[TCT2007]Nationwide Initiatives Reducing Door-to-Balloon Times

Mayo Clinic hospitals reduced door-to-ECG time from 14 minutes to 4 minutes.

Individual hospital systems as well as nationwide programs focused on reducing door-to-balloon times are showing great promise.

At Saint Marys Hospital, a Mayo Clinic hospital in Rochester, Minn., door-to-balloon times have decreased from 90 minutes to 66 minutes in the past 3 years.

“Eighty percent of our patients have a door-to-balloon of 90 minutes or less,” said Henry H. Ting, MD, an associate professor of medicine at the Mayo Clinic. He and his colleagues evaluated door-to-balloon times for 402 patients between May 2004 and June 2007 (Figure 1).

The door-to-balloon time at Saint Marys Hospital for regular hours is now a median of 64 minutes, and for off-hours, 74 minutes, Ting said. He found that the extra time during offhours occurs mostly between catheterization lab activation and catheterization lab arrival: a median of 14 minutes during regular hours vs. a median of 24 minutes during off-hours.

The Mayo Clinic has also implemented a “100-day” project to expand the new processes to the five other Mayo hospitals and has already seen dramatic decreases, Ting said. Doorto-ECG times have decreased from a median 14 minutes to 4 minutes.

This was accomplished by changing the door-to-balloon process so that when patients arrive at the hospital with chest pain, they undergo an ECG and an evaluation by the emergency department staff followed by catheterization lab activation and by final treatment. Saint Marys removed the two previous steps of evaluation by a cardiac-care unit (CCU) fellow and debrief to the CCU department,which had happened before cath lab activation under the old plan.

D2B Alliance and“Mission: Lifeline”

Harlan Krumholz, MD, professor of internal medicine and epidemiology at Yale University in New Haven, Conn., said that other hospitals also have reported successful door-to-balloon reduction times under the D2B Alliance, launched by the American College of Cardiology. MUSC Medical University of South Carolina is one such example (Figure 2).

Krumholz is a member of the D2B Alliance’s evidence-based review subgroup. He reported that more than 900 hospitals now have joined the D2B Alliance; the Alliance has 38 strategic partners, including the American Heart Association.

The AHA launched its own nationwide initiative called “Mission: Lifeline” earlier this year. Alice Jacobs, MD, professor of medicine at Boston University Medical Center and past president of the AHA, presented information regarding the implementation and initial success of “Mission: Lifeline” on Sunday at TCT 2007.
Jacobs cited data from a study examining door-to-balloon time between 1994 and 2004. During this period, the number of nontransfer patients for whom door-to-balloon treatment time was 90 minutes or less increased from 33.1% to 41%. The number of transfer patients for whom door-to-balloon treatment time was 90 minutes or less increased from 3.9% to 5.4%.

Jacobs acknowledged that several limitations exist that may inhibit optimal door-to-balloon time for some patients. “More than 50% of patients do not use EMS,” she said. “Furthermore, the majority of EMS systems do not do 12-lead ECG. Other limitations include the geographic distribution of hospitals, the typically prolonged transfer in rural settings, financial disincentives for patient transfer, and the current common slow transfer times.”
The AHA is now evaluating existing models for STEMI treatment.

Reduce cath lab delays

Reducing cath lab-to-balloon times can improve performance and patient outcomes, according to Jeptha P. Curtis, MD. Potential improvement strategies to reduce delays require setting high expectations, engaging personnel, fostering innovation, and providing feedback.

Curtis, instructor of medicine, section of cardiovascular medicine, Yale University, presented data from a Web-based survey of 365 hospitals using 28 candidate strategies, several of which involved in-lab processes.
Another strategy to reduce delays is cath lab preparation, which includes a sterile table ready for off-hours, and a cross-trained ED and CCU, according to Curtis.

In the Web survey, 88% of responders said the lab was generally prepared in off-hours (door-to-balloon time, 105 min), 7% said it was not (door-toballoon, 103 min), and 5% said there is no policy in place (door-to-balloon, 109 min; P = .49 for all).

Most responders (95%) said their staff is not cross-trained. Door-toballoon times were lower among responders with a cross-trained staff (98 min vs. 105 min; P = .22).

Another improvement strategy involves a cath lab staff that arrives within 30 minutes of being paged – 20 minutes if possible, Curtis recommended. In the survey, 56% of responders said their staffgenerally responds within 21 to 30 minutes (door-to-balloon, 102 min). Thirteen percent reported a staff that responds in under 20 minutes of the page, and this group had the lowest door-to-balloon time of 97 minutes (P < .05 for all). Delays can also be ameliorated by clearing the lab when a patient with acute MI arrives, Curtis said. Nearly all responders (96%) routinely prioritize patients in this situation, and doorto- balloon times were lowest among these responders (104 min) but not different than responders who do not bump patients (107 min).