By Harlan Krumholz, MD, SM, FACC
Krumholz is the lead author of the paper discussed below and a member of the ACC Board of Trustees.
It is with great pride and some awe that I report on the findings of a new paper
published today in Circulation
on door-to-balloon (D2B) times. In a comprehensive assessment of patients of all ages and across virtually all institutions providing primary percutaneous coronary intervention (PCI), we report that median D2B times have declined from 96 minutes in 2005 to 64 minutes in 2010. This is over a 30% reduction. The percent of patients treated within 90 minutes increased from 44% to 91% over those same years. Even more remarkably, the percent of patients treated within 75 minutes increased from 27% to 70%. The story of this success began with the identification of a quality problem with consequence. The benefit of primary PCI depends on its timely application, and in 2002, only one-third of patients received PCI in less than 90 minutes. NIH-funded research helped characterize the problem, while qualitative and quantitative studies revealed the secrets of top performers. Then, the ACC, with the American Heart Association and many other stellar partners, sought to translate that research into action with cardiology leadership throughout the country. The D2B Alliance was launched by the ACC in November 2006. Meanwhile, the Centers for Medicare and Medicaid Services were beginning to publicly report D2B times and, a year later, the AHA launched Mission: Lifeline, with its focus on systems of care.
All this focus on D2B came together to change medical performance. I doubt that any voluntary effort to improve care has ever progressed with such speed and effect. This success reflects directly on the cardiologists, emergency medicine physicians, other clinicians, nurses, technicians, transporters, administrators and so many others who declared that patient care would improve and took the steps necessary to improve the timeliness of care for patients. I particularly cite the interventional cardiologists who embraced this effort even as they knew it entailed more work, including having to endure the false alarms that are unavoidable in a system built for speed.
ACC’s D2B Alliance also played an important role in the reduction. Cardiology leaders John Brush, MD, FACC, Eva Kline-Rogers, RN, Wayne Batchelor, MD, FACC, Brahmajee Nallamothu, MD, FACC, and Henry Ting, MD, FACC, among many others, were instrumental in getting the D2B Alliance off the ground. The Board of Governors and ACC chapters launched into action and delivered volunteers and hospitals throughout the country. At the ACC, the D2B Alliance was led by Amy Stern, with support from Jason Byrd, Matthew Fitzgerald and Karen Collishaw. They have left the ACC, but their made an indelible contribution to this effort. Betsy Bradley, MBA, PhD, at Yale was also critical to the effort. More than 1,000 hospitals enrolled – including many that participate in NCDR – and there is evidence that many other hospitals participated even if they did not formally join. In the end, it was truly people in each location that made the difference.
The improvements that were made are now embedded in the way the work is conducted. New trainees know no other way to treat patients with STEMI than with rapid, delay-free care. This project provides us with a sterling example of what can be achieved when we work together, learn from each other, and collaborate in the best interests of patients.
However, there is still work to be done. Some exceptional hospitals are regularly achieving D2B times of ~60 minutes by strategies such as coordinating with Emergency Medical Services and dissemination of a prehospital ECG. These strategies and others should be implemented nationwide to make 60 minutes the new standard of care. Additionally, studies have shown that time is lost in the transfer of patients from hospitals without PCI capabilities to PCI-capable hospitals. We need to identify and implement strategies that can reduce transfer time.
The results of the study reflect a level of performance that would have been considered impossible a decade ago. And it was achieved not by large investment, not by financial incentive, not by the application of a new technology, but by local efforts to adopt best practices and a drive to succeed on behalf of patients.
Full Circulation article
CardioSource journal scan
D2B: Sustain the Gain website