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Door-to-balloon is a time measurement in emergency cardiac care (ECC), specifically in the treatment of ST segment elevation myocardial infarction (or STEMI). The interval starts with the patient's arrival in the emergency department, and ends when a catheter guidewire crosses the culprit lesion in the cardiac cath lab. Because of the adage that "time is muscle", meaning that delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage due to localised hypoxia,<ref>Soon CY, Chan WX, Tan HC (2007). [Expression error: Missing operand for > "The impact of time-to-balloon on outcomes in patients undergoing modern primary angioplasty for acute myocardial infarction"]. Singapore medical journal 48 (2): 131–6. PMID 17304392. </ref><ref>Arntz HR, Bossaert L, Filippatos GS (2005). [Expression error: Missing operand for > "European Resuscitation Council guidelines for resuscitation 2005. Section 5. Initial management of acute coronary syndromes"]. Resuscitation 67 Suppl 1: S87–96. doi:10.1016/j.resuscitation.2005.10.003. PMID 16321718. </ref><ref>De Luca G, van't Hof AW, de Boer MJ, et al. (2004). [Expression error: Missing operand for > "Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty"]. Eur. Heart J. 25 (12): 1009–13. doi:10.1016/j.ehj.2004.03.021. PMID 15191770. </ref><ref>Cannon CP, Gibson CM, Lambrew CT, et al. (2000). [Expression error: Missing operand for > "Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction"]. JAMA 283 (22): 2941–7. doi:10.1001/jama.283.22.2941. PMID 10865271. </ref> ACC/AHA guidelines recommend a door-to-balloon interval of no more than 90 minutes.<ref>ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction J Am Coll Cardiol 2004;44:671-719</ref> Currently fewer than half of STEMI patients receive reperfusion with primary percutaneous coronary intervention within the guideline-recommended timeframe.<ref name="Bradley_D2B">Bradley EH, Curry LA, Webster TR, et al. (2006). [Expression error: Missing operand for > "Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems"]. Circulation 113 (8): 1079–85. doi:10.1161/CIRCULATIONAHA.105.590133. PMID 16490818. </ref> It has become a core quality measure for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).<ref>National Hospital Quality Measures/The Joint Commission Core Measures Joint Commission on Accreditation of Healthcare Organizations, Retrieved on June 30, 2007.</ref><ref>Larson DM, Sharkey SW, Unger BT, Henry TD (2005). [Expression error: Missing operand for > "Implementation of acute myocardial infarction guidelines in community hospitals"]. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 12 (6): 522–7. doi:10.1197/j.aem.2005.01.008. PMID 15930403. </ref><ref>Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM (2005). [Expression error: Missing operand for > "Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004"]. N. Engl. J. Med. 353 (3): 255–64. doi:10.1056/NEJMsa043778. PMID 16034011. </ref>


Improving door-to-balloon times

Door to Balloon (D2B) Initiative

The benefit of prompt, expertly performed primary percutaneous coronary intervention over thrombolytic therapy for acute ST elevation myocardial infarction is now well established.<ref name="Keeley-2003">Keeley EC, Boura JA, Grines CL. (2003). [Expression error: Missing operand for > "Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials."]. Lancet 361 (9351): 13–20. doi:10.1016/S0140-6736(03)12113-7. PMID 12517460. </ref> Few hospitals can provide PCI within the 90 minute interval,<ref name=Doortoballoon>Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, Roumanis SA, Curtis JP, Nallamothu BK, Magid DJ, McNamara RL, Parkosewich J, Loeb JM, Krumholz HM. "Strategies for reducing the door-to-balloon time in acute myocardial infarction." N Engl J Med 2006; 355(22): 2308-20. PMID 17101617</ref> which prompted the American College of Cardiology (ACC) to launch a national Door to Balloon (D2B) Initiative in November 2006. The D2B Alliance seeks to "take the extraordinary performance of a few hospitals and make it the ordinary performance of every hospital."<ref name="Brush_STEMI">John Brush, MD, "The D2B Alliance for Quality," STEMI Systems Issue Two, May 2007. Accessed July 2, 2007.</ref> Over 800 hospitals have joined the D2B Alliance as of March 16, 2007.<ref name="ACC-D2B">"D2B: An Alliance for Quality". American College of Cardiology. 2006. Retrieved June 30 2007. </ref>

