Improving Door-To-Balloon Time: Partnerships for Excellence

An estimated 500,000 STEMI events per year occur in the United States. Evidence shows that rapid restoration of flow in the obstructed infarct artery is a key determinant of short- and long-term outcomes of STEMI patients.1 The focus to improve quality in the delivery of rapid primary percutaneous coronary intervention for ST-segment elevation acute myocardial infarction (STEMI) has never been greater than the present at Banner Desert Medical Center in Mesa, Arizona. Most facilities are involved in improvement projects that seek to achieve the target of door to primary percutaneous coronary intervention (PPCI) time within ninety minutes. The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial concluded “early perfusion (with PPCI) results in superior clinical outcomes, enhanced microvascular reperfusion and better recovery of left ventricular function.”2 After two years of implementing a rapid-cycle improvement project, Banner Desert Medical Center, a major medical center in the southwestern United States, is finally ready to share results and lessons learned. Leadership from medical staff and clinical staff came together in partnership to achieve the best care for patients. Many processes were redesigned and actions taken that resulted in sustained improvement. Although these actions were nothing revolutionary, what has been truly incredible is the intense passion and enthusiasm by which this team achieved success. The team focused on several key elements: • Real-time case review • Data collection for each case • Ownership by everyone • No-blame mindset • Immediate action when changes were needed The facility began with a median door-to-balloon (or other device) time of 101 minutes and now proudly reports a median door-to-balloon time of 63 minutes in the first half of 2008. The methods, successes and lessons learned are the focus of this article. Building the Guiding Team In July 2006, Banner Desert Medical Center formed a multi-disciplinary team tasked with improving door-to-balloon time results. A sense of urgency was embraced and the team began its work. The vision was to perform better than the 90-minute target. To do so, a tracking sheet was designed (Figure 1) to be placed on the patient’s chart upon determination of a STEMI. The tracking sheet then followed the patient to help the team to gather key milestones. The two key milestones for measurement were door-to-patient arrival in cath lab (within 60 minutes) and door-to-device time (within 90 minutes). The goal times for the steps that contribute to those key milestones intentionally included some “wiggle room,” but the two key milestone measures were firm expectations. Upon completion of each case, each tracking sheet was given to the cath lab leader for immediate review and follow up with the cath lab medical director, cath lab and emergency department (ED) team within 24 hours. Problems were discussed and an immediate solution was agreed upon. The team also reviewed every case monthly to check on corrective actions and make sure they were still in place. A “never let up” attitude was adopted by all. As with any team, there were turbulent times — the attitude of blame was quickly abandoned and replaced with a passion for the goal. While it was easy to see what others were doing wrong, it took true ownership to focus on the process and not the people. This was an important barrier to overcome and was the turning point for success. The key component of real-time review raised the bar for performance for the clinical and medical staff. Staff and physicians could understand the problems when they were fresh in their minds, which made improvement seem logical. Empower Action and Create Short-Time Wins In a major medical center, barriers can be overwhelming. The system does not always respond as needed and human behaviors add to the complexity of systems and processes. It was important to remove “the ability to make mistakes” as a barrier that slowed down the team. Figure 2 describes all the processes and actions that were identified as barriers over the two-year period. Some identified were simple and others were rather complex. The quest for perfection drove the team to have a “can-do” approach to problem solving. The other actions that drove the team were rewards and praise. When a team made the target time, all involved were rewarded with movie tickets and letters of appreciation. This created an environment of short-term wins. Leadership was also a key factor in our success. Previous attempts to improve our door-to-balloon time in past years had limited success, in part due to limited “buy-in.” We were fortunate to have new physician and nurse manager champions in both the ED and the cath lab. Their passion for improving door-to-balloon times was a crucial factor in engaging other physicians and clinical staff. Identified barriers fit into the following categories: • Electrocardiogram (EKG) concerns • Physician contact and arrival • Calls to the cath lab team • Transportation of the patient • Clocks and timing • Support team access and training • Detailed documentation • Weather conditions EKG issues ranged from speed of performance to allocating a greater number of machines for a more timely response. Many processes were streamlined for efficiency. As this was done, each segment of care performed more efficiently. Physician contact and arrival was also a barrier. When the team noted that they had trouble reaching a physician practice group, the practice manager was notified and a solution was put into place. Physician-specific delays were addressed by the cath lab medical director. The physician was notified and the impact of the delay was discussed. This was a very effective method of achieving targets. The team was also careful to recognize great results case-by-case. Congratulatory letters were sent to involved physicians for performance that was within the 90-minute target. Soon it was becoming a more frequent occurrence and a source of pride for the physicians. The portion of the process involving calls to the cath lab team needed improvement across various dimensions. Over time, the process for calling the team improved greatly. The ED physician can now activate the cath lab team for a STEMI patient, rather than waiting for the cardiologist to confirm the STEMI diagnosis and subsequently activate the cath lab team. Setting the expectation that the ED physician contact the cath lab simultaneously with contacting the interventional cardiologist was crucial in reducing our door-to-cath lab arrival time by more than 20 minutes. A new group paging system was implemented which saved time and energy for the ED staff. A “CODE STEMI” was paged to an entire team, which activated many support functions within the hospital, including emergency response (SWAT) RN to the cath lab, which became an extra pair of hands. Transportation of the patient was another area requiring multiple improvements. The team discussed all the aspects of preparing the patient for transport. The ED physician took on the role of