Cath Lab Digest

The American College of Cardiology (ACC) launched its D2B (door to balloon) Alliance for Quality campaign in 2006. The continuing campaign aims to reduce the D2B time for ST-elevated myocardial infarction (STEMI) patients to 90 minutes or less.

The campaign came about in response to a 2004 ACC study indicating that STEMI mortalities declined to 3 percent from much higher levels when primary percutaneous coronary intervention (PPCI) or coronary angioplasty began within 90 minutes of the patient’s arrival at the emergency department (ED).

The ACC developed a six-step strategy to speed the patient’s progress through the ED to the catheterization lab:

1. An ED physician asks for the catheterization lab team to be activated.
2. The hospital implements a system that can notify the entire cath lab staff with a single call.
3. The cath lab team assembles in 30 minutes or less.
4. The team provides prompt data feedback. 
5. Senior management makes a commitment. 
6. Team-based approach is used. 

The ACC included a seventh strategic measure but called it optional: Train emergency medical technicians (EMTs) to complete 12-lead electrocardiograms (ECGs) prior to their arrival at the hospital, identify possible STEMI patients in the field and notify the ED staff of the ECG results.

In the years since the ACC introduced its strategic plan, the pre-hospital ECG has proven so effective that it has begun to lose its optional status. However, it is not yet mandated, since not all ambulance or medic units have been trained to perform and interpret 12-lead ECGs, nor are all ambulances equipped for them. Pre-hospital ECGs are nevertheless strongly recommended if they can be done. The strategy, according to the ACC, would ensure that STEMI patients were identified and transferred to the cath lab within 90 minutes of arriving at the ED, if not faster.

Since the launch of the D2B campaign, more than 1,000 hospitals in the U.S. and around the world have adopted the ACC’s six-step strategy, and experience now proves beyond a shadow of doubt that speed at the hospital saves the lives of STEMI patients. But this is really just the beginning of the story. More recent studies have raised a host of additional issues. For instance, studies now show that reducing time below the 90-minute standard saves even more lives. Other studies have looked at mortality rates of patients who drive themselves to the hospital, patients transferred from EDs at hospitals with no cath lab, patients who lie down and rest for a couple hours before deciding to go to the hospital and non-STEMI patients who eventually develop an elevated ST-segment ECG.

In each study, the shorter the time from the door of the ED to the inflation of the angioplasty balloon, the better the chances of survival.

But once the seven strategic steps have been implemented, how is it possible to go faster?
Healthcare architects and process improvement consultants are moving forward on the theory that ED design and process changes can add speed and add to the lifesaving gains made possible by the ACC’s strategic D2B program.

Reworking ED designs and processes

Experience suggests a host of design and process changes that will improve the quality of care delivered by an ED generally, while further reducing D2B time for STEMI patients. Here are some ideas that have proven useful:

Walk-ins: Sometimes possible MI patients decide not to call the ambulance and go the ED on their own. Older ED designs and traditional processes cannot accommodate the need for a 10-minute door-to-ECG or the proper sorting of emergent versus non-urgent patient presentation. Effective, newer designs allow patients in need of acute care to see an RN first. The RN will assess the patient and, if necessary, move him or her immediately into the acute care area where necessary treatment interventions can begin. In cases of both emergent and non-urgent patients, triage nurses can assess the patient first and ensure that acute patients receive appropriate care as quickly as possible. Registration takes place later.

Universal treatment beds: New ED designs are incorporating the concept of universal treatment beds (UTBs) in which all patients — with complaints from acute to mild symptoms — can be treated. Inside these rooms, the bed parallels the corridor, and a clinical zone with monitors and diagnostic equipment surrounds the bed. UTBs bring care to the patient instead of taking the patient to the care, while ensuring that ED patients with acute needs can be treated comprehensively and that STEMI patients reach the cath lab in 90 minutes or faster.

Another important feature of the UTB is creation of a patient zone and a family zone within a private treatment room of at least 140 square feet, which is larger than required by code. Critical design features include space for the family. The layout also allows room for the clinical staff to treat the patient. In addition, the placement of the bed enables the clinical team to more easily view the patient from the corridor or the nurse’s station. The larger space and new design also provide space for additional medical equipment at the bedside should that become necessary.