title: Aggressive Measures to Decrease "Door to Balloon" Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement.
abstract: OBJECTIVE
  To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy ("door to balloon [DTB] time") on the incidence of false-positive (FP) diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality.
  
  
  METHODS
  The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison.
  
  
  RESULTS
  Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality.
  
  
  CONCLUSIONS
  Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients.
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE. Electronic address: zfanari@gmail.com.
authors.forename: Zaher
authors.initials: Z
authors.lastname: Fanari
authors.affiliation: Heart Health Services, North Oaks Medical Center, Hammond, LA.
authors.forename: Niksad
authors.initials: N
authors.lastname: Abraham
authors.affiliation: Value Institute, Christiana Care Health System, Newark, DE.
authors.forename: Paul
authors.initials: P
authors.lastname: Kolm
authors.affiliation: Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Doorey
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Angela
authors.initials: A
authors.lastname: Herman
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Angela
authors.initials: A
authors.lastname: Hoban
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Vivek
authors.initials: V
authors.lastname: Reddy
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Sumaya
authors.initials: S
authors.lastname: Hammami
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Leonovich
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Ehsanur
authors.initials: E
authors.lastname: Rahman
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE; Value Institute, Christiana Care Health System, Newark, DE.
authors.forename: William S
authors.initials: WS
authors.lastname: Weintraub
authors.affiliation: Center for Heart and Vascular Health, Christiana Care Health System, Newark, DE.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Doorey
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D006328:Cardiac Catheterization; D002985:Clinical Protocols; D004630:Emergencies; D005189:False Positive Reactions; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D058996:Quality Improvement; D061665:Time-to-Treatment; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*