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Aggressive Measures to Decrease "Door to Balloon" Time and Incidence of Unnecessary Cardiac Catheterization:
Zaher Fanari1, Niksad Abraham2, Paul Kolm3
1Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
Insights
Reducing door to balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) increased false-positive diagnoses and associated mortality. Careful monitoring is essential to balance speed with diagnostic accuracy and patient safety.
Area of Science:
- Cardiology
- Emergency Medicine
- Quality Improvement
Background:
- Rapid reperfusion therapy is critical for ST-segment elevation myocardial infarction (STEMI).
- Decreasing door to balloon (DTB) time is a key performance metric.
- The impact of aggressive DTB time reduction on diagnostic accuracy and patient outcomes requires evaluation.
Purpose of the Study:
- To assess the effect of an aggressive protocol to shorten DTB time on false-positive STEMI (FP-STEMI) diagnoses.
- To evaluate the impact on in-hospital mortality in patients with presumed STEMI.
- To determine if a quality improvement initiative could maintain short DTB times while improving outcomes.
Main Methods:
- A retrospective analysis of 1031 patients with presumed STEMI undergoing emergent catheterization.
- Comparison of outcomes before and after implementing an aggressive DTB time reduction protocol.
- Assessment of outcomes before and after a quality improvement initiative aimed at maintaining short DTB times.
Main Results:
- The aggressive DTB time protocol significantly reduced median DTB time (76 to 61 minutes).
- This reduction was associated with a significant increase in FP-STEMI incidence (7.7% to 16.5%).
- In-hospital mortality increased significantly in FP-STEMI patients (P=.03) despite a QI initiative maintaining short DTB times and decreasing FP-STEMI mortality.
Conclusions:
- Aggressive DTB time reduction strategies can increase FP-STEMI and associated in-hospital mortality.
- Systematic monitoring is crucial to prevent unnecessary procedures and potential delays in care for critically ill patients.
- Quality improvement initiatives can help maintain short DTB times while mitigating adverse outcomes.
Objective:
To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy ("door to balloon [DTB] time") on the incidence of false-positive (FP) diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality.
Patients And Methods:
The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison.
Results:
Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality.
Conclusion:
Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients.
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