Strategies to Trim Door-to-Balloon Time



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 fellow was called. He walked from the floor to the ER, read the data and then called the cardiology staff to report a STEMI. This EKG acquisition review process could eat up 10 minutes or more. Next, the cardiologist activated the cath lab with each person paged sequentially. “Paging could take 30 minutes,” recalls Ting.

“Taking out the unnecessary steps reduces door-to-balloon time,” continues Ting. The proof is in the data at Saint Mary’s. Over the last few years, the data consistently show a median door-to-balloon time of 65 to 66 minutes with 75 to 80 percent of patients under the 90 minute mark.

Based on the success of its local program, Mayo Clinic decided to expand its D2B horizons and invited 28 regional critical access hospitals within 150 miles of Rochester to participate in its fast track program. Before the rural initiative, median door-to-balloon time in the 28-hospital group stood at three hours. But after implementing changes based on the initial success at Saint Mary’s Hospital, the group slashed its door-to-balloon time to 112 minutes, with about half of the time spent in helicopter transport from the home hospital to the cath lab site.

Mayo Clinic initiated a similar quality improvement process at the critical access hospitals, beginning with value stream maps. Some newly standardized procedures mirror those at Saint Mary’s. For example, ED physicians now activate offsite cath labs with a single phone call. Protocols are standardized across all sites, so that all STEMI patients receive the same drugs and preparations. The new and improved process, however, involves a conference call between Mayo Clinic and an ER nurse that provides access to Mayo Clinic’s three helicopters and all emergency helicopters in Minnesota. Ting insists, “Our intent with the fast track initiative was not to grow our market share, but to improve the quality of care across the region.” In fact, Mayo Clinic actually refers some hospitals to a more accessible cath lab depending on their location.

Wedding high-tech and high touch

Carolinas Medical Center-NorthEast is a suburban hospital that has successfully combined patient education and state-of-the-art technology to bring its median door-to-balloon time to 60 to 65 minutes. “There are several obstacles to meeting the new ACC guidelines,” admits Paul Campbell, MD, cardiologist with Heart Group of the Carolinas. For starters, physicians can’t treat patients who ignore heart attack symptoms and delay seeking treatment. The medical center addressed the challenge with a major educational campaign in both English and Spanish, educating local residents about the signs and symptoms of a heart attack and encouraging them to dial 911 if a heart attack is suspected. The other essential components of success are coordination among the various disciplines involved in triaging, transporting and treating myocardial infarction.

Several years ago, Carolinas Medical Center-NorthEast and the local ambulance service teamed up to equip ambulances with a 12-lead EKG that could be wirelessly transmitted to the ER. Cardiologists review the data on handheld computers, and in some cases, patients are able to bypass the ER for a lightening fast angioplasty. Since beginning its effort, Carolinas Medical Center has seen the percent of myocardial infarction patients using ambulance services increase from under 40 percent to 50 percent.

But hospitals still need a smooth transmission for patients arriving by private car. Carolinas Medical Center relies on a team approach, soliciting suggestions from all stakeholders in the process. Cardiology and ED worked together to determine gaps and needs. Cardiologists trained ER staff to better recognize and triage heart attack patients, particularly atypical cases like patients with abdominal or back pain. The next step entailed creating a streamlined order sheet with clear responsibilities for each party. The ER is responsible for a heparin bolus and aspirin and Plavix administration. Cath lab staff mix the IV drip and shave the patient’s groin area. It’s inefficient for an ER nurse who only shaves one groin a day to complete this task when our staff shaves 10 a day, says Campbell. Other efficiency boosters include acute coronary care unit (ACCU) secretaries, who proactively obtain patient names and demographics to enter into the computer before patients arrive in the cath lab. Consequently, interventional cardiologists don’t have to input this data into the computer before beginning the procedure. In addition, several clinical staff members are cross-trained in the cath lab and ACCU, so the team is not delayed if someone is stuck in traffic.

The team approach

Alegent Health, a nine-hospital healthcare system based in Nebraska and Iowa, boasts sub-90 minute door-to-balloon times in five of its nine metropolitan hospitals. In fact, Bergan Mercy Medical Center in Omaha, Neb., averages a 60-minute turnaround. “We attribute our success to a team approach,” says Thaddeus Woods, MD, director of the emergency department at Bergan Mercy.

