title: Using quality improvement methods to improve door-to-balloon time at an academic medical center.
abstract: OBJECTIVE
  1) Describe a quality improvement (QI) process to decrease door-to-balloon time (D2B); 2) Explain implementation of evidence-based strategies to improve D2B.
  
  
  BACKGROUND
  The ACC/AHA 2006 guideline target for ST-elevation myocardial infarction (STEMI) is a D2B of 90 minutes (min). QI methods can be used to identify areas for improvement, measure current processes, and provide rapid-cycle feedback about which strategies are effective.
  
  
  METHODS
  We studied all STEMI patients presenting to Vanderbilt University Medical Center from July 2005 through November 2006. A process flow chart was created and all D2B process steps were analyzed. In February 2006, evidence-based strategies were implemented to address bottlenecks and decrease D2B. Statistical process control (SPC) was used to monitor D2B time in real-time.
  
  
  RESULTS
  Targeted changes led to a 44 min decrease (p < 0.001) in overall median D2B time from 108 min (interquartile range [IQR] = 94-122 min) to 64 min (IQR = 56-94 min). Subinterval time periods for emergency department (ED)-to-electrocardiogram (ECG) time decreased by 7 min (p = 0.008), ECG-to-cardiac catheterization laboratory (CCL) time decreased by 18 min (p = 0.01), and CCL-to-balloon time decreased by 4 min (p = 0.19). After implementation, SPC charts revealed a 50% decrease in the central mean line and narrower control limits indicating more reliable performance.
  
  
  CONCLUSIONS
  Using QI methods of flow-charting, identifying bottlenecks, targeting strategies to bottleneck areas, and real-time monitoring with SPC and rapid-cycle feedback, D2B processes can be systematically redesigned for improvement. QI methods can be used by individual institutions to customize and implement strategies for their particular context.
authors.affiliation: Vanderbilt University Medical Center, 383 Preston Research Building, 2220 Pierce Avenue, Nashville, TN, 37232-6300, USA. robert.huang@vanderbilt.edu
authors.forename: Robert L
authors.initials: RL
authors.lastname: Huang
authors.forename: Anderson
authors.initials: A
authors.lastname: Donelli
authors.forename: Jeannie
authors.initials: J
authors.lastname: Byrd
authors.forename: Marc A
authors.initials: MA
authors.lastname: Mickiewicz
authors.forename: Corey
authors.initials: C
authors.lastname: Slovis
authors.forename: Christianne
authors.initials: C
authors.lastname: Roumie
authors.forename: Tom A
authors.initials: TA
authors.lastname: Elasy
authors.forename: Robert S
authors.initials: RS
authors.lastname: Dittus
authors.forename: Ted
authors.initials: T
authors.lastname: Speroff
authors.forename: Tom
authors.initials: T
authors.lastname: Disalvo
authors.forename: David
authors.initials: D
authors.lastname: Zhao
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data*; D004562:Electrocardiography / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D005260:Female; D006785:Hospitals, University / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D013714:Tennessee; D013997:Time Factors; D013996:Time and Motion Studies; D017749:Total Quality Management / Q000379:methods*