Canadian Medical Association Journal 1996; 155: 11-20
However, I object strongly to one of the recommendations. The authors believe that "thrombolytic therapy can, and should, be administered to a patient with AMI within 30 minutes of arrival to hospital." The editorial makes a similar statement. I find these statements surprising and worrisome, especially since they are made by respected, practising emergency physicians. A 30-minute "door-to-needle time" may be more than reasonable under ideal conditions in patients with uncomplicated AMI. Such a time is very unreasonable for a substantial number of patients with more complex problems, who are seen in crowded emergency departments. Although a multitude of clinical trials has shown the important relation between time to thrombolytic therapy and death rates, I am not aware of any trial in which the standard of care was a door-to-needle time of 30 minutes. Several clinical trials involved a time of 60 to 90 minutes,[1-4] and one study involved a median time of 50 minutes. To dogmatically adopt 30 minutes as the time interval during which all eligible patients are to receive thrombolytic therapy may well result in as many as half the patients receiving less than the recommended care. A more reasonable approach would be to try to treat all patients with uncomplicated AMI within half an hour and all other patients within an hour.
I sympathize with the intent of the recommendations; however, setting unrealistic goals for emergency physicians and nurses will only compound our frustration in being unable to improve the care of these patients and will expose us all to unnecessary litigation.
Anton F. Grunfeld, MD, FRCPC
Department of Emergency Medicine
Vancouver Hospital and Health Sciences Centre
Several members of the coalition are practising emergency physicians, nurses and other health care professionals with experience in busy urban teaching hospitals, as well as in sparsely staffed rural hospitals, so we are acutely aware that a door-to- needle time of 30 minutes is difficult to achieve and cannot be achieved simply through good intentions.
In reviewing the literature, we identified factors that produce delay as well as protocols and policies that minimize delay. It is correct, as Dr. Grunfeld states, that departments that do not specifically address and monitor thrombolytic therapy times do not reach the 30-minute goal. But several departments have addressed the causes of delay and found ways to overcome it to meet the 30-minute target. MacCallum and colleagues,[l] after instituting policies to minimize delay and monitor performance, reported a median door-to-needle time of 17 minutes for 50 consecutive patients. In a Seattle study, prehospital identification of eligible patients reduced the mean hospital treatment time from 60 to 20 minutes. In a rural community hospital in Pennsylvania, the introduction of a prehospital electrocardiogram protocol decreased hospital treatment times from a mean of 51 minutes to a mean of 22 minutes. Closer to home, physicians and nurses at the Scarborough Centenary Hospital, a busy urban hospital in Ontario, collaborated to reduce time to thrombolysis from 72 to 29 minutes. These and other studies have shown that the causes of delay can be identified and successfully addressed. In the United States, the National Heart Attack Alert Program undertook an intensive review of delay and its causes, and adopted 30 minutes as a realistic goal for the administration of thrombolytic therapy for patients with a clear diagnosis of AMI.
We believe that 30 minutes is a reasonable and realistic goal, which can be achieved for most patients. If the goal of 30 minutes cannot be achieved among some patients, there should be adequate reasons for the additional time. The fact that an emergency department is busy or crowded should not excuse the staff from providing prompt care.
We emphasize that most hospital delay is caused not by patient factors but by hospital factors. If hospitals set up a system to ensure that patients with a clear diagnosis of AMI can be treated within 30 minutes, then patients in whom the diagnosis is less clear will also benefit.
Michael Shuster, MD, DABEM, FRCPC
Emergency Cardiac Care Coalition
Heart and Stroke Foundation of Canada
Mineral Springs Hospital
Garth Dickinson, MD, FRCPC
Canadian Association of Emergency Physicians
Division of Emergency Medicine
University of Ottawa