title: Emergency department activation of an interventional cardiology team reduces door-to-balloon times in ST-segment-elevation myocardial infarction.
abstract: OBJECTIVE
  American Heart Association/American College of Cardiology guidelines recommend door-to-balloon times of fewer than 90 minutes in patients with acute ST-segment-elevation myocardial infarction. We hypothesized that immediate activation of an interventional cardiology team (code H) would reduce the time to percutaneous coronary intervention by 1 hour and increase the proportion of patients undergoing percutaneous coronary intervention within 90 minutes of arrival.
  
  
  METHODS
  Study design was a before-and-after trial in an academic suburban emergency department (ED) with a certified cardiac catheterization laboratory. Subjects were a consecutive sample of patients presenting to the ED with ST-segment-elevation myocardial infarction evident on the initial ECG. Patients without chest pain and refusing catheterization were excluded. The intervention was the use of a central paging system for activation of the interventional cardiology team (attending physician, fellow, nurse, technician) by emergency physicians in patients presenting to the ED with ST-segment-elevation myocardial infarction. Measures were demographic and clinical information collected with standardized data collection forms. Outcomes were door-to-balloon times and the proportion of patients undergoing percutaneous coronary intervention within 90 minutes of arrival. Groups were compared with chi2 and t tests.
  
  
  RESULTS
  There were 97 patients included in the study; 43 were treated in the 2 years before implementation of the code H and 54 patients were treated the subsequent 2 years. Mean age (SD) was 56.9 years (13.7), 27% were women, and 86% were white. Groups were similar in age, sex, and race. Implementation of a code H reduced the median door-to-balloon time by 68 minutes (from 176 to 108 minutes; P<.001) and increased the proportion of patients undergoing percutaneous coronary intervention within 90 minutes from 2.8% to 29.0% (mean difference 26.5; 95% confidence interval 15.0 to 36.9). To determine whether further improvements occurred, 48 patients treated in 2006 showed a 20-minute further reduction in door-to-balloon time; 52% underwent angioplasty within 90 minutes of ED presentation.
  
  
  CONCLUSIONS
  Institutional implementation of a protocol that requires emergency physicians to activate an interventional cardiology team response in ED patients with ST-segment-elevation myocardial infarction reduces the door-to-balloon time and increases the proportion of patients undergoing percutaneous coronary intervention within 90 minutes.
authors.affiliation: Department of Emergency Medicine, Stony Brook University, Stony Brook, NY 11794-8500, USA. adam.singer@stonybrook.edu
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Singer
authors.forename: Amit
authors.initials: A
authors.lastname: Shembekar
authors.forename: Farid
authors.initials: F
authors.lastname: Visram
authors.forename: Joshua
authors.initials: J
authors.lastname: Schiller
authors.forename: Valerie
authors.initials: V
authors.lastname: Russo
authors.forename: William
authors.initials: W
authors.lastname: Lawson
authors.forename: Carol A
authors.initials: CA
authors.lastname: Gomes
authors.forename: Carolyn
authors.initials: C
authors.lastname: Santora
authors.forename: Mary
authors.initials: M
authors.lastname: Maliszewski
authors.forename: Lisa
authors.initials: L
authors.lastname: Wilbert
authors.forename: Eileen
authors.initials: E
authors.lastname: Dowdy
authors.forename: Peter
authors.initials: P
authors.lastname: Viccellio
authors.forename: Mark C
authors.initials: MC
authors.lastname: Henry
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D010348:Patient Care Team / Q000458:organization & administration*; D013997:Time Factors