About 80 percent of the center’s chest pain patients present in a private car. The key, says Woods, is obtaining the EKG in a timely fashion, so ED staff are trained to move chest pain patients to the front of the line. The EKG is handed to a physician who can call and activate the cath lab if necessary. “Everything is hard-wired,” reports Woods.

Like other D2B stars, Bergan Mercy Medical Center uses a standard acute MI order set in the ER. The ER staff obtains patient consent, weighs, shaves, medicates and transports the patient, enabling the cath lab to focus on its task.

Woods stresses the importance of other key components—bi-monthly meetings to review data and discuss quality and public awareness. During the regular meetings, the entire team reviews chest pain data. “When we look at the data and plot it out, we can see where there is room for improvement,” notes Vice President of Cardiology John May. Woods says facilities can garner improvement by honing in on the longest delays and working from that point.

Making the 90 minute mark

The ACC has brought national attention to the door-to-balloon quality indicator. Hundreds of hospitals across the country have joined the D2B Alliance in an attempt to improve their response time and better patient care. It’s a valuable initiative as door-to-balloon time correlates with patient survival and better outcomes, and sites can trim their time without a tremendous financial outlay.

The tickets to success include: rapid EKG studies, prompt and efficient communication between the ED and cath lab, single call activation of the cath lab, rapid response on the part of the cath team and ongoing assessment and refinement of efforts.


6 steps to 90 Minute Door-to-Balloon TimeBetsy Bradley, PhD, professor of public health at Yale University in New Haven, Conn., and her colleagues at the American College of Cardiology D2B: An Alliance for Quality, have formulated a six-step recipe for door-to-balloon success. “It is simple. Any hospital can do this,” asserts Bradley.

1 Obtain senior management support for the initiative as well as detailed and well-defined hospital goals.

2 Develop a team-based approach. Door-to-balloon quality improvement requires change on the part of multiple internal and external staff members including emergency medical services and ED and cath lab staffs.

3 Use a clean system to activate the entire cath team including physicians, interventional staff, techs and nurses. The ED physician or other frontline decision-maker should be empowered to make the decision to activate the cath team.

4 Implement a simple activation method. Think one call to a central page operator not complex phone trees.

5 Set a standard for how quickly the cath team should be in the cath lab ready to begin the procedure: 20 to 30 minutes is typical.

6 Measure performance and give feedback to the entire team including ambulance, ED, cardiology and administrative staffs.

6 Steps in PracticeSentara Health, a seven-hospital system based in Norfolk, Va., used the ACC door-to-balloon initiative as a springboard for quality improvement across the system. “The ACC initiative has created focus and support. Senior management is committed, which is very important,” says John Brush, MD, chair of the acute myocardial infarction committee at Sentara Health Southside and a cardiologist in private practice. The six strategies provide a good starting point and specific directions for hospitals, so they need not re-invent the wheel, Brush says.

Sentara Health has embraced and tweaked the strategies to fit its needs. One of the key, early changes is the ER activation of the cath lab and a single page of essential staff. “It eliminates the all-too-common phone tag that eats up time. And there’s no cost involved; it’s an attainable quality improvement that doesn’t require spending money on equipment or personnel,” explains Brush. Each five minutes trimmed from the process adds up, he says. One Sentara site implemented an overhead STEMI (ST elevation myocardial infarction) alert page that can be heard hospital-wide five minutes before a page hits a physician’s beeper.

The health system also relies on enhanced data feedback. Since its involvement with the ACC D2B Alliance Sentara Health has developed a real-time data feedback system that consists of an email within 24 hours of each STEMI; all involved personnel receive data detailing various times such as door to EKG, ER call to cardiologist and patient transfer from ED to cath lab. In addition, every month the team reviews aggregate data to determine potential improvements. The health system also shares ideas across facilities. Consequently, multiple Sentara hospitals use the same checklist and engage in regular mock cases to practice skills. The effort is paying off. Sentara Leigh Hospital, for example, consistently turns around most patients in less than 90 minutes.