title: Sustaining improvement in door-to-balloon time over 4 years: the Mayo clinic ST-elevation myocardial infarction protocol.
abstract: BACKGROUND
  American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) <90 minutes for nontransferred patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention. Systems of care to achieve and sustain this DTB performance over several years have not been previously reported.
  
  
  RESULTS
  The Mayo Clinic STEMI protocol was implemented in April 2004 and included activation of the cardiac catheterization laboratory by the emergency medicine physician; a single call system to activate the catheterization laboratory; catheterization laboratory staff arrival within 20 to 30 minutes of activation; and real-time performance feedback within 24 to 48 hours. Data were collected on nontransferred STEMI patients. The preimplementation group (June 2002 to March 2004) comprised 96 patients with a median DTB of 97 (interquartile range, 82, 130) minutes, and 40% had a DTB <90 minutes. The postimplementation group (May 2004 to March 2008) comprised 322 patients with a median DTB of 67 (interquartile range, 55, 82) minutes, and 81% had a DTB <90 minutes. Postimplementation DTB was significantly shorter than preimplementation DTB (P<0.001). In the 4-year follow-up after protocol implementation, the DTB performance remained stable over time (P=0.41).
  
  
  CONCLUSIONS
  The Mayo Clinic STEMI protocol implemented strategies to reduce DTB for nontransferred patients with STEMI. DTB was significantly reduced, and the results were sustained over the 4-year follow-up period. Our experience demonstrates the effectiveness and durability of process changes targeting timeliness of primary percutaneous coronary intervention.
authors.affiliation: Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA. nestler.david@mayo.edu
authors.forename: David M
authors.initials: DM
authors.lastname: Nestler
authors.forename: Amit
authors.initials: A
authors.lastname: Noheria
authors.forename: Luis H
authors.initials: LH
authors.lastname: Haro
authors.forename: Latha G
authors.initials: LG
authors.lastname: Stead
authors.forename: Wyatt W
authors.initials: WW
authors.lastname: Decker
authors.forename: Lori N
authors.initials: LN
authors.lastname: Scanlan-Hanson
authors.forename: Ryan J
authors.initials: RJ
authors.lastname: Lennon
authors.forename: Choon-Chern
authors.initials: CC
authors.lastname: Lim
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
authors.forename: Charanjit S
authors.initials: CS
authors.lastname: Rihal
authors.forename: Malcolm R
authors.initials: MR
authors.lastname: Bell
authors.forename: Henry H
authors.initials: HH
authors.lastname: Ting
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D004562:Electrocardiography; D004632:Emergency Medical Services / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D015397:Program Evaluation; D011787:Quality of Health Care; D013997:Time Factors; D014187:Transportation of Patients / Q000592:standards