[TCT2007]New Programs Help Reduce Door-to-Balloon Time

New Programs Help Reduce Door-to-Balloon Time

An increasing number of patients now receive balloon angioplasty in less than 90 minutes.

In the past 12 years, the number of nontransfer patients receiving balloon angioplasty treatment within 90 minutes of entering the hos¬pital has nearly doubled, from 34% of patients to approximately 65%.

To further help this trend, the American Heart Association implemented “Mission: Lifeline,” an initiative meant to lower door-to-balloon time even more. Hospitals nationwide now are implementing programs to make sure STEMI patients receive balloon angioplasty in less than 90 minutes.

Another factor contributing to this improvement is faster transport times, according to William J. French, MD, from the Harbor-UCLA Medical Center. Nationally, symptom onset-to-door times decreased from approximately 1.75 hours in 2001 to 1.4 hours in 2006.

Another contributing factor is the care patients receive once they arrive at the hospital. Studies show IV lytic therapy has decreased to 15% and primary PCI has increased in the past 5 years to 65%. For nontransfer patients, the door-to-catheterization lab time decreased from nearly 80 minutes in 1994 to approximately 50 minutes in 2006.

French pointed to lagging transfer times and delays as one problem impacting door-to-balloon time for STEMI patients. However, studies show transfer times also are decreasing from 6.4 hours in 1994 to approximately 2.5 hours in 1996.

The number of hours between symptom onset and balloon treatment continues to decrease for both transfer and nontransfer patients when considering STEMI on first ECG only. In 1994, the time between symptom onset and balloon treatment was approximately 6.9 hours compared with 4.3 hours in 2006. Comparatively, for nontransfer patients, this time decreased from approximately 4 hours in 1994 to 3.2 hours in 2006.

French noted that it is important to lessen delay in treatment because time delays lead to increased mortali¬ty during hospitalization. The percent of primary PCI patient deaths during hospitalization decreased from 9.7% in 1990 to 4.2% in 2004 in nontrans¬fer patients and from 5.3% to 4.2% in transfer patients.

Studies also show that patients who have prehospital ECGs decrease their door-to-balloon times. The goal, according to French, is to achieve timely access to PCI for STEMI patients.

Indianapolis program

Umesh Khot, MD, from the St. Francis Heart Center in Indianapolis, Ind., discussed initiatives designed to reduce door-to-balloon time that were implemented in his hospital in 2005. The hospital’s staff resolved to ensure that emergency department physicians activated the catheterization lab when patients with STEMI were admitted.

Furthermore, a policy was implemented to guarantee that patients would be immediately transferred to an available cath lab by in-house nursing staff. To further reduce time, a cardiologist would evaluate the patient in the emergency department, en route to the cath lab, or in the cath lab.

The program was associated with a significant reduction in door-to-balloon times. Prior to its implementation, 28% of patients achieved door-to-balloon time in 90 minutes or less. Following implementation, this percentage increased to 71%.

Khot said the average door-to-bal¬loon time for STEMI patients admitted to his hospital during regular hours is now about 43 minutes. During nights and weekends, the average door-to-balloon time is about 70 minutes. The average door-to-balloon time for transfer patients is about 75 minutes.

The program also has had a significant benefit on total hospital cost per patient (Figure).

 
Boston initiative

Kenneth Rosenfield, MD, section head of vascular medicine and intervention in the Division of Cardiology at Massachusetts General Hospital, discussed recent initiatives in Boston intended to reduce door-to-balloon times. The Boston program dictates that all STEMI patients are transported only to PCI-capable hospitals. This reduces the likelihood that these patients will have to be transferred between hospitals.

Rosenfield said the citywide effort has already achieved results. In 2006, 73% of patients with STEMI experienced door-to-balloon times of 90 minutes or less. This increased from 64% in 2004. In 2006, the average door-to-balloon time was 67.5 minutes. This was a reduction from 83.5 minutes in 2004 and 73 minutes in 2005.

“Significant reductions were achieved in door-to-balloon time as a result of a citywide effort spearheaded by Boston EMS working together with laboratory leaders and emergency department leaders,” he said.Gregory A. Braden, MDGregory A. Braden, MD, a pioneer in the treatment of patients with complex coronary artery disease and emerging interventional devices, died on August 13, 2007, at the age of 50.Dr. Braden was a yearly faculty member at the annual TCT Symposium in addition to numerous other courses sponsored by the Cardiovascular Research Foundation. He was a superb clinician as well as a dedicated academic interventional cardiologist. We will greatly miss Greg’s talents and insights, inspiration, camaraderie, and heartwarming humor. the Cardiovascular Research FoundationIn Memoriam.