ACC NEWS
President’s Page: GAP-D2B: An Alliance for Quality
Steven E. Nissen, MD, FACC, President, American College of Cardiology*,
John E. Brush, Jr, MD, FACC and
Harlan M. Krumholz, MD, FACC
* Address correspondence to:
Dr. Steven E. Nissen, American College of Cardiology, c/o Cathy Lora, 2400 N Street, NW, Washington, DC 20037.
Randomized clinical trials have established that percutaneous coronary intervention (PCI) is the preferred strategy for acute reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) (1
). The time from symptom onset until mechanical reperfusion is a critical determinant of the effectiveness of this approach (2
). Current guidelines recommend performing primary PCI within 90 min of hospital arrival (3
). The 90-min threshold from presentation (door) to reperfusion (balloon) has even been included recently in national measures of hospital quality (4
).
American College of Cardiology (ACC) guidelines tell us that we should reliably achieve door-to-balloon times of <90 min, yet outcomes research tells us that across the nation we achieve that goal only about 35% of the time. Contemporary data portray the majority of patients with STEMI with door-to-balloon times exceeding 90 min (5
).
Responding to these statistics, the ACC is introducing a bold new national quality improvement initiative called GAP-D2B or Guidelines Applied in Practice–Door to Balloon. This initiative seeks to improve the quality of care of patients with STEMI by helping participating hospitals shorten door-to-balloon times.
GAP-D2B was introduced to ACC State Governors at the September 2006 Legislative Conference in Washington, D.C. Because success of the D2B initiative will require broad participation of hospitals and physician leaders nationwide, the College is now recruiting participating hospitals, physician champions, and nurse champions. ACC members who are interested in attending a workshop on GAP-D2B November 12th in Chicago may contact Jason Byrd or Amy Stern (jbyrd{at}acc.org
or astern{at}acc.org
).
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How D2B will work
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How will the D2B initiative improve the performance of hospitals and physicians? A key strategy will be the sharing of "best practices" across the network of participating centers and physicians. We envision a collaborative community of participants who will learn from each other. Studies tell us that the most successful hospitals implement a few key strategies to reduce door-to-balloon times. In GAP-D2B, we will create an awareness of these research findings and ask participating hospitals to implement these simple, evidence-based strategies. The goal is to achieve a door-to-balloon time of 90 min or less in 75% of STEMI patients treated with primary percutaneous intervention at participating hospitals.
In successful hospitals, the arrival of a STEMI patient initiates a chain of well-orchestrated events, including activation of the catheterization laboratory directly by an emergency department physician with a single phone call to the interventional cardiologist on call. The catheterization laboratory team is expected to arrive within 20 to 30 min. Programs with the best outcomes employ a multidisciplinary team-based approach that includes committed administrators, physician champions, and nurse champions, along with mechanisms for rapid data feedback. This collaboration can extend to the local and regional emergency medical systems (EMS). In some successful hospitals, the catheterization laboratory is activated based on a pre-hospital electrocardiography.
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Building on GAP projects
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In designing this new GAP-D2B initiative, the ACC will build on the Guidelines Applied in Practice experience in Michigan and other states. These GAP pilot projects demonstrated that quality-of-care initiatives effectively stimulate hospitals to organize for quality improvement. The College hopes to create a network of ACC chapters, participating hospitals, physicians, and nurses that will be a framework for GAP-D2B and a collaborative group also that can support future quality initiatives to address other quality-of-care challenges.
The GAP-D2B initiative is the result of months of planning and the hard work of many people. The Quality Strategic Directions Committee formulated the idea for a national GAP project to address door-to-balloon time at its retreat in January 2006. The proposal was presented to the Executive Committee and the Board of Trustees of the College in March 2006. Since then, many dedicated ACC staff members from virtually every division of the ACC have worked diligently to create the infrastructure to support this project. A workgroup was appointed, chaired by Harlan Krumholz. Twenty-two ACC members serve on five subgroups that plan and manage various aspects of the project. These subgroups have formulated the evidence-based strategies and have created plans for implementation, coordination, and evaluation of the project.
