UMass Memorial Slashes Door-to-Balloon Time for STEMI
The Medical Center Creates a Regional System for Optimal Heart
This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
As the saying goes, time is muscle. When a patient has a myocardial
infarction, rapid revascularization of the occluded coronary artery limits
infarct size, improves left ventricular function and may improve long-term
survival - underscoring just how vital a timely intervention is for patients
with acute coronary syndrome.
Unfortunately, the time from
initial symptom onset to arrival of emergency medical services has not changed
appreciably in the last decade - despite widespread public awareness initiatives
aimed at educating people to recognize heart attack symptoms and seek prompt
To optimize patient outcomes, there is increased focus on saving time at the
other end of the emergent care continuum by reducing door-to-balloon time (DTB)
- the interval between when the patient arrives at the emergency department (ED)
and when the occluded vessel is opened by performing a percutaneous coronary
intervention (PCI) in the Cardiac Catheterization Lab.
For patients experiencing ST-elevation myocardial infarction (STEMI),
clinical evidence supports primary PCI as the treatment of choice due to its
This focus was fueled by changes in the American Heart Association guidelines
and the Joint Commission's core measure standards for treating patients with
acute MI. The Joint Commission, in fact, established a DTB time goal of 90
minutes or less for 75 percent of STEMI patients.
UMass Memorial Medical Center, however, decided it could do better than that.
And it has.
Exceeding National Standards
"We kicked the tar out of
that goal," said Jay Cyr, RN, MS, MBA, vice president of the UMass Memorial
Heart and Vascular Center of Excellence. He is not exaggerating. In the past
three years, the Medical Center slashed its DTB time from well over 180 minutes
to less than 60 minutes for all its STEMI patients - a 70 percent reduction that
significantly beats national standards in heart attack care!
This exemplary success is attributed to two key factors: an unflinching
willingness to examine every aspect of the care process to identify where there
is room for improvement, and an exceptional partnership between the Departments
of Emergency Medicine and Interventional Cardiology.
But how, exactly, did the region's premier tertiary medical center make this
Measuring and Mentoring
"I think the initial
improvements came about as a result of the Hawthorne effect," Mr. Cyr said,
referring to a well-known management theory which posits that people change
their behavior when they are aware of being watched. "Just by starting to
monitor the care process, DTB times began to decrease," he said. UMass Memorial
did not stop there, however.
"We began to drill down and analyze every aspect of the process," explained
John Keaney Jr., MD, chief of cardiovascular medicine. Dr. Keaney, who is an
internationally recognized expert in the fields of atherosclerosis and vascular
biology, and associate editor of the journal Circulation, noted that
identifying the components of the process was a critical first step. DTB time
was separated into four distinct segments: door to data (entrance into the ED
until EKG completion); data to diagnosis (EKG completion until diagnosis);
diagnosis to decision (treatment approach is finalized); and decision to device
(treatment decision until PCI completion). Once these segments were identified,
individual time goals were established to help clinical leaders improve overall
"Our intent wasn't to change clinical practice but to change how we
coordinate the process of care and its impact on patient outcomes," Dr. Keaney
added. "Each step in the process was examined for inefficiencies, duplication
For example, as the key diagnostic trigger for STEMI, obtaining an immediate
12-lead EKG on patients presenting with chest pain is imperative; waiting for a
technician or equipment to arrive from the central EKG department could delay
treatment 15 minutes or more. Once the EKG was completed, the data-to-diagnosis
time also could be fraught with delays if an ED physician was not immediately
Through re-educating triage nurses and ancillary staff members, ensuring the
immediate accessibility of a 12-lead EKG machine in the ED as well as the
physical presence of an ED physician to read the EKG results, UMass Memorial
compressed the door-to-data and data-to-decision times into a shorter interval
of 10 minutes or less.
One Simple Change Has Major Impact
time segment, however, saw the most dramatic improvement based on one simple
operational change. Mr. Cyr explained: "Previously, when a STEMI patient was
diagnosed in the ED, the practice was to consult with the cardiologist, then
contact the interventional cardiologist, who'd notify the cardiac cath team," he
said. "These multiple contacts delayed care. So we eliminated this layered
approval process by giving ED physicians the authority to activate the cardiac
cath team directly during off-hours." (See sidebar on page 4 for more about the
Cardiac Catheterization Rapid Response Team.)
