Strategies to Reduce the Door-to-Device time in ST-Elevation Myocardial Infarction Patients
Background: Performing primary percutaneous coronary intervention (PPCI) in a timely fashion is a crucial part of the management of ST-elevation myocardial infarction (STEMI). We aimed to evaluate the contributing factors to and the etiologies of a prolonged door-to-device (D2D) time.
Methods: In 2016, the D2D time was measured in all patients who were treated with PPCI at Tehran Hear Center. The major causes of a prolonged D2D time (>90 min) were determined. The second phase was then started in 2017 by focusing on the determined causes, and direct feedback was given to anyone having contributed to the delayed D2D time. The D2D time was compared between these 2 years.
Results: The mean age of the patients was 59.54±11.82 years, and 82.2% of them were men. The median D2D time decreased from 55 minutes (IQR25-75%: 40–82) in 2016 to 46 minutes (IQR25-75%: 34–70) in 2017 (P<0.001). In the first year, 79.8% of the patients had a D2D time of below 90 minutes; the figure rose to 84.1% of the patients in the second year (P=0.017). The first cause of a prolonged D2D time was missed ST-elevation in the first electrocardiogram by physician or nurse (8.4% of the cases). Along with a declining rate of missed STE to 6.7%, the median D2D time in the missed patients also decreased from 205 minutes to 177 minutes (P=0.011). The rate of ambulance arrival increased from 10.2% to 20.7% of the cases, and the median D2D time also declined from 45 (IQR25-75%: 34–55) to 34 (IQR25-75%: 25–55) in these patients (P<0.001).
Conclusion: Even in the setting of a 24/7 on-site interventionist in the hospital, the dispatch system and prehospital electrocardiograms, along with regular assessment and feedback, may improve the D2D time.
Krumholz HM, Bradley EH, Nallamothu BK, Ting HH, Batchelor WB, Kline-Rogers E, Stern AF, Byrd JR, Brush JE. A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality. JACC: Cardiovascular Interventions. 2008;1(1):97-104.
Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients. Circulation. 2007;116(2):217-30.
Antman EM. Time is muscle. Journal of the American College of Cardiology. 2008;52(15):1216-21.
Nallamothu BK, Normand S-LT, Wang Y, Hofer TP, Brush JE, Messenger JC, Bradley EH, Rumsfeld JS, Krumholz HM. Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study. The Lancet. 2015;385(9973):1114-22.
Terkelsen CJ, Sørensen JT, Maeng M, Jensen LO, Tilsted H-H, Trautner S, Vach W, Johnsen SP, Thuesen L, Lassen JF. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. Jama. 2010;304(7):763-71.
Brodie BR, Hansen C, Stuckey TD, Richter S, VerSteeg DS, Gupta N, Downey WE, Pulsipher M. Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms. Journal of the American College of Cardiology. 2006;47(2):289-95.
Bradley EH, Nallamothu BK, Herrin J, Ting HH, Stern AF, Nembhard IM, Yuan CT, Green JC, Kline-Rogers E, Wang Y. National efforts to improve door-to-balloon time: results from the Door-to-Balloon Alliance. Journal of the American College of Cardiology. 2009;54(25):2423-9.
Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. New England Journal of Medicine. 2013;369(10):901-9.
Nallamothu BK, Krumholz HM, Peterson ED, Pan W, Bradley E, Stern AF, Masoudi FA, Janicke DM, Hernandez AF, Cannon CP. Door-to-balloon times in hospitals within the get-with-the-guidelines registry after initiation of the door-to-balloon (D2B) Alliance. American Journal of Cardiology. 2009;103(8):1051-5.
Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, Roumanis SA, Curtis JP, Nallamothu BK, Magid DJ. Strategies for reducing the door-to-balloon time in acute myocardial infarction. New England Journal of Medicine. 2006;355(22):2308-20.
Bradley EH, Nallamothu BK, Curtis JP, Webster TR, Magid DJ, Granger CB, Moscucci M, Krumholz HM. Summary of evidence regarding hospital strategies to reduce door-to-balloon times for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Critical pathways in cardiology. 2007;6(3):91-7.
Cannon CP, Battler A, Brindis RG, Cox JL, Ellis SG, Every NR, Flaherty JT, Harrington RA, Krumholz HM, Simoons ML. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. Journal of the American College of Cardiology. 2001;38(7):2114-30.
