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January 2007 - Volume 3 - Issue 7
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Meeting the Challenge to Reduce Door to Balloon Time for Patients with Acute Myocardial Infarction

The following article is in response to "Hospitals Too Slow on Heart Attacks" by Steve Sternberg, an article that appeared in the Nov 13, 2006 issue of USA Today. You can go to the website www.usatoday.com to read the entire article.

The need to rapidly move the acute myocardial infarction patient from the Emergency Department door to the Cardiac Catheterization Laboratory and quickly reestablish blood flow to the heart muscle (reperfusion) has been documented via research for quite some time, however, achieving the recommended 90 minute door to balloon time has been more elusive. In a November 13, 2006 American College of Cardiology (ACC) news release the ACC and the American Heart Association (AHA) have together launched an initiative to successfully achieve this 90 minute goal. The ACC/AHA "Door to Balloon (D2B): An Alliance for Quality Practice Guideline" was developed from the results of a study funded by the National Heart, Lung and Blood Institute which surveyed hospitals to identify strategies shown to reduce door to balloon time.

Hospitals that currently provide primary (emergency) percutaneous coronary interventions (PCI) certainly strive to meet the 90 minute time frame, but may not fully embrace practice changes that could positively impact the time to treatment for these patients. The majority of hospitals (emergency departments and cardiac catheterization laboratories) have implemented protocols or patient flow processes to expedite patient care from arrival in the emergency department through prep, drape and procedure intervention in the cath lab, however, they may not incorporate all the strategies the ACC/AHA are now advocating.

The strategies offered by the ACC/AHA to reduce time to reperfusion are evidence-based, multidisciplinary and cross several departments requiring a systems approach.

The strategies include:

  1. Pre hospital performance of 12 Lead EKG with early transmission to the emergency department
  2. Allowing the Emergency Department physician to initiate the "call in" process for the cath lab on call team
  3. Using a group page (or single call) system to notify the cardiac catheterization laboratory
  4. Requirement of cath lab team arrival and lab readiness within 20 to 30 minutes from the initial call (this should include 20-30 minute availability of the interventional cardiologist as well)
  5. Provision of ongoing feedback regarding team performance to both the ED and Cath Lab staff members
  6. Commitment from hospital senior management to support the initiatives
  7. Encouragement of a "team" approach to the primary PCI patient (between the pre hospital, emergency and cardiac catheterization personnel)

Each of the first four strategies will work to cut vital minutes from the timeline to treatment. Performance of 12 Lead EKGís in the field by pre-hospital personnel is not in place in vast parts of the nation, but is gaining acceptance as a needed diagnostic modality that is quickly proving itís value in the field. Several issues surround this initiative including: the cost of the equipment, training and education for pre-hospital personnel in use of the equipment and appropriate lead placement and emergency department physician confidence in the quality of the EKG being transmitted to them for interpretation. Having the 12 Lead EKG in hand upon patient arrival with an already determined plan of care can save 5-10 minutes of time.

Likewise, Emergency Medicine physicians have, in some instances, been reluctant to take on the responsibility of initiating the call in of the cardiac catheterization laboratory staff without first talking with the interventional cardiologist and leaving that decision to him/her. In some facilities that have limited numbers of interventionalists available, the emergency department physician may contact the patientís personal cardiologist initially (even if he is not an interventionalist) as not to create any "hard feelings" about his/her patient care being handed off to the interventionalist on call (who may or may not be an associate of the non-interventional cardiologist). Bypassing the call to the patientís PCP or medical cardiologist and direct notification of the interventionalist on call as well as immediate notification of the cath lab team when an ST elevation myocardial infarction (STEMI) is documented can shave off anywhere from 10-20 minutes of time. There are generally hospital concerns that the cath lab team could be called in unnecessarily thus adding to hospital costs and exhausting human resources in the cath lab staff. Researchers have found that there were very few (on average one or two every six months) instances the team was called in and then the patient not taken to the cath lab. (11/13/06- "ER Plan Seeks Faster Heart Attack Care", Marilynn Marchione, the Associated Press).

Hospitals sometimes provide each staff member with a beeper (with an individual number) for on call or use a system of first calling the on call personís home/cell phone prior to initiating a beeper system. Initiating a "group page" system is relatively inexpensive and all members of the on call team should have beepers programmed to the same number and the beeper should be activated as the first notification. This eliminates the time the hospital operator or the nursing supervisor would have taken to call individuals at multiple numbers. A single phone call will activate all the beepers and individuals needed. A process should be put in place to confirm that all on call persons have responded to the beeper page in the allotted timeframe.

Most cath labs currently require on call staff members to be within 20 to 30 minutes of the hospital, but the new guideline calls for these individuals to not only be on site, but ready to perform cath duties within the 20 to 30 minutes. Being ready to perform duties means that major equipment is "warmed up", a procedure tray is set up and they are prepared to receive the patient. This may require some facilities to have cath lab staff members reside in house when on call (if staff members live too far away to meet this timeframe) and require the provision of an on call sleep area. This can present a facility issue (space), a cost issue (in house on call usually pays greater than general call) and can be a social hardship for staff members (time away from family and friends when on call).

All of the initiatives can be accomplished but not without some cost, planning and "give and take" on the part of the physicians, staff and the hospital. Senior management must be supportive of the time, planning, cost and education to implement these initiatives and staff members (pre-hospital, emergency department and cardiac catheterization laboratory) must realize importance of their role in expediting the patient through this process. Although each initiative can serve to eliminate minutes from the "D2B" time, it is only with a true team approach and the implementation of all the strategies that the efforts can be maximized and the of 90 minutes door to balloon can be acheived, thus providing the best quality care possible to our patients.

Marsha Knapik is a Senior Consultant with Health Care Visions, Ltd., a cardiovascular consulting firm based in Pittsburgh, Pennsylvania. She can be reached at (412) 364-3770 or mknapik@hcvconsult.com.
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