Abstract 365: Continuing to Improve the D2B Process

Abstract

Objective: Early reperfusion of patients with STEMI, with a target door to balloon (D2B) time < 90 min, is a core measure of acute myocardial infarction treatment. “Time is muscle” and efforts are continually made to decrease the time from first medical contact to reperfusion, thereby decreasing cardiac morbidity and mortality. SBUH is a primary PCI referral center challenged by an extended hospital network and a predominately community voluntary EMS, meeting community standards. Process review identified two promising interventions to improve D2B times; increasing community and EMS awareness of the importance of an initial referral to a PCI capable center and obtaining and transmitting ECGs from the field. Procedure: Community education and incorporation of the EMS teams as stakeholders in monthly D2B performance review meetings were implemented. The effects of efforts to increase community awareness and provide directed, timely feedback to EMS on process and outcome were assessed. Results: Overall STEMI calls increased from 368 in 2011, to 453 in 2012, and 467 in 2013. The number and percentage of patients directly presenting to SBUH (a PCI capable hospital) versus a local referral center increased progressively from 142 [48.6%] in 2011, to 201 [53.0%] in 2012, and 227 [56.5%] in 2013. In contrast to initial presentation at a local community transfer hospital, direct presentation to the PCI capable hospital reduced first contact to reperfusion time by 60 minutes. EMS demonstrated a progressive increase in the number of ECG’s obtained in the field [2009-25, 2010-39, 2011-46, 2012-65, 2013-98]; 62% of STEMI’s brought in by our EMS were called in the field in 2013. First ECG in the field compared to first ECG in the ED reduced D2B time by an average of 18.7/ median of 15.0 minutes. D2B times showed a progressive improvement in median time from 57 in 2011 to 54 minutes in 2013 and in the percentage of patients receiving reperfusion within 90 minutes. Accompanying the reduction in D2B times, PCI mortality fell from a baseline of 1.9% with O/E of 1.01 in 2011 to 1.4% with O/E of 0.75 in 2013; AMI mortality fell from a high of 5.2% with an O/E of 0.99 in 2011 to 3.4% with an O/E of 0.69 in 2013 with an accompanying decrease in the median STEMI LOS from 3.1 to 2.8 days . Conclusions: Efforts to improve community awareness of the value of early presentation to a PCI capable hospital center and EMS obtaining and transmitting ECGs in the field are effective interventions to improve rapid reperfusion efforts in STEMI. Community awareness of the warning signs of a heart attack is an additional significant contributor to early effective reperfusion efforts and decreasing cardiac mortality.