The initiative draws on many of the strengths of the ACC, particularly the ACC chapters and governors, who will provide a nodal organizational network to help the national ACC staff implement the project. The ACC chapters and governors will play a pivotal role in recruiting hospitals, physician champions and nurse champions. All 39 chapters have committed to participating in this initiative. We hope that GAP-D2B will create a quality-of-care mission for ACC chapters that will invigorate and energize our chapters.
Numerous organizations have endorsed, sponsored, or partnered with the ACC, and we have received commitments from more than 20 organizations, including the Joint Commission for Accreditation of Hospitals (JCAHO), the National Heart, Lung, and Blood Institute (NHLBI), the Society of Cardiovascular Angiography and Intervention (SCAI), Premier, Inc., and the Voluntary Hospitals of America (VHA). Discussions with other organizations are ongoing, and we anticipate that the American Heart Association, the American College of Emergency Physicians, and the Institute for Healthcare Improvement will be key partners.
Even before the official recruitment began, more than 140 hospitals from across the country have expressed interest in participating. The ACC is also reaching out to the international health community, which has sparked the interest of hospitals in five other countries. We expect that hundreds of hospitals will formally join this effort. Participating institutions will sign a participation agreement, committing to implement evidence-based strategies. Hospitals will continue to report their door-to-balloon time data to CMS and JCAHO and will not be required to collect additional data, making participation relatively easy and cost-free. We plan to analyze the project using existing data sources. Hospitals will be analyzed in aggregate and will not be identified by name in any analysis or report of the initiative.
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Core to quality mission
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The GAP-D2B initiative is unique in that it provides participating ACC members and their hospitals practical tools to improve outcomes. Guidelines tell us "what" to do, but typically leave the "how" to physician discretion. Achieving consistent and rapid door-to-balloon times, however, is beyond the control or discretion of individual physicians. Door-to-balloon time involves "systems thinking" and coordinated efforts among many individuals and hospital departments. For complex processes involving multiple participants, the "how" becomes particularly important, and dissemination of consensus statements and shared best practices is particularly relevant.
This initiative is important to the overall ACC mission "to advocate for quality cardiovascular care." It supports our past and future strategies for applying guidelines to practice. It complements other important quality work at the College, including the National Cardiovascular Data Registry (NCDR) and the committees that write the guidelines, performance measures, data standards, and appropriateness criteria.
The ACC is also working with the American Board of Internal Medicine (ABIM) to establish the process for physicians seeking recertification to get credit for their efforts on the GAP-D2B. Members will also receive CME credit for participating.
Participation in GAP-D2B will help our members prepare for the future, which almost certainly will bring more emphasis on quality, public reporting and pay for performance.
There is no better way to educate our members about quality improvement than an innovative quality improvement initiative. This program also strongly supports our advocacy positions, by leading the country in a nationwide quality improvement effort. Help us make the GAP-D2B initiative a success. If your hospital performs primary percutaneous intervention for STEMI, insist that your hospital participate. Become personally involved as a physician or nurse champion. Using simple tools, this organized approach can save lives.
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References
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1. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials Lancet 2003;361:13-20.[CrossRef][Web of Science][Medline]2. Cannon CP, Gibson CM, Lambrew CT. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction JAMA 2000;283:2941-2947.[Abstract/Free Full Text] 3. Antman EM, Anbe DT, Armstrong PW, et al. American College of Cardiology; American Heart Association; Canadian Cardiovascular Society ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summaryA report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:671-719.[Free Full Text] 4. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA clinical performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the ACC/AHA Task Force on Performance Measures (ST-Elevation and Non–ST-Elevation Myocardial Infarction Performance Measures Writing Committee) J Am Coll Cardiol 2006;47:236-265.[Free Full Text] 5. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002–2004 N Engl J Med 2005;353:255-264.[CrossRef][Web of Science][Medline]
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Top
How D2B will work
Building on GAP projects