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Strategies to Improve Door-to-Balloon Times for STEMI
Researchers identified multiple strategies associated with faster D2B times at U.S. acute-care hospitals.
When reperfusion therapy is provided promptly to patients with ST-segment-elevation MI (STEMI), survival benefits are substantial. However, few institutions meet the guideline-recommended door-to-balloon (D2B) time of less than 90 minutes for primary percutaneous intervention (PCI).
To identify the institutional strategies associated with faster D2B times, researchers sent online surveys to 500 U.S. acute-care hospitals randomly selected from among 818 that had PCI volumes of at least 25 cases in 2004 and that reported their D2B performance to the Centers for Medicaid and Medicaid Services. Most hospitals (73%) responded to the survey.
Median D2B times ranged widely among the hospitals, averaging 100 minutes. Strategies independently associated with faster D2B times included having ED physicians activate the catheterization lab directly (implemented by <30% of hospitals and associated with an 8.2-min improvement in D2B time); ED activation of the lab while the patient was en route, based upon a prehospital ECG (9.0%, 15.4 min); using a single page operator to activate the lab (13.7%, 13.8 min); having an expectation that lab staff arrive within 20 minutes of lab activation (10.7%, 19.3-min advantage compared with expected arrival >30 min of lab activation); having an on-site attending cardiologist at all times (3.8%, 14.6 min); and providing real-time data feedback to ED staff (41.5%, 8.6 min). Policies about ECG performance in the ED, about the timing and staff required to transport patients from the ED to the cath lab, and about lab processes showed no association with D2B times. Notably, false alarms were rare, even when ED physicians directly activated the lab or when prehospital ECGs were used for activation.
Comment: This study identified specific institutional strategies that were associated with quantitative improvements in D2B times for STEMI. The editorialists note that although some strategies (e.g., continuous in-house cardiology coverage) are unrealistic for many hospitals, most of the strategies would not require substantial additional resources. Right now, most hospitals don’t implement even the low-cost strategies, and this study provides them with realistic targets for improving D2B benchmarks and, thereby, STEMI outcomes.
— Frederick A. Masoudi, MD, MSPH
Published in Journal Watch Cardiology November 13, 2006
Citation(s):
Bradley EH et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006 Nov 30; 355:2308-20.
Moscucci M and Eagle KA. Reducing the door-to-balloon time for myocardial infarction with ST-segment elevation. N Engl J Med 2006 Nov 30; 355:2364-5.