D2B initiative successful, but more facilities need to sign on

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WASHINGTON—The door-to-balloon (D2B) initiative launched by the American College of Cardiology in 2006 has been successful for those who have taken steps to reduce the time it takes to get STEMI patients to the cath lab. A poll of the audience at the Nurse & Technologist Symposium at the 20th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium on Monday morning, however, revealed that 35 percent of them weren’t even aware of the program.

The D2B Alliance advocates six key evidence-based strategies and one optional strategy to help reduce D2B times to under 90 minutes:

• Emergency department (ED) physician activates the cath lab
• Single-call activation system activates the cath lab
• Cath lab team is available within 20-30 minutes
• Prompt data feedback
• Senior management commitment
• Team-based approach
• (Optional) Pre-hospital 12 lead ECG activates the cath lab

Most people involved in a D2B program start the clock running when the patient arrives in the ED. A more recent focus is to start timing the process from first patient contact.

Ideally, door-to-ECG time should be 10 minutes or less. The STEMI team should be activated in less than 10 minutes and the staff should arrive in under 30 minutes. Of course, these timeframes are arbitrary and a facility should pick the times that work with their situations, said Karen Lieberman of Suburban Hospital.

At Suburban Hospital, for example, the STEMI code team set their times for acquiring an ECG at five minutes or less (rather than 10 minutes or less). That was done because they need more time in other areas, such as staff travel to cath lab, which many need more than 30 minutes.  

“You have to match the time frames to your process,” she said.

Another key element is to have consensus on all the elements of D2B program from the various components involved in STEMI patients care, “from the CEOs on down.”

To achieve ideal D2B time, a facility has to have a standardized process in place. To do that, it has to first identify the result it wants to measure. Then it has to identify the data required to measure to achieve that result, the source of that data and the person who will collect the data.  

“It’s great to have one person collect data, someone who is very detail oriented,” Lieberman said.

Lieberman and her team have added a resource nurse who responds to any STEMI case until staff arrive. Results of a 22-month span show they’ve gone from 38 percent to 80 percent of patients being treated in less than 90 minutes.

Michel R. Le May, MD, from the University of Ottawa, said it’s important to start with the science: Primary PCI is better than fibrinolysis—and it’s cheaper. “You’ve got to convince everyone involved that this is the way to go,” he said. From there, you must involve all the key players, including senior management. Most critical in the process is to have standardized processes, Le May said.

Another critical element to help reduce D2B time is for patients to have a pre-hospital ECG performed by the paramedics. “Studies have shown that as D2B times increase, so does mortality,” Le May said.

In Le May’s area, they have trained the paramedics to administer drugs and to read ECGs. Studies have revealed sensitivity and specificity above 95 percent for paramedics to read the ECGs and diagnose MI.

Paramedics call from their cell phones to the hospital, which has a dedicated STEMI phone that only rings for STEMI cases.

They have an area dedicated for STEMI patients and standardized care: every patient gets 600 mg of clopidogrel. They also have a STEMI coordinator who enters the data, troubleshoots the system and gives feedback to the referring physicians.

A study by Le May and colleagues in the New England Journal of Medicine in 2008 found that of 80 percent of patients from the field were treated in less than 90 minutes.

Le May and colleagues also have instituted a program known as repatriation, which refers to sending stable STEMI patients back to their own hospitals once they are ready. This move cuts down on length of stay and opens up precious bed space, he said.