Door to Balloon Times: How we got to where we are

Brittany Cunningham, RN, MSNVHVI Quality Consultant

July 27th, 2011

Disclosures

Background

• Annually close to 400,000 people suffer from a ST-elevation myocardial infarcation

• In 2004, the median time to percutaneous coronary intervention (PCI) was 293 minutes, according to The Joint Commission.

Historical Timeline

Terminology

Door-to-balloon time (D2B) is a measurement in emergency cardiac care, specifically in the treatment of STEMI. The interval starts with the patient's arrival in the emergency department, and ends when, in the cath lab, a catheter crosses and opens the blockage utilizing a balloon.

Signs/ Symptoms

• Chest Pain• Shortness of Breath• Nausea• Vomiting• Palpitations• Sweating• Anxiety (impending

doom)

• Indigestion• Weakness• Fatigue• “silent”

D2B Alliance

Joined a D2B Alliance in 2006 with over 1000 institutions which developed 6 key measures + 1 additional optional measure for success:

– ED Physician activates the cath lab– Single-call activation system activates the cath lab– Cath lab team is available within 20-30 minutes– Prompt data feedback– Senior Mgmt commitment– Team-based approach– Prehospital 12-lead ECG activates the cath lab (optional)

Multidisciplinary team

• ED management• Educators from all areas • Quality Staff• CVICU management• VHVI administration• NFD administration• VHVI physician leadership• Interventionalists• Cathlab administration• Cathlab management

• ED cardiologist• Pharmacist• ED Medical Director• ED administration• Cathlab Medical Director• Heat station manager• Life Flight Representative• VHVI Quality Consultant• General Cardiologist• Staff from all areas

Chest Pain=Immediate ECG (10 minutes or less) for:• Any patient who presents to the ED with: • Non-traumatic chest discomfort > 30 years old (all patients with a history of recent

cocaine use)– Pressure/aching/tightness/heaviness– Burning– Sharp/stabbing/pleuritic

• Any patient with a recent history of having a coronary stent placed• Chest discomfort prior to arrival• Shortness of breath• Non-traumatic arm or shoulder pain• Beware atypical symptoms:

– Diaphoresis– Dizziness, syncope/near syncope – Palpitations – Nausea > 50 Years Old– Epigastric pain >50 years old– Weakness > 50Years Old – Altered mental status or any symptom you think might be cardiac in origin

Must have an immediate EKG performed and reviewed by an ED attending!!!!!

Streamlined Process

Clear definitions/ time stamps

Individual Case Review within 24-48hrs

Continuous Monthly Review

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 320

20

40

60

80

100

120 EWMA chart of Total D2BNights/Weekends FY 09

Series1

Series2

Series3

Series4

Mean=54.5 minutes

SPC charts to identify interval delays

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 410

102030405060708090

100

EWMA chart of Total D2B processWeekday FY09

LCL

Mean

Process

UCL

Mean=48.0 minutes

SPC charts to identify interval delays

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29-202468

10121416

EWMA chart of Door to ECG processNights/Weekends FY09

LCL

Mean

Process

UCL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42-5

0

5

10

15

20

EWMA chart of Door to ECGWeekday FY09

Series1

Series2

Series3

Series4

Mean= 3.85

Mean=7.58

SWAT Team Implementation• CVICU Charge Nurse

• On-Call Cardiology Fellow• ED Nurse

• Cathlab RN• Cathlab Procedure Tech• Interventional Fellow

• Interventionalist

Questions?