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PCI: Small Changes Can Improve Door-to-Balloon Times

Activating the cath lab on the basis of the prehospital or ED ECG is a highly effective strategy.

The Centers for Medicare and Medicaid Services has set a door-to-balloon time standard of 90 minutes, but only a minority of U.S. hospitals achieve this goal. These authors sought to determine which of the many actions involved in the care of ST-segment-elevation myocardial infarction (STEMI) patients are most effective in reducing door-to-balloon time delays. They sent an internet survey asking about 28 discrete strategies to 500 randomly selected hospitals that performed at least 25 percutaneous coronary intervention cases per year. Among the 365 responding hospitals (75%), median door-to-balloon time averaged 100.4±23.5 minutes.

The most effective strategies were related to the time to initial electrocardiogram and staff response to that ECG. Six strategies were associated with significantly faster door-to-balloon times:

• An expectation that staff arrive in the cath lab within 20 minutes of being called (vs. >30 minutes): mean reduction, 19.3 minutes
  
• Use of the prehospital ECG as the basis for cath lab activation: 15.4 minutes
  
• On-site cardiologist: 14.6 minutes
  
• A single call to activate the cath lab: 13.8 minutes
  
• Regular (weekly) feedback to the emergency department and cath lab on performance: 8.6 minutes
  
• Emergency physicians activate the cath lab: 8.2 minutes
  

Inappropriate cath lab activation was uncommon, at a rate of four per year. Most actions dealing with staff processes either in the ED or in the cath lab did not reduce delays.

In an editorial, two cardiologists note that most of the effective strategies are "simple and safe" and do not necessarily add cost. Exceptions are continuous presence of a cardiologist and expecting cath lab staff to arrive within 20 minutes, which the editorialists deemed "difficult to achieve on a wide scale" because of costs and personnel dissatisfaction. They conclude that "it is now time to act" to promote improved survival for patients with STEMI.

Comment: This study has two striking findings: That simple changes can radically improve delivery of care for acute myocardial infarction patients, and that most factors contributing to delays are cultural. The clear message is that avoidable delays are attributable not to inefficiencies within either the ED or the cath lab but to the communication, authority, and trust between the two services.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine November 17, 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.