Strategies to Trim Door-to-Balloon Time

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Door-to-balloon time (D2B) is a critical cardiac quality indicator. As a whole, U.S. hospitals are doing fairly well with other quality indicators, says Betsy Bradley, PhD, professor of public health at Yale University in New Haven, Conn., but D2B time is a challenge for many sites. Here are some prescriptions to break the 90-minute barrier.

American College of Cardiology guidelines put the door-to-angioplasty time at 90 minutes for optimal therapy. No more than 90 minutes should pass between the time a STEMI (ST elevation myocardial infarction) patient arrives at the hospital to the angioplasty. There is a high correlation between door-to-balloon time and patient survival, but only 30 to 40 percent of U.S. hospitals meet the guideline, says Bradley. Patients whose angioplasty and stents are completed within the ‘golden hour’ tend to have better outcomes with improved cardiac pumping function and less scarring.

That’s because achieving optimal door-to-balloon time is a complex undertaking that requires a high degree of collaboration among multiple disciplines, reorganized processes and constant vigilance. Nevertheless, hospitals are making progress. More than 900 hospitals enrolled in the American College of Cardiology’s (ACC) D2B: An Alliance for College in the six months since the organization’s inception. About half, such as Saint Mary’s Hospital, a Mayo Clinic hospital in Rochester, Minn., Carolinas Medical Center-NorthEast in Concord, N.C., and Alegent Health hospitals in Omaha, Neb., already meet the 90-minute mark and provide models for their colleagues.

“[Door-to-balloon] strategies are simple and inexpensive. Improvements don’t require a new CT scanner, new drugs, smarter physicians or faster helicopters,” asserts Henry Ting, MD, vice chair division of cardiovascular disease at Mayo Clinic. In fact, it’s possible to produce hefty improvements in door-to-balloon time with minimal investment. The end result, however, is quite powerful as sites that minimize door-to-balloon time can point to improved patient outcomes and care.

This month, Cardiovascular Business details what it takes to meet the 90-minute goal. Individual site prescriptions vary, but there are common denominators among hospitals that meet the mark. These include:

  • Prompt EKG studies
  • Streamlined activation of the cath lab by the ED physician
  • Ongoing and consistent data and process reviews
  • Multidisciplinary teamwork

Inside a D2B pioneer


“There are very few things I can do as a cardiologist in 30 minutes that can have a tangible impact on patient survival, but time and minutes really do matter when it comes to getting patients to the cath lab,” says Ting. Mayo Clinic began evaluating door-to-balloon processes at its two Rochester hospitals in 2003. At that time, the median door-to-balloon time stood at 90 to 92 minutes. “Half of our patients were above the 90 minute ceiling,” says Ting, “we were stunned.”

The clinic mobilized and started a quality improvement process. The goal was straightforward. “We wanted to consistently and reliably achieve a door-to-balloon time of less than 90 minutes at Saint Mary’s Hospital,” states Ting. The goal translates into a median door-to-balloon time of 60 to 70 minutes.

The clinic turned to Lean Six Sigma tools to value stream map every step that occurred after a heart attack patient arrived at the hospital, determining which processes benefit patients and which do not add value to patient treatment. After the initial analysis, Saint Mary’s Hospital implemented four changes.

  • Suspected myocardial infarction patients receive an electrocardiogram (EKG) within five minutes of arrival in the emergency room. The EKG does not sit outside a door waiting to be read. Instead, a nurse places it in the hands of a clinical decision-maker.
  • The ED clinician activates the cath lab team with a single phone call; a group page alerts the entire cath lab team. “Our job is to show up,” sums Ting.
  • The hospital set a benchmark of cath lab response time of 20 to 30 minutes.
  • The entire team participates in a concurrent case review within 24 to 48 hours of each emergency cath case. To avoid delays, notes are sent electronically to all involved staff.

The changes are not earth shattering, but they did produce a significant improvement in door-to-balloon time at Saint Mary’s Hospital. “Each delay adds up,” notes Ting. For example, before the analysis, a suspected myocardial infarction patient would receive an EKG in the ER. Next, the cardiac