OPTIMIZING DOOR-TO-BALLOON TIME:

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• OPTIMIZING DOOR-TO-BALLOON TIME
• STRATEGIES FOR SUCCESS
• B. Hadley Wilson, MD.
• J. Lee Garvey, MD.
• Patricia M. Pye, RN, MS
• Kevin M. Collier, RCIS
• Carolinas Medical Center

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Background

• Time is Muscle Every 10 minute delay to
  Percutaneous Coronary Intervention (PCI) results
  in a 1 change in mortality
• In 2004, National Registry for Myocardial
  Infarctions (NRMI) data for STEMI reported median
  time for door to reperfusion was 97 minutes, only
  43 were reperfused in less than or equal to 90
  minutes.

Source Nallamothu BK et al, AM Journal
Cardiology 2003
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Process Improvement Case StudyCarolinas Medical
Center (CMC)

• 2004 evaluation demonstrated CMC had
  opportunities for improvement
• 72 minutes EMS patients
• 116 minutes non-EMS patients
• 87 minutes overall
• Multi-disciplinary team was challenged to improve
  Door-to-Balloon process
• EMS, ED Physicians, Cardiologists, ED Staff, Cath
  Lab, CCU, Bed Management, Lab, Radiology,
  Respiratory Care, House Supervisor
• CMCs process improvement plan was based on
  practices paralleling Code Trauma gt Code STEMI

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Process Improvement Case StudyCarolinas Medical
Center (CMC)

• Team developed enhanced goals for Code STEMI that
  exceed the ACC/AHA Standard
• Goal 1 90 of patients reperfused within 60
  minutes of ED arrival (compared to national
  guidelines of lt 90 minutes)
• Goal 2 90 of patients reperfused within 90
  minutes of first medical contact (compared to
  national guideline of lt 90)

Source ACC/AHA Guidelines 7/04
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New CMC ProcessCode STEMI Protocol Driven
Program
Program objective develop a coordinated system
of care - modeled after Code Trauma - that
streamlines the identification, activation, and
provision of treatment for STEMI that surpasses
national targets.

• Identification Medic paramedics are trained to
  acquire and read 12-lead electrocardiograms (ECG)
  on patients suspected of a heart attack. The ECG
  result is quickly transmitted from the field to
  an ED physician at CMC.
• Activation If the ECG shows specific changes in
  certain electrical impulses (ST segments) within
  the heart, the Emergency physician activates
  Code STEMI initiating an immediate response
  from the Code STEMI Team.
• Treatment Patient is received by Code STEMI
  Team upon arrival to CMC ED with a rapid triage
  process to confirm STEMI and then immediately
  transported to the cardiac catheterization lab
  where the coronary artery is opened

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Critical Success Factors

• EMS and ED Physician initiate Code STEMI
• Single page activates entire team gt parallel
  actions commence
• ED and Cath Lab begin preparations
• On-Call Cardiologist and CCU Nurse go to ED
• Respiratory Care and Laboratory are available in
  ED
• Joint assessment occurs in the ED
• Cardiologist and CCU Nurse assist EMS in
  transporting patient to
  Cath Lab
• Patient is prepared for PCI
• Bed Management finds accommodations
• Trust in revised roles and responsibilities

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CMC Code STEMI Protocol Standing Ready 24/7
Patient presents with symptoms of ACS
12 Lead ECG
Dx for STEMI?
Proceed to ED without activation of Code STEMI
No
Yes
Radio report to ED
ED activates Code STEMISimultaneous Page to
CCU
Respiratory
Radiology
Cardiologist on Call
CCL Call Team
Bed Management
Hospital Lab
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Lessons Learned fromCarolinas Medical Center

• It takes real commitment from the
  Multi-disciplinary Team
• EMS, ED Physicians, Cardiologists, ED Staff, Cath
  Lab, CCU, Bed Management, Lab, Radiology,
  Respiratory Care, House Supervisor
• Establish a specific goal to Meet or Exceed ACC
  Standard
• Adopt a continuous process improvement philosophy
  gt on-going monitoring and modification of the
  process
• Intensive education for EMS on acquiring and
  interpreting ECGs
• Recognize that a cultural change is necessary
• Be flexible forward thinking gt all play in
  same sandbox
• Trust in revised roles and responsibilities
• Be patient-focused Time is Muscle

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Bottom Line Results Overall Door-to-Balloon Time
ImprovementsOctober 2004 June of 2006
Number of cases Range Mean (minutes) Median (minutes) lt 90 minutes lt 60 minutes
Before Code STEMI 59 27-289 88.9 76.0 33/59 56 18/59 31
After Code STEMI 153 10 - 172 58.4 54.0 134/153 88 92/153 60
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Bottom Line Results EMS Non EMS
ArrivalsOctober 2004 June of 2006
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Bottom Line ResultsCarolinas Medical Center
Minimizing Time to Treatment from Arrival in the
ED to treatment in the Cath Lab
Saving Lives Mortality Rate
American College of Cardiology Benchmark lt90
minutes
Source  NRMI Solucient