The D2B Alliance advocates six key evidence-based strategies and one optional strategy to help reduce door-to-balloon times:<ref name="Brush_STEMI"/><ref name="D2B-Checklist">"D2B Strategies Checklist". American College of Cardiology. 2006. Retrieved June 30 2007. </ref>

  1. ED physician activates the cath lab
  2. Single-call activation system activates the cath lab
  3. Cath lab team is available within 20–30 minutes
  4. Prompt data feedback
  5. Senior management commitment
  6. Team based approach
  7. (Optional) Prehospital 12 lead ECG activates the cath lab

Mission: Lifeline

On May 30, 2007, the American Heart Association launched 'Mission: Lifeline', a "community-based initiative aimed at quickly activating the appropriate chain of events critical to opening a blocked artery to the heart that is causing a heart attack."<ref name="AHA_News">"Mission: Lifeline - a new plan to decrease deaths from major heart blockages," American Heart Association, May 31, 2007. Accessed July 3, 2007.</ref> It is seen as complementary to the ACC's D2B Initiative.<ref>ACC Targets STEMI Times with Emergency CV Care 2007, Accessed July 3, 2007.</ref> The program will concentrate on patient education to make the public more aware of the signs of a heart attack and the importance of calling 9-1-1 for emergency medical services (EMS) for transport to the hospital.<ref name="AHA_News"/> In addition, the program will attempt to improve the diagnosis of STEMI patients by EMS personnel.<ref name="AHA_News"/> According to Alice Jacobs, MD, who led the work group that addressed STEMI systems,<ref name="O'Riordan_Heartwire">Michael O'Riordan, "AHA Announces Mission: Lifeline, a New Initiative to Improve Systems of Care for STEMI Patients," Heartwire (a professional news service of WebMD), May 31, 2007. Accessed July 3, 2007.</ref> when patients arrive at non-PCI hospitals they will stay on the EMS stretcher with paramedics in attendance while a determination is made as to whether or not the patient will be transferred.<ref name="O'Riordan_Heartwire"/> For walk-in STEMI patients at non-PCI hospitals, EMS calls to transfer the patient to a PCI hospital should be handled with the same urgency as a 9-1-1 call.<ref name="O'Riordan_Heartwire"/>

EMS-to-balloon (E2B)

Although incorporating a prehospital 12 lead ECG into critical pathways for STEMI patients is listed as an optional strategy by the D2B Alliance, the fastest median door-to-balloon times have been achieved by hospitals with paramedics who perform 12 lead ECGs in the field.<ref name="Bradley_JACC">Bradley EH, Roumanis SA, Radford MJ, et al. (2005). [Expression error: Missing operand for > "Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?"]. J. Am. Coll. Cardiol. 46 (7): 1236–41. doi:10.1016/j.jacc.2005.07.009. PMID 16198837. </ref> EMS can play a key role in reducing the first-medical-contact-to-balloon time, sometimes referred to as EMS-to-balloon (E2B) time,<ref name="Rokos_STEMI">Rokos I. and Bouthillet T., "The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance," STEMI Systems, Issue Two, May 2007. Accessed June 16, 2007.</ref> by performing a 12 lead ECG in the field and using this information to triage the patient to the most appropriate medical facility.<ref>Rokos IC, Larson DM, Henry TD, et al. (2006). [Expression error: Missing operand for > "Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks"]. Am. Heart J. 152 (4): 661–7. doi:10.1016/j.ahj.2006.06.001. PMID 16996830. </ref><ref name="EMS_PCI_Boston">Moyer, Feldman, Levine, et al. "Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services: The Boston EMS Experience" Crit Path Cardiol 2004;3:53-61.</ref><ref name="EMS_PCI">Terkelsen, Lassen, Norgaard, et al. "Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutanous coronary intervention" Eur Heart J 2005;26(8):770-7.</ref><ref name="PCI_STEMI_National_Policy">Henry, Atkins, Cunningham, et al. "ST-Segment Elevation Myocardial Infarction: Recommendations on Triage of Patients to Heart Attack Centers - Is it Time for a National Policy for the Treatment of ST-Segment Elevation Myocardial Infarction?" J Am Coll Cardiol 2006;47:1339-1345.</ref>

