Door-to-balloon times under 90 min can be routinely achieved for patients transferred for ST-segment elevation myocardial infarction percutaneous coronary intervention in a rural setting.

OBJECTIVES: The purpose of this study was to demonstrate the feasibility of routine transfer of ST-segment elevation myocardial infarction (STEMI) patients to achieve percutaneous coronary intervention (PCI) in less than 90 min from presentation. BACKGROUND: Many PCI hospitals have achieved routine door-to-balloon times under 90 min for patients with STEMI presenting directly to the hospital. However, few patients transferred from a non-PCI center undergo PCI within 90 min of presentation. METHODS: Our rural PCI hospital implemented a program in 2005 for rapid triage, transfer, and treatment of STEMI patients and made additional improvements in 2006 and 2007. Intervals between milestones in the STEMI triage/transfer/treatment process were assessed before and after implementation of the program. RESULTS: During the 5-year study period, 676 patients with 687 STEMIs were transferred from 19 community hospitals and underwent PCI. Median door-to-balloon time decreased from 189 min to 88 min (p < 0.001). The time intervals reflecting efficiency of the referring hospitals, transfer services, and PCI hospital all significantly improved. In 2008, median door-to-balloon times were <90 min for 6 of the 7 most frequently referring hospitals. Delays during off-hours presentation in 2004 were abolished after the program was implemented in 2005. In-hospital mortality decreased from 6% before to 3% after implementation of the program. In multivariate modeling, presentation before initiation of the STEMI program predicted increased risk of in-hospital mortality (odds ratio: 3.74, 95% confidence interval: 1.22 to 11.51, p = 0.021). CONCLUSIONS: A program of rapid triage, transfer, and treatment of STEMI patients presenting to non-PCI hospitals can reduce in-hospital mortality and produce progressive improvements in door-to-balloon time such that median door-to-balloon times under 90 min are feasible.

Frequency of allergic or hematologic adverse reactions to ticlopidine among patients with allergic or hematologic adverse reactions to clopidogrel.

BACKGROUND: Clopidogrel and ticlopidine are structurally very similar. In patients with an allergic or hematologic adverse reaction to either one of these drugs, the likelihood that an allergic or hematologic adverse effect will develop to the other is unknown. It is also unknown whether a reaction to the second thienopyridine is likely to be life threatening. METHODS AND RESULTS: Medical records from 2 academic institutions were reviewed to identify patients who had an allergic or hematologic adverse reaction to either of the 2 currently commercially available thienopyridines and who were subsequently prescribed the other thienopyridine. Patient demographics, details of the adverse reactions, and subsequent clinical course were reviewed. A total of 76 patients were identified with an allergic or hematologic adverse reaction to clopidogrel or ticlopidine who had also received the other thienopyridine. Fourteen (27%; 95% CI, 16 to 41) patients who had an allergic or hematologic adverse reactions to clopidogrel had a similar reaction to ticlopidine; none developed a life-threatening reaction. The most common reaction was a rash (93%). CONCLUSIONS: In patients with an allergic or hematologic adverse reaction to one thienopyridine, there seems to be an increased frequency of such reactions to the other thienopyridine. However, no patient had a life-threatening reaction after exposure to the alternative thienopyridine.

Primary percutaneous coronary intervention expansion to hospitals without on-site cardiac surgery in Michigan: a geographic information systems analysis.

BACKGROUND: In 2005, Michigan expanded primary percutaneous coronary intervention (P-PCI) capability to 12 hospitals without on-site cardiac surgery. We determined the potential impact of this expansion on geographic access to P-PCI for patients. METHODS: Geographic information systems using the US Census Survey and hospital data from the state of Michigan were used to construct maps with 20-mile hospital service areas around P-PCI hospitals with and without on-site cardiac surgery. Geographic access was calculated as the percentage of the population living within the hospital service areas of these 2 types of hospitals. RESULTS: Of 9,938,444 persons in Michigan, 7,694,834 (77.4%) lived within 20 miles of a P-PCI hospital. Thirty centers with on-site cardiac surgery provided access for 7,219,995 persons (72.6%). The 12 P-PCI hospitals without on-site cardiac surgery increased access by 474,839 persons (4.8%). Of these, 3 geographically isolated facilities, which were at least 20 miles away from another P-PCI hospital, accounted for the greatest improvement in geographic access (n = 425,700 [4.3%]), whereas the remaining 9 hospitals increased access by only 49,139 persons (0.5%). CONCLUSIONS: Expansion of P-PCI to hospitals without on-site cardiac surgery in Michigan improved geographic access to a modest extent.

Pediatric farm-related injuries: a series of 96 hospitalized patients.

Ninety-six children were admitted during a 9-year period to a pediatric level 1 trauma center for treatment of farm-related injuries. The age range was from 6 weeks to 17 years (median, 7.5 years; mean, 7.6 years; standard deviation, 4.4). Thirty-nine patients (40.6%) had an animal-related injury, including 36 children (37.5%) who had an injury associated with a horse. Amish children had an increased risk of horse-related injury when compared with non-Amish children (p=0.04; RR=2.09, 95% CI: 1.18