Sustaining and spreading reduced door-to-balloon times for ST-segment elevation myocardial infarction patients
Jay Cyr1, Peter Paige, Paula Paige
1Heart and Vascular Center of Excellence, UMass Memorial Health Care, Worcester, Massachusetts, USA. Jay.Cyr@umassmemorial.org
Insights
Implementing a STEMI initiative significantly reduced door-to-balloon times for ST-segment elevation myocardial infarction (STEMI) patients. This improved care pathway led to decreased mortality rates and faster treatment, enhancing patient outcomes.
Area of Science:
- Cardiology
- Healthcare Management
- Public Health
Background:
- Prompt primary percutaneous coronary intervention (PCI) is crucial for ST-segment elevation myocardial infarction (STEMI) patients, reducing mortality and morbidity.
- The American College of Cardiology (ACC) and American Heart Association (AHA) aimed to reduce door-to-balloon (D2B) times to under 90 minutes for 75% of STEMI cases by 2004.
- UMass Memorial implemented a regional STEMI care system in 2006, extending the initiative to prehospital emergency medical services.
Purpose of the Study:
- To improve door-to-balloon (D2B) times for ST-segment elevation myocardial infarction (STEMI) patients.
- To reduce mortality and morbidity associated with STEMI through optimized treatment pathways.
- To implement and evaluate a regional STEMI care system.
Main Methods:
- The STEMI/D2B leadership team analyzed and streamlined D2B time into four segments: door to data, data to diagnosis, diagnosis to decision, and decision to device.
- The initiative was expanded from internal hospital processes to include prehospital emergency medical services.
- A regional system was rolled out to community hospitals lacking on-site PCI capabilities.
Main Results:
- In the first full year (2007), 94% of STEMI cases achieved D2B times under 90 minutes, with 62% under 60 minutes.
- By 2008, 96% of D2B times were under 90 minutes, and direct-admit STEMI patients averaged under 50 minutes.
- Mortality rates following PCI for STEMI were significantly lower than predicted (62% in 2006, 57% in 2007).
- The ACC/AHA metric of prehospital ECG to balloon time under 90 minutes was achieved in 90% of eligible patients.
Conclusions:
- The D2B time optimization process has demonstrated significant success in improving STEMI care.
- The established D2B protocol is being adapted for other clinical areas, such as reducing door-to-incision time for ruptured abdominal aortic aneurysms.
- The initiative highlights the effectiveness of systematic process improvement in reducing critical treatment times and improving patient outcomes.
Background:
Prompt primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity. In 2004 the American College of Cardiology (ACC) and American Heart Association (AHA) set a goal to reduce door-to-balloon (D2B) time to < 90 minutes in 75% of STEMI cases. IMPLEMENTING THE STEMI INITIATIVE: In 2004, the STEMI/D2B leadership team broke down D2B time into four segments: door to data, data to diagnosis, diagnosis to decision, and decision to device. Each segment was examined for inefficiencies, duplication, and nonstandardization. In 2005, after the internal D2B processes and results showed improvement, the STEMI/D2B leadership team extended the project to prehospital emergency medical services. In 2006, UMass Memorial began to roll out a regional system for STEMI care to the 12 community hospitals in its service area without on-site PCI capabilities.
Results:
In 2007, the STEMI program's first full year, D2B times averaged < or = 90 minutes in 94% of the 87 STEMI cases; 62% had a D2B of < or = 60 minutes. In 2008, 96% of the D2B times averaged < or = 90 minutes. Mortality rates following PCI for STEMI were 62% and 57% less than predicted in 2006 and 2007, respectively. In 2008 the D2B time for direct-admit STEMI patients averaged < 50 minutes. From December 2007 through April 2009 UMass Memorial achieved the new ACC/AHA metric of prehospital EKG to balloon in < or = 90 minutes for 64 (90%) of the 71 patients for whom a prehospital electrocardiogram was obtained.
Discussion:
The D2B time process is being applied to other clinical venues; a vascular surgery project is underway to reduce "door-to-incision time" for patients with ruptured abdominal aortic aneurysms.
