	23 (44.2)	12 (46.2)	11 (42.3)
Pain score, mean	4.27	4.44	4.12	0.834
Glasgow coma scale score, mean	14.82	14.88	14.76	0.332
Transport conditions (n, %)
Weather conditions				0.720
Sunny-fine	46 (88.5)	24 (92.3)	22 (84.6)
Light rain	2 (3.8)	1 (3.8)	1 (3.8)
Heavy rain	1 (1.9)	0 (0)	1 (3.8)
Windy	2 (3.8)	1 (3.8)	1 (3.8)
Traffic conditions				0.871
Light	4 (8.0)	2 (8.3)	2 (7.7)
Moderate	43 (86.0)	21 (87.5)	22 (84.6)
Heavy	3 (6.0)	2 (7.7)	1 (4.2)
Prehospital interventions by paramedic (n, %)
GTN (sublingual or transdermal)	28 (53.8)	13 (50.0)	15 (57.7)	0.578
Aspirin	7 (13.5)	3 (11.5)	4 (15.4)	0.685
Process of care intervals, median (range), minute
Call-to-dispatch time	2.48 (1.47-16.55)	2.04 (1.60-5.02)	2.92 (1.47-16.55)	0.023
Dispatch-to-arrival-at-patient time	8.067 (1.30-22.13)	5.75 (3.58-12.75)	9.37 (1.30-22.13)	<0.01
Arrival-at-patient-to-leaving patient time	13.12 (3.12-32.2)	10.78 (3.12-19.20)	14.37 (8.07-32.22)	<0.01
Leaving-patient-to-door time	9.90 (1.62-32.92)	7.80 (1.62-17.45)	12.88 (5.25-32.92)	0.016
Symptom-to-balloon time	217 (96.0-3038.0)	222.0 (104.0-3038.0)	189.0 (96.0-736.0)	0.104
Door-to-balloon time	92.0 (62.0-177.0)	91.0 (62.0-160.0)	94.0 (65.0-177.0)	0.331

Table 1

Figure 2.

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