Sustaining and spreading reduced door-to-balloon times for ST-segment elevation myocardial infarction patients.
BACKGROUND
Prompt primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity. In 2004 the American College of Cardiology (ACC) and American Heart Association (AHA) set a goal to reduce door-to-balloon (D2B) time to < 90 minutes in 75% of STEMI cases. IMPLEMENTING THE STEMI INITIATIVE: In 2004, the STEMI/D2B leadership team broke down D2B time into four segments: door to data, data to diagnosis, diagnosis to decision, and decision to device. Each segment was examined for inefficiencies, duplication, and nonstandardization. In 2005, after the internal D2B processes and results showed improvement, the STEMI/D2B leadership team extended the project to prehospital emergency medical services. In 2006, UMass Memorial began to roll out a regional system for STEMI care to the 12 community hospitals in its service area without on-site PCI capabilities.


RESULTS
In 2007, the STEMI program's first full year, D2B times averaged < or = 90 minutes in 94% of the 87 STEMI cases; 62% had a D2B of < or = 60 minutes. In 2008, 96% of the D2B times averaged < or = 90 minutes. Mortality rates following PCI for STEMI were 62% and 57% less than predicted in 2006 and 2007, respectively. In 2008 the D2B time for direct-admit STEMI patients averaged < 50 minutes. From December 2007 through April 2009 UMass Memorial achieved the new ACC/AHA metric of prehospital EKG to balloon in < or = 90 minutes for 64 (90%) of the 71 patients for whom a prehospital electrocardiogram was obtained.


CONCLUSIONS
The D2B time process is being applied to other clinical venues; a vascular surgery project is underway to reduce "door-to-incision time" for patients with ruptured abdominal aortic aneurysms.
Cyr
Jay
J
Heart and Vascular Center of Excellence, UMass Memorial Health Care, Worcester, Massachusetts, USA. Jay.Cyr@umassmemorial.org
Paige
Peter
P
Paige
Paula
P
Fisher
Daniel
D
D000046:Academic Medical Centers; D015906:Angioplasty, Balloon, Coronary; D004059:Diffusion of Innovation; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006764:Hospitals, Community; D006801:Humans; D008404:Massachusetts; D009203:Myocardial Infarction / Q000628:therapy*; D019982:Organizational Case Studies; D010360:Patient Transfer; D012017:Referral and Consultation; D014218:Triage / Q000379:methods*