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Improving Door-to-Balloon Time for Patients with ST-Segment-Elevation MI

One institution achieved impressive results with just two changes to its procedure.

Supervisors at most hospitals that perform primary percutaneous coronary intervention for ST-segment-elevation MI (STEMI) track their institutions’ door-to-balloon (D2B) times and try to reduce those times with quality improvement initiatives. In this study, investigators compared median D2B time in 164 consecutive STEMI patients during two time periods at a community hospital. During the first period (October 2004 through August 2005), a cardiologist activated the catheterization lab after evaluating the patient in the emergency department (ED), and transfer to the catheterization lab was not initiated until a catheterization room was available (during regular hours) or until catheterization lab personnel arrived (during off hours). During the second period (September 2005 through June 2006), after initiation of a new protocol, the ED physician activated the catheterization lab directly, and an in-house "heart attack response team" transferred the patient; cardiac evaluation took place either before, during, or after transfer.

Median D2B time decreased from 114 to 76 minutes (P<0.0001) between the first and second study periods. Although reductions were observed during both regular and off hours, a greater reduction (from 124 to 78 minutes) occurred during off hours. Both time spent in the ED and time spent in transfer to the catheterization lab decreased considerably. Other benefits included reductions in mean infarct size (peak creatine kinase from 2623 to 1517 IU/L), mean length of stay (from 5 to 3 days), and mean in-hospital costs (from US$26,826 to $18,280). The proportion of patients treated within 90 minutes increased from 28% to 71%.

Comment: This study shows that clear improvements in D2B time can be achieved by ED-physician activation of the catheterization lab and a dedicated in-hospital transfer team. As the editorialist notes, combining such multidisciplinary single-hospital efforts to reduce D2B time with regional efforts to reduce symptom-to-door time and to utilize PCI centers of excellence could further benefit patients.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology August 1, 2007

Citation(s):

Khot UN et al. Emergency department physician activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction. Circulation 2007 Jul 3; 116:67-76.

• Original article (Subscription may be required)
• Medline abstract (Free)

Ornato JP. The ST-segment–elevation myocardial infarction chain of survival. Circulation 2007 Jul 3; 116:6-9.

• Original article (Subscription may be required)
• Medline abstract (Free)