THE DELAY TO THROMBOLYSIS - AN ANALYSIS OF HOSPITAL AND PATIENT CHARACTERISTICS

Objective: To describe the various components of the delay to thrombol ytic treatment for patients with acute myocardial infarction (MI) and to identify the hospital and patient characteristics related to these delays. Design: Cohort analysis from a hospital registry of patients r eceiving thrombolytic treatment. Setting: Forty acute care hospitals i n Quebec. Subjects: All 1357 patients who received thrombolysis betwee n January 1995 and May 1996. Main outcome measures: Time from onset of symptoms to arrival at hospital and the various components of the in- hospital delay. Results: The median delay before presentation to hospi tal was 98 (interquartile range [IR] 56 to 180) minutes and was longer for women (p < 0.001), patients over 65 years of age (p < 0.001) and patients with diabetes mellitus (p < 0.01). The median time from arriv al at hospital to thrombolysis was 59 (IR 41 to 89) minutes, the medic al decision-making component taking a median of 12 (IR 4 to 27) minute s. Women (p < 0.05), older patients (p < 0.001) and patients with a pa st history of MI (p < 0.001) had increased in-hospital delays to throm bolysis. Delays were longer in community hospitals (p < 0.05) and low- volume centres (p < 0.01) and when a cardiologist made the decision to administer thrombolysis (p < 0.001). Multivariate analysis showed tha t increased age (odds ratio 1.5, 95% confidence interval 1.3 to 1.7, p < 0.001) and having the medical decision made by a cardiologist (odds ratio 1.8, 95% confidence interval 1.6 to 2.0, p < 0.001) were indepe ndently associated with an increased risk of being in the upper median of in-hospital delays. Conclusions: Despite certain improvements, the re remain substantial delays between symptom onset and the administrat ion of thrombolysis for patients with acute MI. A large part of the de lay is due to the hesitation of patients (particularly women, older pa tients and patients with diabetes) to seek medical attention. Although the median time for medical decision-making appears reasonable, care must be taken to ensure that all patient groups receive timely evaluat ion and therapy. The delay associated with having the treatment decisi on made by a cardiologist probably represents a marker for more diffic ult, complex cases. Methods should be developed to permit specialty co nsultation, if needed, while minimizing treatment delays. Community an d low-volume hospitals may require special attention.