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 <120 minutes to <90 minutes. Meeting this goal saves heart muscle, reduces infarct size, saves lives and decreases the number of patients permanently disabled from CHD in the United States. The Centers for Medicare and Medicaid (CMS)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 <90 minutes as one of their core measures. If hospitals do not meet this goal, it may affect their accreditation and Medicare reimbursement. Facilities which have the capability of performing percutaneous coronary intervention (PCI), yet are not meeting the 90 minutes goal, must improve. The requirement is that a consistent 88% be achieved on door-to-inflation time. If this goal cannot be met, the following questions should be asked:

1. What are the root causes for delays?
2. What improvements are necessary?

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 <2 hours after symptom onset were shown to have lower 30-day mortality and improved systolic function than those treated later.8 Those treated in <60 minutes had a mortality of 4.2%. As the time increased, mortality increased up to 7.9% among patients treated >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 <90 minutes that began in July 2006, changes would need to begin immediately.

Following are steps taken by this facility to evaluate their processes, along with initiatives implemented for improvement. These tips will assist all facilities performing PCI and working to meet the national standards.

Review present process step-by-step for each department involved.
Review how the ED is notified.
Review how the ED notifies the interventionalist and cath lab.
Perform a literature search to obtain evidence-based practice guidelines.
Contact other facilities in the area to see how they are meeting the goal.
Interview staff members and obtain their input and suggestions.
Organize an action committee to address the problem.
Present all of the above information to the members and obtain feedback.
Identify and make changes to reduce the time and meet the goal.
Discuss potential failures that could occur with the new process.
Educate staff and perform mock alerts.

The following changes were suggested at the south Florida facility, all of which aided in decreasing door-to-inflation times:

Install LifeNet, capable of transmitting a 12-lead ECG from the field to the ED and catheterization lab for immediate use. Educate paramedics and all staff that will be involved in the process. (LifeNet was purchased by the emergency department).

Implement a 24/7 dedicated emergency interventional call rotation.

Standardize order sets in the ED for the chest pain patient.

Purchase digital clocks, synchronizing all clock times in ED and cath lab.

Post a Code STEMI page in the ED and define each code member's role.

Put a STEMI box together with all the essential equipment required, such as a stopwatch, IV solution, aspirin, clopidogrel, heparin, sublingual and intravenous nitroglycerin, beta blocker, consent forms for cardiac protocol, and a data collection sheet which outlines the times by which all procedures should be completed and tracks door-to-inflation target <90 minutes.

Develop a data collection sheet and have it filled out by the ED nurse as each step of the process is completed. Use it as a hand-off tool to the cath lab nurse to continue once the patient is in the lab. Sheets should be collected and reviewed monthly to track times and evaluate if the goal was achieved.

Initiate the setting of a timer by the triage nurse to track the timed process and increase staff awareness.

Set time limits for each part of the process, for example, a time-to-ECG of <10 minutes.

Revise the transfer to catheterization lab process, having a catheterization lab staff member pick up the patient from the ED. This will promote communication between the ED and catheterization lab.

One STEMI patient must be reviewed monthly by the committee for delays and feedback on processes.

Once new initiatives are implemented, continually keep the staff abreast of data. Present data at monthly staff meetings and discuss what adjustments could be made for continued improvement.

Overcome barriers to change by posting the monthly percentages in a colorful graph format in order for the staff to track their progress and work towards continued improvement.

Conclusion
The facility implemented the new plan. Working as a team, they were able to improve. The door-to-inflation time goal of <90 minutes for the month of July 2006 was met 100% of the time (10 patients). The goal was also met 100% of the time in August 2006 (6 patients). Since all the STEMI patients treated during July and August occurred on the day shift, meeting this goal was easier since there were no delays in waiting for the arrival of the on-call team. Further data on how well the cath lab performs on the night shift is being tracked by the cath lab committee.

Meeting the door-to-inflation time goal requires substantial effort along with interdisciplinary trust and communication. It also requires administrative support, clinical leadership, shared goals, and effective data feedback. Important are organizational commitment, strategies for overcoming barriers to change and 100% buy-in from employees and physicians.

Education of the staff and communication between the emergency room and the catheterization lab appears to be the primary reason for the rapid improvement in meeting the goal at this facility. Always knowing the time the patient was diagnosed and time to perfusion of the artery (via the stopwatch) encouraged employees to beat the clock. Communication between all the involved departments has dramatically improved.

Items such as the STEMI box, the stopwatch and the data collection sheet appear to be small changes, but they made a tremendous impact on improving door-to-inflation time at this facility, thereby assisting in improving patient outcomes.

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