According to the American Heart Association, about 785,000 people experience a first-time myocardial infarction (MI) in the U.S. each year. Almost 250,000 will experience an ST-elevation myocardial infarction (STEMI), the deadliest type of MI. In an effort to save more lives, hospital emergency departments (EDs) and cardiology staffs across the country have been working to shorten the time interval between the patient’s arrival in the ED and when a stent is inserted to open the artery in the catheterization lab—an interval commonly referred to as door-to-balloon time. It’s a time when minutes truly matter.
Door-to-balloon time is critical in limiting the extent of cardiac muscle damage. Consequently, it has become a key performance measure and the focus of regional and national quality improvement initiatives. Since the American College of Cardiology and the American Heart Association published an analysis of STEMI-related treatment times in 2011, hospitals have been working to get patients into the catheterization lab faster, basing their procedures on results revealed in a study led by Dr. Harlan Krumholz at Yale University School of Medicine. The study analyzed protocols at 11 top-performing hospitals and presented a short list of best practices that these hospitals had in common. What the study found didn’t require expensive new equipment or technologies or payment incentives, only collaboration among hospital staff to rethink procedures.
Previously, when a STEMI patient arrived, the ED physician would see him first. He would call the primary care physician who decided whether or not to call a cardiologist. If the patient needed a stent, the cardiologist would call an interventional cardiologist. Then the hospital page operator would begin making individual calls to the catheterization lab nurses and technicians. When all of the staff had arrived, the patient would be transported to the catheterization lab. In many of these cases, time elapsed exceeded 90 minutes.
What the study revealed was that timesaving best practices can dramatically shorten the door-to-balloon interval and should begin even before the patient arrives in the ED. Paramedics in the field could transmit electrocardiogram (ECG) readings to the ED physician who could decide if the patient was having a STEMI rather than wait for a cardiologist to arrive. Then, if the proper beeper equipment was in place, the hospital operator could make a single phone call, and beepers for every member of the catheterization lab team would go off simultaneously.
By making these relatively small changes, door-to-balloon time at major medical centers, such as Mayo Clinic, Yale-New Haven Hospital, and Cleveland Clinic, is now down to an average of 50 minutes—nearly half of what it was a few years ago. What’s truly amazing is that the ED and catheterization lab staffs at Our Lady of Lourdes Medical Center in Camden, N.J., have been able to match this time. The hospital is located in one of the poorest cities in the country and, consequently, one whose population exhibits a high rate of risk factors for heart disease that include obesity, high cholesterol levels, hypertension, and tobacco smoking—making the occurrence of myocardial infarction more likely.
Small Changes, Major Impact
Our Lady of Lourdes Medical Center sees 80 STEMI cases on average in its ED each year. Before 2011, roughly half of these patients waited at least 90 minutes before entering the catheterization lab, an interval that was within the national standard at the time. But Dr. Reginald Blaber, head of Cardiology at Lourdes, believed they could do better. At a staff meeting, he challenged his team. He pointed out that 16% of Lourdes cases still had a door-to-balloon time of more than 90 minutes. To meet this challenge, the D2B (Door-to-Balloon) Task Force was initiated and began studying the hospital’s procedures. Using the best practices outlined in the Yale study as a guidepost, the group began looking for opportunities to shave off a minute or two wherever possible.
Both Michelle Winters, RN, manager of Invasive Cardiology, and Dianne Kelly, RN, assistant nurse manager of the catheterization lab, have served on the D2B Task Force from the beginning. Along with the director of the catheterization lab and director of the ED, task force members began collaborating with staff from the ED to see what might be done a little better or a little faster. “We saw that we could make changes that were within the control of our two departments,” Michelle explains. Simply posting treatment times—the time that the patient arrived in the ED, the time that the ECG was done, the time the patient arrived in the catheterization lab, and the time that the stent was deployed—on a STEMI bulletin board along with staff and physician names made an impact. The staff was always eager to know their time and, if there was a delay, the cause and what could be done to improve it.
Initially, much of the discussion on the task force focused on making small changes in ED procedures that would save time in the catheterization lab. For example, ED staff began removing the patient’s clothes before transporting him to the catheterization lab. They started two IV lines, shaved the patient’s groin where the catheter would be inserted, and placed ECG leads according to the way the catheterization lab needed them. “We also asked the ED staff to use a portable monitor so that we would not have to change monitors before transporting the patient,” says Michelle.
Getting patient information into the hospital’s registration system was also streamlined. To save precious time, STEMI patients would be entered through a “quick registration” that required only critical information. In cases when a cardiologist was not in-house, a medical resident would be called in to start a history and physical, rather than waiting for a cardiologist to arrive. The task force also worked with the Legal Department to obtain permission to treat STEMI patients without having to wait for a physical consent.
These changes got Lourdes’ door-to-balloon time down to 71 minutes, but the task force was not willing to stop there. “We continued to focus on what else we could do,” Dianne remembers. Now, when paramedics transmit the ECG, the ED physician can determine if the patient is experiencing a STEMI and activate the catheterization lab team directly if a cardiologist is not in-house. There have been times that the catheterization lab staff has arrived in the ED before the patient. Other changes include an upgraded beeper system that allows the hospital operator to alert the entire team with a single phone call when a STEMI patient is on the way. And one room in the ED is now designated and stocked appropriately for MI patients so no time is lost gathering supplies.
With these changes, the door-to-balloon time at Our Lady of Lourdes Hospital is now 51 minutes—on par with Mayo Clinic and Cleveland Clinic.
Even from the beginning, the new procedures were met with little resistance. The biggest challenge was getting the ED and catheterization lab staffs, the physicians, and the hospital operator on the same page. It wasn’t long before everyone was on board because the efforts proved successful quickly.
“Our staff totally bought into all of these changes,” says Dianne. “Before, we would wait in the catheterization lab for the ED staff to bring the patient to us. Now someone is getting the catheterization lab ready and two other people are running down to the ED to expedite the patient. It’s really become a point of pride for all of us to have the lowest door-to-balloon time.”
“By getting everyone on the task force working together in the same room, the ED staff could see the catheterization lab’s issues and vice versa,” says Michelle. “Talking about it got each department to see the other’s point of view, and it became a matter of communication and collaboration.”
The task force was able to bring about all of these changes fairly quickly and without involving hospital personnel outside of the catheterization lab and the ED with the exception of relying on the Legal Department for approval to treat the patient before a physical consent was obtained if needed. “It’s attainable,” Dianne says. “It didn’t take a lot of revenue, and we didn’t change any policies or treatment protocols. These were mainly only small changes that we made. We just streamlined the process so that it was better and faster.”
But the impact on nursing has been powerful. “It has given our nurses a real sense of accomplishment,” Michelle says. “When you hear that your hospital ranks with Mayo Clinic, it makes you feel really good about what you’re doing.”