Emergency Department and Cardiac Catheterization Laboratory collaborate to provide efficient care and potentially better outcomes for patients suffering an ST elevation myocardial infarction (STEMI).
A collaboration of the Brigham and Women’s Hospital (BWH) Emergency Department and Cardiac Catheterization Laboratory is resulting in more efficient care and potentially better outcomes for patients suffering an ST elevation myocardial infarction (STEMI). Some 400,000 patients are admitted to hospitals with STEMI every year. Primary percutaneous intervention (PCI) to open blocked vessels is an effective therapy, but it needs to be administered as early as possible in the evolving heart attack in order to save heart muscle and improve survival.
Frederic S. Resnic, MD, MSc, medical director of the Cardiac Catheterization Laboratory, says, “Minimizing the time that a patient has obstructed flow correlates very closely with improved outcomes. The national standard of care calls for an interval of no more than 90 minutes from arrival to the hospital to successful balloon placement and restoration of blood flow. This door-to-balloon time has become a standard metric for assessing the quality of care for patients who present with STEMI.”
Leaders from the BWH Emergency Department and Cardiac Catheterization Laboratory developed the door-to-balloon time quality initiative that went into effect on May 1. In the first month, median door to balloon time was 53 minutes. In fact, the first case, that involved pre-hospital notification, was completed in less than 16 minutes, which, according to Dr. Resnic, is a markedly fast time for the administration of such complex care.
Multidisciplinary collaboration
Minimizing door-to-balloon time can be quite challenging and requires successful coordination of multiple complex processes under the control of different staff. The multidisciplinary STEMI Task Force was established as a collaborative effort of the emergency department and cath lab physician and nursing leadership to improve hospital processes involved in the care of STEMI patients and to ensure door-to-balloon times of 90 minutes or less.
Richard D. Zane, MD, vice-chair of the Department of Emergency Medicine, says, “Minimizing door-to-balloon times requires a dedicated team approach, breaking down traditional silos of responsibility and attacking the challenge from a patient-centered, multidisciplinary view where all involved feel a shared responsibility for all aspects of patient care.”
Education and new protocols
The Task Force identified the processes critical to getting patients to PCI, reviewed the time intervals associated with each process, and collectively identified and implemented strategies including focused education and new protocols designed to minimize each interval and reduce total door-to-balloon time. These strategies were identified in a special article in the New England Journal of Medicine* as being significantly associated with faster door-to-balloon times.
- The attending emergency physician activates the entire cath team;
- Single call to the page operator activates cath team;
- Pre-hospital notification. For certain EMS systems that have trained prehospital providers to interpret ECGs and recognize STEMI, the emergency department will activate the cath lab based on pre-hospital notification. The patient may bypass the emergency department and proceed directly to the cath lab;
- Real-time feedback, including e-mail distribution of actual care interval times to all participants within minutes of the procedure.
Next steps
The BWH STEMI Task Force monitors not only endpoints but also intermediate points in the door-to-balloon process. Time targets have been established for each of four intervals – from patient arrival in the ED to notification of the cath team, from notification to patient arrival in the cath lab, from the beginning of the diagnostic procedure to the beginning of the therapeutic procedure, and from to the beginning of the therapeutic procedure to balloon placement and successful reperfusion. If any of these times is over target, it is cause for concern and action, even if the combined door-to-balloon time is within the 90 minute target.
Dr. Resnic says, “Reducing door-to-balloon time to a bare minimum is a priority, because although 90 minutes is the national standard, we know that if we can reperfuse a patient in even less time, the result will be more heart muscle saved. At the BWH Cardiovascular Center, we treat a relatively sicker patient population, and we know there will be patients who present with complex pathology who will benefit from a longer initial evaluation. However, for most STEMI patients, the shortest door-to-balloon time will result in the best outcomes. We intend to be national leaders in this area.”
* New England Journal of Medicine, Volume 355:2308-2320, Number 22, November 30, 2006.
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