Depending on how the prehospital 12 lead ECG program is structured, the 12 lead ECG can be transmitted to the receiving hospital for physician interpretation, interpreted on-site by appropriately trained paramedics, or interpreted on-site by paramedics with the help of computerized interpretive algorithms.<ref name=Granger_2007>Granger CB, Henry TD, Bates WE, Cercek B, Weaver WD, Williams DO (2007). [Expression error: Missing operand for > "Development of Systems of Care for ST-Elevation Myocardial Infarction Patients. The Primary Percutaneous Coronary Intervention (ST-Elevation Myocardial Infarction-Receiving) Hospital Perspective"]. Circulation 116: e55. doi:10.1161/CIRCULATIONAHA.107.184049. PMID 17538039. </ref> Some EMS systems utilize a combination of all three methods.<ref name="Rokos_STEMI"/> Prior notification of an in-bound STEMI patient enables time saving decisions to be made prior to the patient's arrival. This may include a "cardiac alert" or "STEMI alert" that calls in off duty personnel in areas where the cardiac cath lab is not staffed 24 hours a day.<ref name="Rokos_STEMI"/> The 30-30-30 rule takes the goal of achieving a 90 minute door-to-balloon time and divides it into three equal time segments. Each STEMI care provider (EMS, the emergency department, and the cardiac cath lab) has 30 minutes to complete its assigned tasks and seamlessly "hand off" the STEMI patient to the next provider.<ref name="Rokos_STEMI"/> In some locations, the emergency department may be bypassed altogether.<ref>David Jaslow, MD, "Out-of-Hospital STEMI Alert - If Time is Muscle, What's Taking So Long? EMS Responder, March 2007. Accessed July 3, 2007.</ref>

Common themes in hospitals achieving rapid door-to-balloon times

Bradley et al. (Circulation 2006) performed a qualitative analysis of 11 hospitals in the National Registry of Myocardial Infarction that had median door-to-balloon times = or < 90 minutes. They identified 8 themes that were present in all 11 hospitals:<ref name="Bradley_D2B"/>

  1. An explicit goal of reducing door-to-balloon times
  2. Visible support of senior management
  3. Innovative, standardized protocols
  4. Flexibility in implementing standardized protocols
  5. Uncompromising individual clinical leaders
  6. Collaborative interdisciplinary teams
  7. Data feedback to monitor progress and identify problems or successes
  8. Organizational culture that fostered persistence despite challenges and setbacks

Criteria for an ideal primary PCI center

Granger et al. (Circulation 2007) identified the following criteria of an ideal primary PCI center.<ref name=Granger_2007/>

Institutional resources

  1. Primary PCI is the routine treatment for eligible STEMI patients 24 hours a day, 7 days a week
  2. Primary PCI is performed as soon as possible
  3. Institution is capable of providing supportive care to STEMI patients and handling complications
  4. Written commitment by hospital administration to support the program
    1. Identifies physician director for PCI program
    2. Creates multidisciplinary group that includes input from all relevant stakeholders, including cardiology, emergency medicine, nursing, and EMS
  5. Institution designs and implements a continuing education program
  6. For institution without on-site surgical backup, there is a written agreement with tertiary institution and EMS to provide for rapid transfer of STEMI patients when needed

Physician resources

  1. Interventional cardiologists meet ACC/AHA criteria for competence
  2. Interventional cardiologists participate in, and are responsive to formal on-call schedule

Program requirements

  1. Minimum of 36 primary PCI procedures and 400 total PCI procedures annually
  2. Program is described in a "manual of operations" that is compliant with ACC/AHA guidelines
  3. Mechanisms for monitoring program performance and ongoing quality improvement activities

Other features of ideal system

  1. Robust data collection and feedback including door-to-balloon time, first door-to-balloon time (for transferred patients), and the proportion of eligible patients receiving some form of reperfusion therapy
  2. Earliest possible activation of the cardiac cath lab, based on prehospital ECG whenever possible, and direct referral to PCI-hospital based on field diagnosis of STEMI
  3. Standardized ED protocols for STEMI management
  4. Single phone call activation of cath lab that does not depend on cardiologist interpretation of ECG

Gaps and barriers to timely access to primary PCI

Granger et al. (Circulation 2007) identified the following barriers to timely access to primary PCI.<ref name=Granger_2007/>

  1. Busy PCI hospitals may have to divert patients
  2. Significant delays in ED diagnosis of STEMI may occur, particularly when patient does not arrive by EMS
  3. Manpower and financial considerations may prevent smaller PCI programs from providing primary PCI for STEMI 24 hours a day
  4. Reimbursement for optimal coordination of STEMI patients needs to be realigned to reflect performance
  5. In most PCI centers, cath lab staff is off-site during off hours, requiring a mandate that staff report with 20–30 minutes of cath lab activation

External links

Media coverage

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