Gibson CM, Pride YB, Frederick PD, Pollack CV, Canto JG, Tiefenbrunn AJ, Weaver WD, Lambrew CT, French WJ, Peterson ED. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. American heart journal. 2008;156(6):1035-44.
Krumholz HM, Herrin J, Miller LE, Drye EE, Ling SM, Han LF, Rapp MT, Bradley EH, Nallamothu BK, Nsa W. Improvements in door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011:CIRCULATIONAHA. 111.044107.
Tra J, van der Wulp I, de Bruijne MC, Wagner C. Exploring the treatment delay in the care of patients with ST-elevation myocardial infarction undergoing acute percutaneous coronary intervention: a cross-sectional study. BMC health services research. 2015;15(1):340.
Ikemura N, Sawano M, Shiraishi Y, Ueda I, Miyata H, Numasawa Y, Noma S, Suzuki M, Momiyama Y, Inohara T. Barriers Associated With Door-to-Balloon Delay in Contemporary Japanese Practice. Circulation Journal. 2017;81(6):815-22.
Goldstein JM, Rahman A, Batra R, Jayasinghe R. Accurate Reporting of Door-to-Balloon Times. Heart, Lung and Circulation. 2015;12(24):1236-7.
Victor SM, Gnanaraj A, Vijayakumar S, Pattabiram S, Mullasari AS. Door-to-balloon: where do we lose time? Single centre experience in India. indian heart journal. 2012;64(6):582-7.
Akimbaeva Z, Ismailov Z, Akanov AA, Radišauskas R, Padaiga Ž. Assessment of coronary care management and hospital mortality from ST-segment elevation myocardial infarction in the Kazakhstan population: Data from 2012 to 2015. Medicina. 2017;53(1):58-65.
Ellis SG, Kapadia S, Heupler F. The weasel clause: excluding patients from door-to-balloon analyses. Journal of the American College of Cardiology. 2010;56(21):1763.
Khot UN, Johnson‐Wood ML, VanLeeuwen R, Ramsey C, Khot MB. A hospital‐wide system to ensure rapid treatment time across the entire spectrum of emergency percutaneous intervention. Catheterization and Cardiovascular Interventions. 2016;88(5):678-89.
Cotoni DA, Roe MT, Li S, Kontos MC. Frequency of nonsystem delays in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention and implications for door-to-balloon time reporting (from the American Heart Association Mission: Lifeline program). The American journal of cardiology. 2014;114(1):24-8.
Sutton NR, Gurm HS. Door to balloon time: is there a point that is too short? Progress in cardiovascular diseases. 2015;58(3):230-40.
Askandar S, Bob-Manuel T, Singh P, Khouzam RN. Shorter Door-To-Balloon ST-Elevation Myocardial Infarction Time: Should There Be a Minimum Limit? Current Problems in Cardiology. 2017;42(6):175-87.
Rao A, Kardouh Y, Darda S, Desai D, Devireddy L, Lalonde T, Rosman H, David S. Impact of the prehospital ECG on door‐to‐balloon time in ST elevation myocardial infarction. Catheterization and Cardiovascular Interventions. 2010;75(2):174-8.
Kurz MC, Babcock C, Sinha S, Tupesis JP, Allegretti J. The impact of emergency physician–initiated primary percutaneous coronary intervention on mean door-to-balloon time in patients with ST-segment-elevation myocardial infarction. Annals of emergency medicine. 2007;50(5):527-34.
Tödt T, Thylén I, Alfredsson J, Swahn E, Janzon M. Strategies TO reduce time delays in patients with AcuTe coronary heart disease treated with primary PCI—the STOP WATCH study: a multistage action research project. BMJ open. 2013;3(9):e003493.
Kunadian B, Morley R, Roberts AP, Adam Z, Twomey D, Hall JA, Wright RA, Sutton AG, Muir DF, de Belder MA. Impact of implementation of evidence-based strategies to reduce door-to-balloon time in patients presenting with STEMI: continuous data analysis and feedback using a statistical process control plot. Heart. 2010;96(19):1557-63.
McNamara RL, Herrin J, Bradley EH, Portnay EL, Curtis JP, Wang Y, Magid DJ, Blaney M, Krumholz HM, Investigators N. Hospital improvement in time to reperfusion in patients with acute myocardial infarction, 1999 to 2002. Journal of the American College of Cardiology. 2006;47(1):45-51.