We found that the introduction of CODE STEMI at our institution has successfully improved D2BT and reduced in-hospital MACE and mortality. In our study, the implementation of CODE STEMI resulted in 45% (130 min) improvement of D2BT, from 288 min to 158 min. This result is similar to a study in Australia and Saudi Arabia which showed a 22.1 min and 30.5 min reduction of D2BT in post CODE STEMI period.11,12 Previous studies have revealed that prolonged D2BT for patients with STEMI was associated with increased mortality.13–15 The target of D2BT in STEMI patients undergoing PPCI according to American heart Association and European Society of Cardiology (ESC) is ≤ 90 min.16 Although we have not reached the international standards, the CODE STEMI program has significantly reduced the door to balloon time, since even small reduction in D2BT has become of critically important in reducing mortality risk.17 The D2BT of less than 90 minutes has been shown to be associated with a reduction in major in-hospital complications.18,19
We were able to observe a decrease in the incidence of MACE in STEMI patients by 10.83% in CODE STEMI group with risk ratio 0.78. This means that there is a 0.78 risk of MACE in STEMI patients who are not treated using CODE STEMI protocol. Although the decrease was not proven to be statistically significant, but these results still show a downward trend in the incidence of MACE in STEMI patients, which is still an important value in clinical practice. This results are consistent with one study that reported a non statistically significant decrease in the incidence of MACE 30 days (5% reduction) and 12 months MACE (10.1% reduction) by the activation of CODE STEMI program. 11 Another study in 2018 also reported lower complications in patients treated with the STEMI CODE program, specifically the incidence of recurrent infarction which drops to 8%. (p = 0.043).12
In alignment with MACE, there was a decrease in mortality by around 4% after the implementation of the CODE STEMI program with risk ratio 0.53. Clinically, this means there is a reduced risk of mortality in STEMI patients treated using by the CODE STEMI. A study conducted in Canada, also showed a decrease in hospital mortality from 10–4.7% in the first year the CODE STEMI was applied.20 Every minute of delay in primary angioplasty for STEMI affects 1-year mortality, even after adjustment for baseline characteristics.21 Both result means that CODE STEMI protocol can reduce risk of mortality and MACE in STEMI patients. This is closely related to the reduction of D2BT after CODE STEMI was implemented. Shorter D2BT, which prompt early revascularization, has been associated with improved clinical outcomes in STEMI patients.17,22,23
The one day drop in length of stay of STEMI patients after the implementation of CODE STEMI program is consistent with a study in a teaching hospital in New Jersey, which found that during the first year CODE STEMI implementation, the average length of stay of patients dropped from 4 days to 3 days.24 Other study from Le May also stated that 1 year implementation of CODE STEMI as a city-wide program in Ottawa successfully reduced hospital length of stay to only 4 days.
The reduction of MACE, mortality, and length of stay contributes to the reduction of total hospitalization cost of STEMI patients. Lower treatment cost is required when patients don’t have to go through extensive treatment and stay too long in the hospital after PPCI. Our study found that the implementation of CODE STEMI program has successfully reduced total hospital cost up to 21%.
Efficiency is the ability to reduce service costs without reducing the benefits of services provided to patients, whereas optimalization is when an effective service is accomplished with the lowest expenditure of resources. (Donabedian, 2003) The results of data analysis concluded that the total hospital cost was reduced after the implementation of the CODE STEMI program. The benefits of CODE STEMI provided to patients can be seen from the improvement of the length of stay, door to balloon time, MACE, and mortality, which makes CODE STEMI an effective program as it yield a better clinical outcome.
According to the above efficiency formula, the improvement of clinical outcome and reduction of total hospitalization cost showed that this program has successfully improved the cost efficiency of STEMI treatment. Furthermore, CODE STEMI may also be considered as an optimal intervention for STEMI patients for its ability to provide an effective treatment with the lowest cost.
Providing timely emergency PCI is a complex undertaking demanding rapid coordination of care by multiple physicians, nurses and hospital staff. In 2006, the D2B alliance was launched, listing emergency physician-initiated Code STEMI as a method to reduce the door to balloon time.25 The success of CODE STEMI program in reducing D2BT thus reducing the in-hospital MACE and mortality in our institution was made possible by changing the system that previously required a step-by-step serial processes to a parallel process system with simultaneous activation of the catheterisation laboratory, the cardiology on call, the interventional cardiologist on call, and the administrative and clerical staff. This strategy has been shown to reduce transfer time from ED to catheterization laboratory and the arrival of catheterization laboratory team.
In our study, the mean age of presentation was 57 years, which is almost a decade earlier than that reported in several other studies.26,27 It highlights the fact that people tend to get STEMI at younger age these days, especially in our country. Moreover, our patients have a high prevalence of risk factors for coronary artery diseases especially hypertension, diabetes mellitus, and dyslipidemia. This emphasizes the increased incidence of metabolic syndrome as a risk factor of atherosclerosis, which is the main cause of most STEMI. Therefore, a well-designed program to deal with the consequences is very much needed. Our country established a universal health coverage insurance program from the government so the cost efficiency of the program is also an important aspect to be aware of to maintain the national healthcare financial stability.
Although the number of patients included in this study is relatively small, the trends in favourable outcomes are encouraging and generalisable to most healthcare organisations, especially for general hospitals in developing country. The results of this study reveal that the CODE STEMI program will provide immense benefit when implemented in general hospitals where there are myriad patients with multivarious diseases, due to its optimal result albeit easy implementation and low cost. A larger sample size might be able to reveal a significant differences in the in-hospital MACE and mortality between the two groups.
Our study had several limitations. First of all, it is a retrospective cohort study without randomization to either CODE STEMI or Pre CODE STEMI group. Our study is a also single-center study with data collected specific to our institution, so the result might not reflect the performance of other general hospitals. Furthermore, there might be confounding factors that could affect the clinical outcomes between the year 2015 to 2018, such as physician and interventional cardiologist clinical experience and skills which can improve throughout the years.