CLINICAL RESEARCH: TREATMENT STANDARDS FOR ACUTE INFARCTION
Achieving Door-to-Balloon Times That Meet Quality Guidelines
How Do Successful Hospitals Do It?
Elizabeth H. Bradley, PhD*,
Sarah A. Roumanis, RN#,
Martha J. Radford, MD, FACC ,#,
Tashonna R. Webster, MPH*,
Robert L. McNamara, MD, MHS,
Jennifer A. Mattera, MPH#,
Barbara A. Barton, RN#,
David N. Berg, PhD ,
Edward L. Portnay, MD,
Harry Moscovitz, MD ,
Janet Parkosewich, RN, MSN**,
Eric S. Holmboe, MD||,
Martha Blaney, PharmD and
Harlan M. Krumholz, MD, SM, FACC*,,¶,#,*
* Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
Section of Emergency Medicine, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
|| Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
¶ Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
# Yale New Haven Health Center for Outcomes Research and Evaluation, New Haven, Connecticut
** Yale New Haven Hospital and Yale University School of Nursing, New Haven, Connecticut
Genentech Inc., South San Francisco, California
Manuscript received August 20, 2004;
revised manuscript received November 17, 2004,
accepted November 22, 2004.
* Reprint requests and correspondence: Dr. Harlan M. Krumholz, Yale University School of Medicine, 333 Cedar Street, P.O. Box 208088, New Haven, Connecticut 06520-8088. (Email: harlan.krumholz{at}yale.edu).
OBJECTIVES: We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally.
BACKGROUND: Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA).
METHODS: We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals.
RESULTS: Top performers were those with median door-to-balloon times of  90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG.
CONCLUSIONS: Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.
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Abbreviations and Acronyms
| | ACC = American College of Cardiology | | AHA = American Heart Association | | AMI = acute myocardial infarction | | ECG = electrocardiogram | | ED = emergency department | | NRMI = National Registry of Myocardial Infarction | | PCI = percutaneous coronary intervention | | STEMI = ST-segment elevation myocardial infarction |
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