For patients with ST-elevation myocardial infarction (STEMI), the early use of primary percutaneous coronary intervention (PCI) to restore coronary perfusion is associated with significant reductions in mortality and morbidity. The American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines recommend a door-to-balloon time goal of 90 minutes when primary PCI is indicated. Caring for Atlanta for more than 125 years, Saint Joseph’s Hospital is the city’s oldest hospital and one of the leading acute-care referral centers in the Southeast. Saint Joseph’s was the first hospital in the region to develop a comprehensive cardiac catheterization laboratory (cath lab) and the first hospital in the Southeast to offer angioplasty as an alternative to bypass surgery. Saint Joseph’s is one of three hospitals in the United States, and the only one in Atlanta, to receive Magnet Recognition for Nursing Excellence three consecutive times. In 2007, we served 1,298 MI patients, with over 80% transferred from other facilities. Eighty-one STEMI patients were admitted through our emergency department (ED). In 2007, our volumes for diagnostic and interventional cardiac catheterization procedures were 5,170 and 1,830, respectively. Saint Joseph’s has seven catheterization, two electrophysiology, and one shared catheterization/electrophysiology laboratory. In total, we are staffed by 13 cardiology groups and 61 cardiologists, with 23 board-certified interventional cardiologists.

Data Collection and Problem Identification

In 2004, data gathered on 100% of MI patients identified 13-20 primary PCIs for STEMI per quarter. Only 16% of STEMI patients had an open artery within 90 minutes. Delays at that time were identified as:
• Delayed identification of STEMI, due to delays in either performance of, or physician interpretation of, the electrocardiogram (EKG)
• Delayed response from the nursing supervisor to notify the cath lab team
• Excessive number of telephone calls required to reach all team members
• Delayed response from security service when called by the ED to secure the patient’s valuables
• Delayed cath lab team arrival
• Delayed times from 12 noon to 4 pm.

Performance Improvement Steps
A multi-disciplinary ED to PCI Performance Improvement Team was formed to evaluate our current practice and to optimize strategies for managing STEMI patients who arrive directly to our ED. The team began regular monthly meetings in August 2004. Team members included cardiologists, ED physicians, hospital executives, directors and managers of the ED, cath lab, nursing, information technology and patient safety and quality. A core measures performance improvement coordinator provided data and case studies to identify priority areas for improvement and factors contributing to success. The team proposed the following steps to accelerate diagnosis and treatment times for STEMI patients: • Establish written STEMI time target goals for each step of the process, from arrival to PCI.
• Dedicate a private, specific area in the ED for performing 12-lead EKGs on all patients with suspected AMI to assess for ST elevation within 10 minutes of arrival. These are performed by ED personnel on machines stationed in the ED.
• Ensure that the EKG is then immediately carried to the ED physician, who examines it for ST elevation and initials it. If ST elevation is present, the ED physician immediately examines the patient and alerts the cath lab team and the interventionalist.
• Establish a written protocol for notification of all members of the STEMI team, including the nursing supervisor, cath lab team, EKG tech, pastoral care, radiology and security with a single telephone call. This one-call paging system is in place 24 hours a day, 7 days a week.
• Adjust cath lab staffing to improve efficiency from 12 noon to 4 pm.
• Celebrate success by recognizing STEMI team members who have participated in STEMI cases treated within 90 minutes. Recognitions are made with “Caught by an Angel” cards, which are part of a preexisting hospital award system. Also, all participants in the case, from technologists to physicians are recognized on a “Celebrating Success” photo display posted in the ED and in the cath lab. This photo display is updated weekly.
• Collect data on cath lab team arrival times.
• During weekends and after normal hours of cath lab operation, provide a place for on-call cath lab team members to stay overnight if they are unable to reach the hospital within 30 minutes.
• Assure accurate time-keeping by synchronizing the ED computer clocks with the cath lab clocks.
• Utilize pre-hospital EKGs whenever available. The cath team and the interventionalist are notified prior to the patient’s arrival. Implementation

Written STEMI time target goals were established and approved by the cardiology and ED section chiefs, and all team members. Construction of a private area in the ED for rapid 12-lead EKG performance was completed, and patients with suspected AMI undergo 12-lead EKG testing by an ED technician within 10 minutes of arrival. The EKG is given immediately to the ED physician who writes the date and time on the tracing and signs it. After examining the patient, if a STEMI diagnosis is made, the ED physician immediately initiates a one-call page to notify the STEMI team. The cardiologist is notified simultaneously. The first two cath lab team members are expected on site within 30 minutes. Although on-call cath lab team members who cannot meet this requirement were initially provided lodging in a nearby hotel, we now have an on-site call room. Pastoral care, radiology and security personnel report to the ED immediately to assist as needed. Accurate time-keeping is assured because cath lab and ED computer clocks have been synchronized with U.S. Naval Observatory time. The purchase of radio-signal clocks is being considered as a means to further ensure accuracy of timing.

Evaluation
Data gathered for the first half of 2005 showed improvement beginning in March. Our average door-to-PCI time for a total of eight cases in March was 98.6 minutes. The percent of STEMI cases having an open artery within 90 minutes was 38%. Throughout the remainder of 2005, performance continued to improve. Our mean door-to-PCI time for the year 2005 had decreased to 96 minutes for 68 cases, with 48% in <90 minutes. For 2006, our average door-to-PCI time, representing 80 patients, was 76 minutes, with 75% of first inflations within 90 minutes. (It should be noted that in 2006, the Atlanta Time Program was implemented. This consortium of five area hospitals ensured that patients requiring primary PCI would be transported to the nearest treatment facility by participating EMS providers. Pre-hospital EKGs were reported or transmitted by the EMS.) For 2007, with 81 cases, our average door-to-PCI time was 69 minutes, with 84% treatment within 90 minutes. As our efficiency continues to improve, we have identified a few important barriers. Barriers
One barrier that has been identified has been lack of physician compliance with provision of an accurate interventionalist call schedule to the ED. This problem has been resolved by daily verification and confirmation of the interventionalist call schedule for the following day by our cath lab manager and scheduler. This information is communicated to the ED daily. For assigned patients (patients with an established cardiologist), our policy is to call the assigned cardiologist and allow ten minutes for response prior to resorting to the interventionalist on call for ED STEMI patients. Additionally, on-site call rooms has resulted in less compliance with the cath lab team 30-minute arrival rule. This reduced compliance is primarily due to staff dissatisfaction with these rooms compared with hotel rooms, which allow them to be with their families while on call. Negotiations are currently underway to try to solve these accommodation issues. Conclusion
Performance improvement strategies to improve door-to-PCI times for ED STEMI patients involve interdisciplinary teamwork along with careful examination of care processes, comprehensive data collection and meticulous data analysis. Administrative, physician and staff support are vital. The authors can be contacted at dyarde@sjha.org