Treatment and care of these patients has improved significantly over the past decade, which has resulted in a decline in mortality and morbidity.
The AHA and the American College of Cardiology (ACC)2 formed a task force to develop guidelines and performance measures that would address the care of patients presenting with a STEMI or NSTEMI.3 The task force published their guidelines in January 2006.
On July 1, 2006, the ACC/AHA set a goal to reduce door-to-inflation time from 4 and Joint Commission on Accreditation of Hospital Organizations (JCAHO)5 have also followed suit by switching their door-to-inflation time standards from 120 minutes to 90 minutes. Ninety minutes is now considered to be the standard of care by these agencies. Facilities must track door-to-inflation times of A Review of the Evidence
A review of the literature was done in order to obtain evidence-based research results. Information was obtained through Medline, Citations in Nursing and Allied Health Literature (CINAHL) and Ovid databases. Key words were: door-to-inflation time, chest pain, CHD, MI, and angioplasty.
The Results of the Global Use of Strategies To open Occluded arteries in acute coronary syndromes (GUSTO-IIb) trial was the largest international randomized trial comparing thrombolytic therapy to direct coronary angioplasty. The most important finding of the study was that for patients with an acute MI randomized to direct coronary angioplasty, hospital delay in performing the angioplasty procedure appeared to be associated with an increase in 30-day mortality.6
The Second National Registry of Myocardial Infarction (NRMI-2) study, conducted in over 1400 hospitals with over 700,000 participants between the years 1994-1998, investigated patients presenting with the onset of chest pain, ST-segment elevation in two or more leads or left bundle-branch block who underwent PTCA. Median door-to-balloon time was 1 hour and 56 minutes. Researchers noted: It appears that door-to-balloon time and institutional volume of primary angioplasty are 2 important and modifiable factors relating to survival of patients treated with primary angioplasty. Our data suggests that physicians, hospitals, and health care systems should work to reduce door-to-balloon time…our data support the current guideline (by ACC/AHA) recommendation of a door-to-balloon time of 90 ± 30minutes.7 This study concluded that any facility meeting the criteria of two important, modifiable factors of: 1) a large volume of procedures performed each year and 2) the ability to perform PCI within 90 minutes of arrival, should provide this service to the community.
A phase-four study regarding clinical outcomes of patients presenting with acute MI by Genentech, Inc., the National Registry of Myocardial Infarction (NRMI), performed between June 1994 and April 2000, also discussed door-to-balloon delays. Researchers found that It has become clear that delays in primary PTCA are associated with worse outcomes in AMI. Patients treated 8 Those treated in 3 hours after reaching the hospital.
These studies clearly indicate that facilities that cannot perform PCI should not spend time administering a thrombolytic. Instead, they should rapidly transport the patient to a facility that can perform PCI. Time means cardiac muscle loss, decreased left ventricular function and increased patient mortality.
Evidence-based Practice
Any facility that has the capability of performing PCI needs to have a plan in place in order to meet the 88% door-to-inflation time goal.
One way to decrease time spent in the diagnosis of AMI is to have the ECG performed in the field by paramedics via LifeNet® (Medtronic, Inc., Santa Rosa, CA). This system allows the ECG to be transmitted to emergency department (ED) physicians so they can immediately diagnose the patient. The patient can then be rerouted (if necessary) to a facility that can performs PCI and the cath lab call team can be notified of an incoming patient. Others have used additional initiatives to obtain a positive effect. A survey of 365 hospitals performed by Bradley et al9 revealed strategies significantly associated with a faster door-to-balloon time:
Emergency medicine physicians activate the catheterization lab (8.2 min. mean reduction time).
A single call to a central page operator to activate the lab (13.8 min).
Emergency department activates the catheterization lab while patient is en route to the hospital (15.4 min).
Expecting staff to arrive within 20 minutes after being paged (19.3 min).
Having an attending cardiologist always on site (14.6 min).
Have the emergency department and catheterization lab use real-time data feedback (8.6 min).
To implement these initiatives, facilities need to have administrative support, leadership, shared goals between departments, trust and communication. Rapidly obtaining and interpreting the ECG is mandatory to reduce time. Training paramedics to interpret the ECG and a trusting relationship between the ED physician/cardiologist and paramedics is required for success.
Case Study: An Action Plan
A primary, tertiary cardiac facility of 205 beds in south Florida was having difficulties meeting the door-to-inflation goal. It performed thousands of PCI each year. According to the U.S. Department of Health and Human Services Hospital Compare Quality Measure graphs10, this facility, as of December 2005, met the then 120-minute goal only 49% of the time. As of June 2006, percentages varied from 50% to 85.7%. (Hospitals achieving 88% represent the top 10% in the United States.) The graphs also showed that two hospitals within a 50-mile radius of this facility met the time deadline 75“82% of the time.
In June 2006, a team was assembled in order to develop a plan to address the problem. The team noted that for the fourth quarter of 2005, there were 36 STEMI patients treated within 120 minutes (56.6%). Table 1 displays data obtained from January to May 2006. It indicates door-to-inflation time percentages when the goal was within 120 minutes.
The data clearly showed that the 120-minute goal was not being met. In order to meet the even more stringent goal of Conclusion
The facility implemented the new plan. Working as a team, they were able to improve. The door-to-inflation time goal of Barbara Lamia has since resigned from her previous position and is now working as a CNS in Cardiology for Boca Raton Community Hospital, Boca Raton, Florida. She is a resource person for staff in the cath lab, interventional telemetry floor and critical care unit. She can be contacted at babslrn (at) adelphia. net
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4. Centers for Medicare & Medicaid Services. Available at: http://www.cms.hhs.gov
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