Hospitals make big strides in delivering timely angioplasties

American hospitals have dramatically improved their performance in providing timely heart attack care, according to a study published in the Dec. 15/22 Journal of the American College of Cardiology.

Every minute counts when it comes to treating patients with ST-segment elevation acute myocardial infarction, or STEMI.

The sooner the patient's blocked artery is opened with balloon angioplasty after arriving at the emergency department door, the better the chances of survival.

The "door-to-balloon" time should be 90 minutes or less, according to guidelines adopted in 2004 by the American College of Cardiology and the American Heart Assn. Yet as of mid-2005, only about half of U.S. patients with STEMI were getting angioplasties within that time frame.

By mid-2008, 831 American hospitals with primary percutaneous coronary intervention capabilities achieved a 90-minute door-to-balloon time for 75% of patients with STEMI, according to the new study.

Progress has been sustained since then, said the study's senior author, Harlan M. Krumholz, MD. Nearly 90% of patients with STEMI had door-to-balloon times of less than 90 minutes as of December 2009.

"The innovations were relatively inexpensive," said Dr. Krumholz, who helped formulate an ACC initiative, the D2B Alliance, that advised hospitals on how to reduce door-to-balloon times.

"It was just about changing the way we provide the care, about changing the systems," Dr. Krumholz said. "It was a remarkable thing -- people did it because it was the right thing to do. ... Nobody said, 'Pay me more.' And the evidence is in the data."

About 1,000 of the 1,400 hospitals with PPCI capabilities joined the alliance, although the initiative's materials were free to all hospitals regardless of whether they joined.

Research by Dr. Krumholz and others formed the basis of the D2B Alliance's recommendations to participating hospitals on how to reduce their door-to-balloon times. Hospitals were advised to:

• Allow an emergency physician to activate the cardiac catheterization lab without consulting a cardiologist.
• Use a single-call system to activate the cath lab.
• Expect the cath lab team to arrive within 20 to 30 minutes of being contacted.
• Provide cath lab team members with feedback on their performance within a week.
• Have senior management commitment to the initiative.
• Use a team-based approach.

Not all hospitals employed every element of the approach, according to the study, although nearly 90% were able to get the cath team to the lab within a half hour.

"Some places said they had to have a two-call system instead of a one-call system," said Dr. Krumholz, professor of medicine and public health and epidemiology at the Yale School of Medicine in New Haven, Conn. "We didn't tell them they were wrong. It's still an improvement from a 10-call system. The commitment to getting to the goal was the most important thing, and people around the nation responded. That's what's amazing."

Some hospitals are doing so well at coordinating with emergency medical services before patients arrive that they have achieved door-to-balloon times as low as 21 minutes, Dr. Krumholz said.

"If the patients come in soon enough after their symptoms, they can leave as if nothing ever happened," he said. "They stop the heart attack so quickly that it's as if no damage occurred."

Evidence, teamwork spur change

There was no single solution to reducing door-to-balloon times at Baptist Memorial Hospital-DeSoto in Southaven, Miss., said Debbie Stubblefield, RN, who directs emergency services there. Rather, physicians, nurses and other health professionals sought to shave minutes wherever they could.

"This was about making it a culture, instead of a procedure," Stubblefield said.

As of November 2007, the hospital was falling short of the ACC goal of a 90-minute door-to-balloon time for 75% of patients with STEMI. At its worst, for one month, the hospital had an average 147-minute door-to-balloon time. But for 2009, the hospital met the 90-minute goal 96% of the time and achieved an average door-to-balloon time of less than an hour, Stubblefield said.

"Everyone in our facility that has anything to do with code STEMI -- from the EKG tech to the cardiovascular surgeon -- knows our processes, and knows what's an acceptable time for each portion of the process," she said. "Our EKG techs know they need the EKG finished and read by a physician in less than 10 minutes. That's the greatest piece of it."

Baptist Memorial's progress represents where many hospitals are headed on this measure of quality, said Robert C. Solomon, MD.

"There is substantial evidence in the literature on the care of STEMI patients that there's not anything really magical about a 90-minute cutoff," said Dr. Solomon, who served as a liaison to the D2B Alliance on behalf of the American College of Emergency Physicians, an initiative partner. "What we know is that the earlier you open the artery, the better."

Most hospitals are shooting to get their door-to-balloon times to under an hour, said Dr. Solomon, a member of the ACEP board of directors and an emergency physician at the Trinity Health System in Steubenville, Ohio. The all-time low door-to-balloon time at his hospital is 23 minutes.

Dr. Solomon said the D2B Alliance has succeeded where so many quality initiatives have floundered because it was based on high-caliber evidence.

"The ACC didn't just say, 'Well, we need a time, so we're going to pick 90 minutes because it's a nice number,' " Dr. Solomon said. "They picked 90 minutes because they thought it was an achievable goal, and we have evidence that if you do it in less than 90 minutes, you get better outcomes.

"So let's start promoting it, and when we promote it, let's say, 'Here's the published evidence and the scientific literature,' " he said.