There is nothing like a nice snowstorm in Portland to get you started writing an article. It doesn’t snow in Portland, you say? Well, sometimes it does, and the effect is total chaos. The end result is a three-hour transportation delay and time to write.
How does this relate to acute myocardial infarction (AMI) time-to-treatment, or what is now being labeled door-to-balloon (D2B)? AMIs occur under all weather conditions, even in snowstorms. In fact, statistics might indicate they are more likely to happen in such circumstances. If you already have a response barrier such as weather, every minute you can save through a well-developed D2B protocol is even more valuable.
While attending conferences throughout the country, even as recently as three years ago, you would only occasionally encounter formal presentations on D2B protocols. Occasionally, a group of managers would engage in an impromptu discussion of what each was doing to address this situation. Now, suddenly, this is a topic on fire. As a result of a flurry of articles and the recent American College of Cardiology (ACC) D2B initiative, you can hear people talk about this at every turn. Some are even trading protocol elements like baseball cards.
Aside from that brief period of “to balloon or not to balloon” in the early 1990s, direct angioplasty has been used as the primary mechanism to limit muscle damage as a result of acute coronary blockage. Here in our Providence facilities, we have had a protocol for direct percutaneous cardiac intervention in AMI as far back as 1986. Over the years, some facilities have developed their own D2B protocols while others have had a more unstructured approach. It has not been until recently that examples of formal protocols have been published. If you are just starting on this process, the ACC D2B website (www.d2balliance.com) has an excellent compilation of protocols. My recommendation: save you and your team a great deal of bottom line time and use the ACC protocols as a strong foundation.
As I mentioned, our hospitals have had a D2B protocol in place for many years. Although we had initial success in reducing treatment times, we soon reached a point at which making significant changes was becoming an increasing challenge. We had most of the right people at the table including the emergency department (ED), cardiovascular lab (CVL), cardiac care unit and the physicians, but our meetings were not consistent, and we were lacking real data to target opportunities. I have met many individual cardiovascular leaders who have been at this frustrating point in their journey: protocols in place, many people involved, but no great gains.
Even the best protocols, including the ACC D2B protocols, are simply tools. You can have the best carpentry tools in the world, but as most of my home projects demonstrate, unless you have someone who can use these tools, the end result will not be impressive. I am convinced that every successful program, including ours, is strongly influenced by two key elements: a dedicated coordinator and champion for the process, and strong physician leadership. I will speak to each individually.
It was not until our corporate leadership identified D2B as a primary initiative that our Heart and Vascular Institute leadership was able to justify, from a resource allocation standpoint, assigning our quality coordinator as the leader of this group. It was then that we started to make significant improvement in response times. The ACC D2B guidelines do identify this position within their framework, but I feel it should be in bold, 25-point font. I can’t overemphasize the importance of this person and the role he/she will play in your efforts.
Implementing the D2B protocols is a difficult process. But keeping these protocols in place is like herding cats. I have yet to speak to someone with a successful process who does not have a person in the quality coordinator role. This person needs to be focused, process-oriented, data-smart, and be just a little bit of a bulldog. She/he doesn’t have to be mean, just persistent.
It is inevitable that a process involving so many different departments and disciplines will encounter barriers. Sometimes these barriers evolve into an ‘us/them’ scenario. Our coordinator is based in the Heart and Vascular Institute, which allows her to approach the different disciplines from a neutral position and work swiftly to identify and improve the process. This is not her only responsibility, but she is able to devote the time necessary to work on this initiative and always keeps it on the front burner. One of our physician leaders will argue that this constant attention alone plays a significant role in the overall level of success you will achieve.
The second key element is strong physician leadership. Our D2B physician leaders have been committed to this process for years. They not only help run our monthly meetings, where every D2B patient is reviewed, but they are involved in many other improvement efforts. One of our physicians has worked closely with the ED physicians in electro-cardiogram (ECG) interpretation to improve AMI identification. Another D2B physician has worked closely with our EMS provider, recently presenting results and details of our protocol to over 200 EMTs and paramedics.
These leaders must have a true passion for this initiative. They must have the patience to wade through data relating to each patient encounter and have the political savvy to approach other physicians who are not meeting the established thresholds. Providence’s program rewards the physician and team who have the lowest D2B time each month. These individuals are recognized on our bulletin board and receive a gift of chocolate. Our physician leaders are very competitive when it comes to the chocolate. Without this type of physician leadership, any D2B initiative will be much less successful.
OK, you have implemented your D2B protocols. Your multi-departmental team meets monthly, maybe even weekly. You have a strong physician leader and a quality coordinator. What now? The publications and e-mails are filled with communications from people throwing out their D2B times like they are their kid’s sports achievements. Some numbers have been so low that I wonder if the patient was one of the cath team members coming in for one of those ‘IR’ cases and just happened to have their AMI at the same time! These reductions in time are all great, but now what? How do you identify and eliminate those last few minutes? One item that is immensely helpful is having a simple-to-read chart, which breaks down every component of care during this 90-minute window. Figure 1 is an example of the chart we have used for some time. It was developed by one of our ED team leaders, and I believe it to be the best of its kind.
Another suggestion is bringing each department team together to map out each action taken in their part of the process. Once these actions are listed, study them for any waste or duplication. In such a meeting with the cardiovascular team, we identified a stoplight in front of the hospital that often delayed our staff by up to three minutes. Now, three minutes does not seem like much, but it accounts for 10% of a 30-minute response time. After six months and many phone calls to the city, the light has been addressed and now takes no more than 15 seconds to change. It sometimes comes down to simple things, like the staff agreeing that it is okay to respond without brushing your teeth. Three minutes here, one minute there, every minute counts! This is the type of mindset the whole team must adopt.
As mentioned, I have heard of some very creative and aggressive protocol elements being adopted across the nation. Some of these include:
• Pre-hospital, ECG-based, EMS activation of the D2B response team.
• 20-minute response time requirements, or even 24 hours per day, seven days per week in-house teams, including interventional cardiologists.
• ST-segment elevation myocardial infarction (STEMI) teams, comprised of in-house staff who respond and treat these patients until the interventional cardiologist and CVL team arrive.
• Atomic clocks, which allow for determining exact response times. This eliminates the potential that you might have actually achieved the D2B 90-minute threshold, but the clock in the ED was five minutes faster than the clock in the cath lab. We tried those small, sticky clocks on our clipboards, but they disappeared within a week.
• Direct transfer to the cath lab by the EMS staff, bypassing the ED.
I am amazed at the level of energy being dedicated to this relatively small, but critical, patient population. I believe it is important to note that this D2B structure can also become the vehicle for other procedures demanding rapid response. We have now used this structure for our stroke team and our newest initiative: endovascular repair of acute rupture of abdominal aortic aneurysms. Lastly, I cannot over-emphasize the importance of a sense of mission for all of the team members. The leaders in the case review meetings are often participating as an extra voluntary function. Recognize and reward these individuals. A sense of mission is especially important for those staff members who are hands-on caregivers. Those on-call individuals who crawl out of bed at 2:00 am constantly have the ability to make small choices about how they respond that can add up to real minutes saved. These team members must be engaged and have a commitment to patient care. With this dedication, and the tools now becoming so readily available, everyone can have a successful D2B program. I encourage everyone to join in this effort. Talk to one another at meetings. Share your new ideas and throw your D2B times out as if they were your kid’s latest sports accomplishment. We should all make this as competitive a process as possible because in the end, it will benefit all our patients.
Dan Scharbach can be contacted at: Dan.Scharbach@providence.org