90 minutes or less: From left, Scott Taylor, of Professional Ambulance; Lt. Phil Arsenault, of the Cambridge Fire Department (CFD); Perrin; Lt. Ray Vaillancourt, of the CFD; and Rosenfield
From the time a person first experiences symptoms of a heart attack, such as shortness of breath or chest discomfort, to the time he or she undergoes cardiac catheterization -- a procedure used to diagnose and treat a blocked coronary artery -- every second is of utmost importance.
In 2003, the MGH established the ST-segment Elevation Myocardial Infarction (STEMI) Quality Improvement Task Force, a team with representatives from the Heart Center, Emergency Department (ED), and MGH/MGPO Center for Quality and Safety. Their goal was to focus on ways the team -- along with emergency medical service (EMS) personnel -- could shorten the timeframe between a patient's arrival at the hospital to the restoration of blood flow to the patient's heart in the cardiac catheterization lab. This critical period of time, known as the door-to-balloon (DTB) time, has a target set by national quality organizations of 90 minutes or less.
"The multidisciplinary STEMI task force looked closely at ways to streamline existing processes and also develop new strategies to decrease DTB time," says Kenneth Rosenfield, MD, section head for Vascular Medicine and Intervention and chair of the task force. "As a team, we examined all the pieces of the puzzle -- EMS activities, ED protocols, transport issues and cardiac cath lab processes -- so we could better fit the pieces together and significantly decrease the time it takes to get the patient into the cath lab to remove the blockage and restore blood flow."
Among the ways the task force improved the average DTB time was implementing a process to review all cases arriving at the MGH as possible heart attacks. "May Cadigan, a registered nurse in the Cardiology Division, regularly compiles an information sheet about each case," says Liz Temin, MD, attending physician in the ED. "She records data from every part of the case -- such as the names of all staff involved, presenting symptoms, whether or not there was prenotification by the ambulance personnel and the interventions performed in the cardiac cath lab. Feedback and suggestions for improvement are requested."
Temin explains that EMS staff members also receive a report. Information including the EMS assessment, the electrocardiogram, the cardiac cath lab intervention and a before-and-after photo of the occluded vessel is sent to the team. This feedback is important for continued improvement in coordination between EMS and MGH providers.
"Gathering these data and sending them back to all of the caregivers involved from start to finish enables all parties to see themselves as part of a larger care team working toward the common goal of optimizing the outcome for the patient," says Rosenfield.
Since 2005, the average DTB time has steadily improved at the MGH. In 2010, approximately 95 percent of cases at the hospital met or exceeded the goal of 90 minutes or less, putting the MGH in the top tier of hospitals across the United States. To celebrate this accomplishment and the teamwork involved, the STEMI Quality Improvement Task Force gathered with members of the ED, cardiac cath lab, MGH/MGPO Center for Quality and Safety, and EMS at a celebratory breakfast March 24 in the East Garden Room. As a highlight of the event, two patients who had benefited from short DTB times and received life-saving cardiac catheterization gave remarks expressing their gratitude.
Steven Perrin, one of the two patients, suffered a heart attack and cardiac arrest at his office in June 2010. Unconscious, he was given CPR by a coworker. EMS arrived within minutes to continue the resuscitation and bring Perrin to the MGH, alerting the MGH along the way so ED staff would be ready to receive him. The DTB time for Perrin was 76 minutes, and he is now riding his bicycle 20 miles a day. He cannot remember what happened after he collapsed in his office, but he expressed his appreciation to all of the team members at the event for saving his life.
Says Elizabeth Mort, MD, vice president for the MGH/MGPO Center for Quality and Safety: "Door-to-balloon time is a very specific measure of quality. There are so many steps and multiple staff and hospital departments involved in the process. It was critical to look at existing processes and develop ways to restructure them. I am extremely proud of
all of the individuals involved in these remarkable achievements. It really is a team effort."
For more information about the STEMI Quality Improvement Task Force, contact Paul Nordberg, senior consultant for Performance Improvement at the MGH/MGPO Center for Quality and Safety, at email@example.com.