Door-to-Balloon Time: Shaving minutes off, when minutes count! How low can we go?

Let’s face it, when it comes to myocardial ischemia, minutes count. Period. The nationwide door-to-balloon (D2B) guideline is under 90 minutes, but we all know major adverse cardiac events (MACE), necrosis of heart muscle, and reducing permanent wall motion abnormalities are directly related to the speed at which blood flow can be restored to the myocardium. The question is, how low can you go? Where can we shave minutes off? Is it possible or appropriate to “call it” in the field, bypass the ED and come straight to the cath lab? What are the risks and benefits of doing so? It seems like just yesterday our 254-bed community hospital located in Orange Park, Florida, transitioned from a one-suite, diagnostic-only cath lab to a full-service cardiac and peripheral interventional center. It was October 13, 2008 when our application of waiver was approved to perform ST-elevation myocardial infarction (STEMI) procedures exclusively and just mere months later, we were granted privileges for percutaneous coronary interventions, acute or elective. Throughout 2009, we performed 1,400-plus procedures, justifying an open-heart program and the construction of two brand new cath lab suites. Our call back system began with the patient being diagnosed in the ED; the ED staff would contact the nursing supervisor, who would then page the cath lab call team to a “universal” pager number. Initially, we had some minor technical difficulties with our beepers and the call back process in general. We changed pager companies, changed the pagers themselves, modified and honed the system as needed, and now seem to have found a more streamlined process. The ED staff now notifies the PBX operator, who sends out a mass text and page to the on-call team. The text/page includes the patient’s age, sex, ED room number, first three letters of their last name, and first two letters of their first name. If a cath lab team member does not call back within five minutes, the PBX operator will attempt to call their personal phone number. If still unsuccessful, the cath lab supervisor is contacted. So what’s the next step? Short of having the cath lab call team stay at the hospital 24/7, what can hospital ED staff do to more efficiently prepare the patient while waiting for the call team? Our ED director, Darin Roark, and ED physicians have been phenomenal with their support, experience, and in a way, a sort of “letting go” of control in the ED. Please don’t misunderstand me on this one; I don’t mean providing sub-par care. What I mean is the creation of a system that allows for a quicker hand-off between ED and cath lab. It may mean allowing cath lab staff to help the ED staff by shaving the patient’s groins or doing whatever helps to facilitate getting the patient to the cath lab as quickly as possible. These are responsibilities which usually fall on ED staff, but can easily be done by the cath lab personnel. Sharing responsibility, re-aligning priorities, and collaborating with other departments has been an ongoing learning process for us in order to shave these life-saving minutes off our D2B time. We have also incorporated the help of our local EMS. They hold STEMI meetings to help determine the best way to cut down on D2B times, and analyze and scrutinize the time in the field. These meetings consist of local cardiologists, ED directors and physicians, and hospital administrators from 5 surrounding counties. One issue brought up at these meetings was, “Would calling the STEMI from the field can help to reduce time?” One of our local fire and rescue departments already has the technology to email ECGs directly to our ED, allowing for a time savings. We have also collaborated with another hospital in the area to purchase equipment for our Clay county EMS that will allow ECGs to be sent to specific PCs in the ED, SMS/email, PDA or any other type of handheld device. The ultimate goal is to develop a common initiative that would allow all area hospitals to share in this sort of STEMI network, where data could be shared and analyzed for quality, efficiency and performance improvement. A common STEMI network among all area hospitals creates a path of data collection, allowing cross-referencing of STEMI amounts, types, dates and times of events, and geographical info. The ability to instill a highly reliable system, assuring quality, efficiency, and providing performance improvement measures, only justifies such an investment further. If it can be measured, it can be managed more efficiently and more effectively. Finally, the STEMI meetings have also been holding discussions as to whether it is appropriate to allow the paramedics themselves to call STEMIs in the field. This would allow the cath lab team to be paged immediately and depending on travel time, the team could possibly be waiting on the patient to arrive, rather than the patient waiting on us to arrive. Nonetheless, there is a chunk of time that is being underutilized. The time between the patients being picked up in the field to the actual arrival and diagnosis in the ED could be greatly reduced by calling the STEMI in the field and relaying said info electronically to the nearest PCI facility for cath lab team activation. The feeling and thought process of all individuals involved in these STEMI meetings is not focusing just on D2B time anymore, but now thinking more in the terms of EMS-to-balloon time. The question is, how low can we go without compromising the quality of patient care and keeping to a highly reliable system? With all of this in the works, it’s still yet to be determined what route we will take. But what is clear is that there are very smart people thinking about this topic today, to lay the groundwork for a better tomorrow. In the meantime, we continue to do our part to shave off these precious live-saving minutes in whatever way we can. We have virtually made all D2B times in less than 90 minutes over the last year and a half. We have noticed low and mid 40-minute times when called from the field from Jacksonville Fire and Rescue, and a couple 20-minute times with walk-in arrivals during the day. When I started this article, I thought it would be a quick and easy article to write, but there are many interesting variables that play into the D2B time which I never considered. We can control the variables that occur once the patient arrives to the ED, but what about that window of time before they arrive? How can we manipulate these times even more? The fact is, and remains, that with the availability of sending 12-lead ECGs electronically from the rescue unit, well-qualified field medics calling STEMIs in transit, the coordination of ED and cath lab, redundancy of protocols, and a highly reliable organizational system in place as a whole, 45 minutes should be a very achievable standard. We are just one hospital of thousands that will continue to prove it and that will continually strive to be better for the sake of our patients. n Paul can be contacted at: Paul.Trenteseaux@hcahealthcare.com Note: This version has been altered from the original publication to include updated information from the author.

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