January - April 2008 Issue
Door-to-Balloon Time — a Critical Quality Measurement
David S. Marks, MDMedical College of Wisconsin Interventional Cardiologist
Director, Cardiac Catheterization Laboratory
Named one of the “Best Doctors in America®” 2007 by Best Doctors, Inc.
The American Heart Association and other groups have established a standard “door-to-balloon time,” which measures how long it takes before a heart attack patient receives often lifesaving balloon angioplasty or coronary intervention. Dr. David S. Marks discusses the importance of door-to-balloon time and having procedures in place to treat heart attack patients quickly.
Q. What is door-to-balloon time?Door-to-balloon time is the speed in which a hospital can perform angioplasty or other coronary intervention in a patient who’s having a myocardial infarction or heart attack. Door-to-balloon time is a very specific measure of quality, and it starts when a patient enters the door of a healthcare facility. There are many steps and multiple staff and hospital departments involved in this process. It involves everything from prompt diagnosis of the heart attack, the patient agreeing to have a heart catheterization and being transported to the Cardiac Catheterization Laboratory to the physician being able to open the blood vessel.
Q. What should a hospital’s door-to-balloon time be?The Centers for Medicare and Medicaid Services (CMS), the Joint Commission and many other organizations have agreed that a door-to-balloon time of 90 minutes or less is optimal.
Q. What conditions are helped by having a faster door-to-balloon time?Patients who have a particular kind of heart attack, called a myocardial infarction with ST-segment elevation, are helped by faster door-to-balloon times. This type of heart attack is caused by an abrupt decrease in blood flow to a piece of the heart, and the heart muscle will die if blood flow is not restored quickly. Patients may also experience cardiac arrest-the sudden, abrupt loss of heart function-or an arrhythmia, which causes the heart to beat very rapidly or erratically due to a heart attack. Arrhythmia is one of the main causes of death when someone is having a heart attack.
Q. Why is door-to-balloon time important?Door-to-balloon time is important because we know that the faster we’re able to re-establish blood flow to a blocked artery, the better the outcome for the patient. Most patients have a blood clot that is obstructing blood flow, so the more quickly we can restore blood flow to that part of the heart, the less heart damage and the lower mortality we have. By intervening quickly, we can rescue the heart muscle.
Q. How does door-to-balloon time affect patient outcomes?What we have been able to do in cardiology continues to amaze me. I treat patients who have massive heart attacks, but if I can quickly restore blood flow, their hearts can function normally. They can have a cardiac arrest, and yet the timely delivery of appropriate treatment is demonstrating fantastic results.
That’s why reducing door-to-balloon time has become such a national effort because the improvement in health is dramatic. We’re now able to effectively intervene in one of the major causes of morbidity and mortality in this area. It’s an important thing that can dramatically save people’s lives.
Q. Do all hospitals meet the standard door-to-balloon time?No. Hospitals are ranked on a number of criteria, and there are national efforts to help hospitals reduce their door-to-balloon times. I wouldn’t choose a hospital based on its door-to-balloon time being 68 minutes and another’s being 72 minutes. But, there is a difference between 68 and 120 minutes.
Door-to-balloon time is an important quality measure in health care. The absolute value is probably less important than whether an organization meets national criteria and has quality improvement in place and the physicians are truly aligned with the organization.
Q. What is the door-to-balloon time for Froedtert & the Medical College of Wisconsin?It’s different each quarter, but we have been substantially less than 90 minutes for the past two years. In fact, in the last quarter of 2006, the American College of Cardiology ranked Froedtert & the Medical College at the top in the country (among 602 healthcare facilities) in door-to-balloon time. Occasionally, we’ll have a patient that has difficult anatomy, so doing the procedure may take longer. Door-to-balloon time doesn’t take that issue into account. What’s even more important than the door-to-balloon time is the quality and improvement processes in place to limit door-to-balloon time.
Q. What makes Froedtert & the Medical College of Wisconsin different in their approach?One of the special things about Froedtert & the Medical College of Wisconsin is that the doctors all work together in an integrated approach to improve patient outcomes, and that’s truly different.
Years ago we recognized that it was very important to minimize the door-to-balloon time, and it was going to require not only better and improved communication between doctors, but would also improved communication between hospital departments. We decided then that we would begin tracking all the steps in our door-to-balloon time process.
Certain elements have been identified nationally as being very important. The Emergency Department needs to activate the Cardiac Catheterization Laboratory. There needs to be one doctor who’s in the emergency room who can say this patient needs cardiac catheterization. That person needs to be able to activate the entire system rather than calling for a consultation.
The system includes rapid notification of the performing physician, transportation and preparing the patient for cardiac catheterization in the Emergency Department — all of the steps needed to do a safe procedure. We’ve measured each of these components and conducted a statistical improvement analysis.
We had to change technology. For example, all hospital clocks weren’t necessarily the same. Our initial step was to apply a timer to the bed of the patient when they arrived so we could keep track of the exact time elapsing. Now, we’ve got satellite clocks throughout the pathway the patient follows so we can be very accurate and have everybody working on the same time. It sounds like a simple thing, but it was one of the first things that we did to have a consistent way of measuring times.
Because we have Flight for Life and connect to the Emergency Medical Services program from the Emergency Department, we’ve been able to obtain EKGs in the field so we can activate the system even before the patient arrives here. That was an important decision to make. It’s so important to get the appropriate patients to the Cardiac Catheterization Laboratory that it’s worth those times when the Cath Lab will be activated and the patient won’t be appropriate.
You have to be really committed to this process. Our physicians cannot be more than 30 minutes away from the hospital at any time when they’re on call. There are some doctors who take calls in-house for this exact purpose.
Q. How do Froedtert & the Medical College of Wisconsin continually improve door-to-balloon time?We look at every single case, and we’ve broken the procedure out into each component. How long did it take to get a patient’s EKG? How long did it take for the diagnosis? How long did it take the operator to page the appropriate staff? All those small things added together make a big difference. If there is a delay — if transportation takes 12 minutes rather than 4 minutes — that prompts a quality feedback mechanism. If it’s a problem in the system, we have to fix that because it’s unacceptable.
We work on speed of diagnosis. If a patient walks in complaining of anything that might be in the least way related to a heart attack, our triage is set up so the patient immediately gets an EKG. One can then make the decision based on the EKG. Everything has been streamlined so that if a patient is coming in with a heart attack, he or she is rapidly identified and a blocked artery is rapidly opened.
We do the paperwork at the same time that we’re taking care of the patient. Activation of the Cath Lab and care delivery doesn’t occur sequentially, it occurs simultaneously. You need a history and prior records, but we don’t stop to wait for those elements. We do them simultaneously while we’re getting the patient ready for potentially life-saving care.
Source: Every Day
Date: Jan - April 2008 Issue