Door-to-balloon campaign: shorter time to treatment

ACC and AHA set national goal for reducing door-to-balloon time.

The American College of Cardiology and the American Heart Association have launched “Door to Balloon (D2B): An Alliance for Quality,” a campaign to increase prompt treatment for myocardial infarction.

“The D2B campaign provides a great way for the nation’s hospitals to come together and make a promise to patients that they will deliver rapid care and eliminate needless [hospital] days,” said Harlan M. Krumholz, MD, chair of the D2B working group and director of the clinical scholars program at Yale University. Krumholz and colleagues launched the initiative in November at the AHA Scientific Sessions 2006.

The committee has set 90 minutes or less as the target time for how long it takes physicians caring for a patient experiencing an MI to start an angioplasty after arriving at the hospital.

The campaign is based in part on a Yale study of treatment times for MI and STEMI at 365 hospitals. The results were published in The New England Journal of Medicine.

Patients treated more quickly were more likely to survive STEMI. Only about a third of U.S. hospitals are able to treat half of their patients with STEMI in 90 minutes or less, Krumholz said.

In the past, protocols were created for each patient as an individual, instead of using a streamlined, tested strategy for prompt treatment as the campaign recommends, he said.

Advancement in the field of care for MI has greatly improved, but these advancements need to be applied uniformly across the country for effective patient treatment.

Strategies are opportunities

In the Yale study, 500 hospitals were selected for a Web-based survey. The National Heart, Lung, and Blood Institute provided funding as part of a larger study of this topic. Each had reported at least 25 percutaneous coronary intervention cases in 2004.

Twenty-eight key time-saving strategies were identified from prior qualitative research by the group and tested in 365 participant hospitals. The association between hospital strategy and door-to-balloon time was determined by evaluating the relationship between the strategies and the times from patients who underwent PCI between April and September 2005. Mean door-to-balloon time for all hospitals was 100.4 minutes.

Six strategies were identified as most effective in creating faster door-to-balloon times by saving minutes – sometimes up to 15-minute intervals – in each step of the admittance to intervention process.

Time-saving strategies included assigning an emergency medicine physician to activate a cath lab with one call or assembling the cath lab team within 20 minutes to 30 minutes.

Saving time in each piece of the hospital process can save lives, explained Elizabeth Bradley, PhD, co-director of the clinical scholars program at the Yale School of Public Health.

“That is the place where we really do have huge opportunities to save lives,” she said.

Door-to-balloon strategy success is contingent upon real-time data feedback in both the ED and the cath lab, senior management commitments and a team-based approach, according to the study.

Time is money

Decreased door-to-balloon times mean a smoother course for the patient and, in turn, cost savings to the hospital, according to Wayne Batchelor, MD, a cardiologist at Tallahassee Memorial Hospital. The hospital door-to-balloon time at Tallahassee went from 110 minutes to 88 minutes in six months during the study. The hospital also reported a 36% drop in mortality in less than a year, a success that Batchelor attributes to the D2B campaign.

“We shaved off a day of our median length of stay simply by getting patients treated earlier,” he said.

Hospitals invited

The AHA and ACC will send tool kits to hospitals within the next few months. Tool kits include door-to-balloon time reduction manuals and are designed to empower hospitals as they make strategic moves for faster patient treatment times.

Steven Nissen, MD, president of the American College of Cardiology and chairman of the department of CV medicine at the Cleveland Clinic, said the national campaign will not be easy to implement quickly, but will save lives.

“Changing what we have done on a national scale is something that is not often tried,” Nissen said. – by Kirsten Ellis

For more information:

• Bradley EH, Herrin J, Want Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Eng J Med. 2006;355:2308-2320.