facilitator for quick action. The cath lab RN would go directly to the ED to pick up the patient upon the RNs arrival to the facility. Finally, the entire team understood what “getting the patient ready” meant. Assigning these responsibilities to specific team members was an important action to shave a few more minutes off our overall door-to-balloon time. We found that when a portion of the process is “everybody’s responsibility,” accountability gets diluted and “nobody” is responsible. When evaluating timing of events during case reviews, we discovered timing issues (e.g. 20 minute transport time from ED to cath lab when involved staff were certain that the transport took no more than 5 minutes). Our investigation also revealed that clock, staff watch, and/or EKG machine times didn’t match. We installed atomic clocks in the ED and cath lab, synchronized the EKG machine times to the atomic clocks daily and educated team members to use only the atomic clocks when documenting time segments. Without consistent use of atomic clocks and synchronizing the EKG machines to the atomic clocks, it was very difficult to improve our door-to-EKG time. The atomic clocks were also essential to accurately measure all other segments of our door-to-balloon process. The entire team worked on documentation. This was important in order to understand the facts of the case and if any other documentation was necessary to exclude cases, based on current core measure specifications. The quality management department worked diligently to educate physicians and staff regarding what needed to be documented, and communicated core measure specifications as these specifications changed. The turbulent weather of the southwest, mainly monsoon storms, was to blame for delays on occasion. In 2006, this was an acceptable exclusion for core measures, but at this time, it is no longer acceptable. By spring of 2007, our results were very promising — the team had achieved the target of within 90 minutes for 75% of our STEMI patients. Unfortunately, the team lost focus and learned quickly that nine months was not enough to achieve lasting change in culture. April 2007 plummeted to 17% of cases meeting the 90-minute target. The median time for April 2007 was 104 minutes. The team was humbled but not discouraged. The lesson was that the change in practice had not firmly taken hold. In December 2007, we saw that a surge in the volume of ED cases (all types of ED patients) was impacting the triage time of chest pain patients. Our rapid-cycle improvement process helped us to quickly identify and act on that issue. Don’t Let Up With renewed vigor, the team continued its work. A well-respected clinical manager was reassigned the duty of case review. This was the turning point for lasting success. This leader instilled a sense of passion and pride for the work, and did not let up in her review of the cases. The team saw that this level of dedication was what it would take to keep the mission alive. A quick partnership was ignited (again) between the ED and cath lab. Over the next fourteen months, the team continued to shave minutes from segments of care, but at times, it was still not enough. There were frequent occurrences where we missed the target by one or two minutes. A new strategy was born: “Target Time.” As the team looked at our tracking sheet, we found one thing missing. When the patient arrived in the cath lab, the team did not assess how much time it had left to meet its goal. There was much debate about how the team might alert the cardiologist of the time remaining to successfully meet the 90-minute target. This was a sticking point for some, as it did not seem like a good idea to lose time figuring out how many minutes were left when the team had critical work to finish. Finally, a timing tool was developed and placed on the back of the STEMI tracking sheet (readers can contact the authors for a sample if they wish). This easy-to-use tool became the answer and the clinical staff could easily communicate the target time to the interventional cardiologist. As the leaders reassessed these cases and rapid-cycle feedback was provided to involved physicians and staff members, we saw incredible change. Everyone had taken ownership and a true partnership was formed. Walls were broken down and the process of care drove the results. A culture of defeat was transformed into one expecting success and taking pride in that success. For the first 6 months of 2008, Banner Desert Medical Center performed at 97% for meeting door-to-balloon time. In the literature, these results are most frequently seen when a program implements a Cardiac Alert team in the field.3 Yet these results have been achieved without the addition of use of a pre-hospital EKG (Cardiac Alert) to activate the cath lab team as recommended by best practices from the D2B: An Alliance for Quality campaign.3 When the team implements a strong Cardiac Alert system, a mean door-to-balloon time of below 60 minutes is not impossible. Summary of Results Over the course of a year and a half, Banner Desert Medical Center was able to move from “merely average” to a top performer in providing rapid reperfusion to our STEMI patients. We were able to improve our median door-to-balloon time for STEMI patients from 101 minutes to 63 minutes. We now meet the 90-minute target 97% of the time instead of 56% of the time. Passion for providing excellent patient care, through evidence-based practices, was the driving force that kept our team motivated. Our team was able to progressively improve the median time of multiple sub-processes, which were crucial to improving our overall target of door-to-balloon time within 90 minutes. Examples include: • Reducing median “door-to-EKG” from 19 minutes to 6 minutes; • Reducing median “call cardiologist-to-arrival” from 55 minutes to 20 minutes; • Reducing median “call cath lab team-to-arrival” from 40 minutes to 19 minutes; • Reducing median “leave ED-to-arrive in cath lab” from 23 minutes to 4 minutes. Based on CADILLAC and GUSTO-IIb results, our improved median door-to-balloon time increases the likelihood of improved long-term clinical outcomes for our STEMI patients.2,4 The results of this teamwork are shown in Figures 3-5. Figure 3 helps staff to quickly identify whether or not we are meeting targets for each of our time segments within the door-to-balloon process for STEMI patients. For ease of reading, quarterly data is displayed rather than monthly data. The authors can be contacted at Paula.Durston@bannerhealth.com

1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004. Available at www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed August 14, 2008. 2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003; 361:13-20. 3. Krumholz HM, Bradley EH, Nallamothu BK, et al. A Campaign to Improve the Timeliness of Primary Percutaneous Coronary Intervention Paula.Durston@bannerhealth.com — Door-to-Balloon: An Alliance for Quality. J Am Coll Cardiol Intv 2008; 1:97-104. 4. Berger PB, Ellis SG, Holmes DR, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation 1999;100:14-20.