January 18, 2008

MGH quality and safety: Reducing door-to-balloon time

When a patient experiences a heart attack, quick and effective communication, proper training and coordination among the staff of the Emergency Medical Services (EMS), the Emergency Department (ED) and the Cardiac Catheterization Lab are crucial. The less time it takes for a patient arriving by ambulance to receive balloon angioplasty — a lifesaving treatment restoring blood flow to the heart — the greater the patient's chance of survival.

The MGH has identified several strategies to reduce the critical window of time between the patient's arrival at the ED and their treatment with angioplasty and stenting in the catheterization lab. This interval of time — known as "door-to-balloon time" — has a nationally accepted target of 90 minutes or less. While the MGH door-to-balloon times were slightly better than this benchmark in 2004, the opportunity for improvement existed.

"Reducing door-to-balloon time requires the coordination of people and resources," says Kenneth Rosenfield, MD, interventional cardiologist who directs the MGH's Acute Myocardial Infarction program. "At the MGH, we reduced this critical timeframe by strengthening the communication between the staff of the Emergency Department and the Division of Cardiology. Working together, we analyzed the data, examined the processes and arrived at solutions to reduce the time from the patient's arrival to opening the blocked artery in the cath lab."

Among the solutions implemented to reduce the door-to-balloon time include working with EMS and private ambulance companies to have them call ahead when they recognize a potential heart attack patient en route to the hospital. In addition to this early alert, the ED attending doctors are now empowered to activate the catheterization lab directly while remaining in close communication with cardiology colleagues to expedite the process so that angioplasty can take place as soon as possible.

"From the time the MGH began its initiative to enhance the door-to-balloon time through the second quarter of 2007, average time has fallen nearly 25 percent," says Gregg Meyer, MD, senior vice president of the Center for Quality and Safety. "At approximately 56 minutes, it is well below the national benchmark. Eighty-five
percent of MGH heart attack patients have a door-to-balloon time of less than
90 minutes. This reduction means more heart attack patients have the chance
to survive."

"The tremendous improvements we have made at the MGH are a result of the hard work, determination and dedication of the nurses, techs, physicians and other staff in both the ED and the cath lab," says Rosenfield. "They are all to be commended for their efforts, which have had a direct and immediate impact on the survival and well-being of our patients."

ED and cardiology members, from left, Sharon McKenna, RN, BSN, and May Cadigan, RN, both of Cardiac Invasive Services; Howard Blanchard, MEd, of the ED; and Eugene Pomerantsev, MD, PhD, of Cardiac Invasive Services