According to recent estimates, about 250,000 people in the United States suffer a ST segment elevation myocardial infarction (STEMI), which is the most severe type of heart attack. For these types of patients, time is life. “Many STEMI patients will require emergency PCI, but certain individuals who present with cardiorespiratory arrest or are in-hospital patients are commonly excluded from door-to-balloon public reporting metrics,” explains Umesh N. Khot, MD.

Studies indicate that this excluded population of patients with STEMI does not achieve the guideline recommendation of having door-to-balloon times of 90 minutes or less. These patients have been shown to have very high mortality rates, according to recent data.

Testing an Intervention

For a study published in Catheterization & Cardiovascular Outcomes, Dr. Khot and colleagues described experiences after implementing a hospital-wide system to deliver rapid door-to-balloon times across the entire spectrum of emergency PCI. The protocol involved ED physicians or cardiologists immediately activating the catheterization lab when managing patients with STEMI or other emergency indications for catheterization. In addition, STEMI patients were immediately transferred to an available catheterization lab by an in-house Emergency Heart Attack Response Team.

 


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The study included 526 consecutive patients who underwent emergency PCI and found that the hospital-wide system approach significantly reduced door-to-balloon times. Overall, the median door-to-balloon time was 68 minutes, and 85.7% of patients received PCI in less than 90 minutes. The median door-to-balloon times were also less than 90 minutes for patients who:

  • Presented to the ED first: 62.5 minutes.
  • Experienced cardiorespiratory arrest: 71 minutes.
  • Experienced cardiogenic shock: 68 minutes.
  • Needed a temporary pacemaker or balloon pump: 67 minutes.
  • Had an initial ECG without ST-elevation: 66.5 minutes.
  • Were transferred from another ED: 84 minutes.
  • Suffered an in-hospital STEMI: 70 minutes.
  • Were activated to the catheterization lab for indications other than STEMI: 68 minutes.

“Patients who were treated with our rapid response protocol also experienced a reduction in infarct size, had shorter hospital lengths of stay, and lower hospital costs,” says Dr. Khot. “In addition, the 30-day mortality rate from acute myocardial infarction was substantially lower than national averages. These are important findings because we can reduce door-to-balloon times while simultaneously improving outcomes for these patients.”

Examining Implications

The protocol was used in the analysis was simple to administer and removed extra steps and redundancy that can lead to delays in door-to-balloon times, according to Dr. Khot. “It also didn’t require more resources or staffing,” he says. “We repurposed the available staff, and the cost of implementing the protocol was low. Hospitals should consider using this protocol so that they can reduce door-to-balloon to 90 minutes or less, regardless of how STEMI patients present to the hospital for care.”

References

Khot UN, Johnson-Wood ML, Van Leeuwen R, Ramsey C, Khot MB. A hospital-wide system to ensure rapid treatment time across the entire spectrum of emergency percutaneous intervention. Catheter Cardiovasc Interv. 2016. Dec 23 [Epub ahead of print]. Available at: http://onlinelibrary.wiley.com/doi/10.1002/ccd.26372/abstract.

Khot UN, Johnson ML, Ramsey C, et al. Emergency department physician activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction. Circulation. 2007;116:67-76.

Parikh R, Faillace R, Hamdan A, et al. An emergency physician activated protocol, ‘Code STEMI’ reduces door-to-balloon time and length of stay of patients presenting with ST-segment elevation myocardial infarction. Int J Clin Pract. 2009;63:398-406.

Wilson BH, Humphrey AD, Cedarholm JC, et al. Achieving sustainable first door-to-balloon times of 90 minutes for regional transfer ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2013;6:1064-1071.