Strategies for Reducing the Door-To-Balloon Time in Acute Myocaridal Infarction: Bradley EH, Herrin J, Wang Y, et al. N Engl J Med 2006;355:2308–20

Abstract

This cross-sectional study surveyed 365 acute care hospitals to determine strategies that determined door-to-balloon times (DBT) in acute myocardial infarction. All hospitals were capable of percutaneous coronary intervention and reported the core quality measure of door-to-balloon time. Twenty-eight strategies were identified and, through multivariate analysis, six strategies were noted to significantly reduce door-to-balloon time. Catheterization laboratory activation by an emergency physician alone reduced DBT by 8.2 min (p = 0.01). The process that provided the fastest activation of a catheterization team involved the emergency department calling a single central page operator, who then paged the cardiologist and staff with a reduction of 13.8 min (p = 0.001). When prehospital electrocardiograms were available, the emergency departments that activated the catheterization laboratory while the patients were still en route to the hospital reduced DBT by 15.4 min (p = 0.001) and those with no set protocol reduced DBT by 23.3 min (p = 0.001). As expected, the longer time allowed for catheterization laboratory staff to arrive, the longer DBT by 19.3 min (p = 0.002). Finally, having an attending cardiologist always in the hospital and having the hospital give real-time feedback to staff of the emergency department and catheterization laboratory were both associated with decreased DBT by 14.6 (p = 0.01) and 8.6 (p = 0.001) min, respectively. The median door-to-balloon time among participating hospitals was 100.4 ± 23.5 min. The standard for percutaneous coronary intervention set by the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services is 90 min. The authors conclude that the greater number of the six identified strategies implemented, the shorter the DBT. However, given that information, the authors found that, for instance, only 23% of hospitals permitted the emergency physician to activate the catheterization laboratory and only 14% of hospitals had a central paging operator.