Using quality improvement methods to improve door-to-balloon time at an academic medical center.
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.
Huang
Robert L
RL
Vanderbilt University Medical Center, 383 Preston Research Building, 2220 Pierce Avenue, Nashville, TN, 37232-6300, USA. robert.huang@vanderbilt.edu
Donelli
Anderson
A
Byrd
Jeannie
J
Mickiewicz
Marc A
MA
Slovis
Corey
C
Roumie
Christianne
C
Elasy
Tom A
TA
Dittus
Robert S
RS
Speroff
Ted
T
Disalvo
Tom
T
Zhao
David
D
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*