ACC: The ABCs of D2Bs

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Integrating three distinct care segments into primary PCI facilities can improve overall STEMI response and help improve door-to-balloon (D2B) times, according to data presented at a poster presentation at the 60th annual American College of Cardiology scientific sessions last week in New Orleans.

Jason C. Hatch, MD, of the Saint Luke’s Hospital in Kansas City, Mo., and colleagues set out to see whether a process of care model including three segments—door to activation (D2A), activation to the cath lab (A2C) and cath lab to balloon inflation (C2B)—could help improve D2B times and decrease mortality.

“Prompt and complete myocardial reperfusion or ‘door-to-balloon’ (D2B) time, is increasingly used as a quality care metric for ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention (PCI),” Hatch et al wrote.

When D2B times are delayed, outcomes are reduced and mortality is increased, particularly in STEMI patients undergoing PCI.

The model used the following criteria:
  • Using D2A in the emergency room with activation occurring within 15 minutes (goal);
  • Having a nurse responsible to initiate A2C within 30 minutes; and
  • Having the cardiologist become responsible for C2B within 30-45 minutes of patients presentation.

The authors said that the care model should be performed in parallel rather than sequentially and should be multidisciplinary team-based approach including nursing, emergency, cardiology and a 24/7 STEMI nurse who should oversee all care aspects.

The study showed that STEMI response times went from 86 minutes in 2005 to 66 minutes in 2009 after the care processes were changed, and while 54 percent of D2B times were under 90 minutes in 2005, these numbers improved to 85 percent in 2009.

From 2005 to 2009, rates for door to activation, activation to cath lab and cath lab to balloon inflation improved from 16 min. to 6 min., 48 min. to 39 min., and 27 min. to 17 min., respectively.

“Focusing on reducing D2B times is manageable when divided into care segments, which highlight individual and departmental responsibilities, and allow for analysis of data where delays or lengthy response for treatment time intervals exist,” the authors concluded.

The authors hope that the dissemination of these types of care model improvements will help improve D2B times and help other facilities in enhancing their own D2B protocols.