Critical pathways (CP) are clinical management plans that provide the sequence and timing of actions of medical staff. The main goal of a CP is to provide optimal patient care and to improve time-effectiveness. Current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommend a door-to-balloon time of <90 minutes for patients undergoing primary percutaneous coronary intervention (PCI). The aim of this study was to identify the effects of CP on the management of patients with STEMI in an emergency department.
The study population consisted of 175 patients undergoing primary PCI for STEMI who presented to the emergency department of Kangwon National University Hospital (Chuncheon, South Korea) with chest pain from July 1, 2005 to November 30, 2010. We retrospectively analyzed medication use, symptom onset-to-door times, door-to-balloon times, total ischemic times, and the reperfusion rate within 90 minutes. We also measured the 30-day and 1-year total mortality rates pre- and post-CP implementation.
The effects of CP implementation on the medication use outcomes in patients with acute myocardial infarction were increased between the pre- and post-CP patients groups. The median door-to-balloon time declined significantly from 85 to 64 minutes after CP implementation (P = 0.001), and the primary PCI rate within 90 minutes was significantly increased (57% vs. 79%, P = 0.01). However, the symptom to door time was not changed between the pre- and post-CP groups (150 minutes vs. 149 minutes; P = 0.841). Although the total ischemic time was decreased after CP implementation, it was not statistically insignificant (352.5 minutes vs. 281 minutes; P = 0.397). Moreover, the 30-day and 1-year total mortality rates of the 2 groups did not change (12.0% vs. 12.0%, P > 0.999; 13.0% vs. 17.3%, P = 0.425, respectively). However, the 1-year mortality rates of 2 groups based on a total ischemic time of 240 minutes, which was median value, decreased significantly from 19.0% to 9.0%. (P = 0. 018)
Implementation of a CP resulted in greater use of recommended medications and reductions in the median door-to-balloon time. However, it did not reduce the symptom onset-to-door time, total ischemic time, or the 30-day and 1-year mortality rates. Therefore, additional strategies are needed to reduce mortality in patients with acute myocardial infarction undergoing primary PCI.
From the *Division of Cardiology, Department of Internal Medicine, School of Medicine, Kangwon National University; and †Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea.
Received for publication July 1, 2014; accepted September 20, 2014.
Dong Ryeol Ryu and Jang Won Choi contributed equally to the study.
Reprints: Byung Ryul Cho, MD Division of Cardiology, Department of Internal Medicine, Kangwon National University Hospital, 156 Baengnyeong-ro, Chuncheon-si, Gangwon-do 200–722, Republic of Korea. E-mail: firstname.lastname@example.org.