"This is probably the single most significant structural change and the
biggest reason for how and why our STEMI program has such a low DTB time," said
Peter Paige, MD, vice chair of emergency medicine, noting that it transformed
what was the most delay-plagued step in the DTB process into the simplest and
most efficient step. "Many hospitals still don't allow this. But if you look at
hospitals like ours that are doing well in reducing their DTB time - and doing
well by their patients - it is standard operating procedure."
"It also speaks to the strength of the relationship between cardiovascular
and emergency medicine here at UMass Memorial," Dr. Keaney added, noting that
the departments meet monthly to identify ways of doing things better. "These are
areas never ventured into years ago. But we're willing to do whatever we can to
ensure optimal care for patients."
Using Technology to Enhance Prehospital
Having gotten its proverbial ducks in a row regarding the
inhouse DTB process for STEMI patients, UMass Memorial next set its sights on
the prehospital component.
"Once we were satisfied with our internal process and results, it made sense
to extend our quality improvement efforts to the paramedics bringing STEMI
patients to the hospital," Dr. Paige said. So members of the Emergency
Department, accompanied by interventional cardiologists, gave presentations to
the region's emergency medical services (EMS) providers, starting with the UMass
Memorial EMS that serves Worcester and Shrewsbury.
The ubiquitous cell phone enabled one major improvement. New technology
allows paramedics and emergency medical technicians to transmit 12-lead EKGs via
cell phone from an ambulance to the Emergency Department at UMass Memorial. The
cell phone connects to the EKG monitor, then transmits the data to the ED, where
physicians provide paramedics with guidance on the necessary intervention.
"The rescue squad is essentially providing hospital-level care during
transit," Dr. Paige said. "This shortens the time between symptom onset and
treatment, and results in a higher likelihood of a better patient outcome."
Today, a dozen towns around Worcester have adopted this approach, with several
more on track to add the lifesaving equipment to their EMS operations.
With the enhanced communication system at the Medical Center, incoming STEMI
patients can bypass the ED and go directly to the Cardiac Cath Lab, further
reducing DTB time. "We've developed a great relationship and communication with
the area's emergency medical service personnel," said Mr. Cyr. "Without them,
this just wouldn't work."
A Regional System for Heart Attack
Building on this success, UMass Memorial is now focusing on
creating a truly regional system of care for heart attack patients.
"For those community hospitals without cath labs, UMass Memorial is a major
referral center, and our aim is to facilitate the best possible care for their
patients," said Dr. Paige. "So we've begun meeting one-on-one with these
hospitals to explain our STEMI program and come up with the best ways of helping
them to get patients here promptly."
For example, at HealthAlliance Hospital in Leominster, the ED team worked out
a new protocol for Life Flight air ambulance transport of MI patients.
"Before, the helicopter would land, offload the crew into an ambulance, ride
to the ED, pick up the patient, ride the ambulance back to the helicopter, load
the patient into the helicopter, then take off for UMass Memorial," explained
Dr. Paige. "Now, appropriate patients are delivered right to the helipad,
shaving significant time off the time in the field.
"The initial reaction from the community hospital was, ‘Wow, you guys will do
that?'" he added. "Our attitude is that we'll do whatever we can to ensure
optimal care for patients."
"Why shouldn't STEMI patients served by
community hospitals receive care that's just as consistent and timely?" asked
Mr. Cyr. "We know it can improve outcomes. It comes down to making the emotional
investment to really look at the process involved in getting patients from there
to here, and being willing to undertake the necessary initiatives to improve the
"It is more difficult in a community hospital because our location adds
time," admitted Nicholas Mercadante, MD, HealthAlliance Hospital cardiologist.
"But teams of physicians at both UMass Memorial and HealthAlliance are working
together, looking at all the specific steps taken to identify where we can save
minutes. And we have made improvements.
"Most referral hospitals in Worcester County are within a 30-minute range of
UMass Memorial and it's an easily accessible location. So it is possible to
achieve a reasonable DTB time to give patients the standard of care for acute
MI," he added, referring to primary angioplasty and stent placement. "And that
obviously has a lot of value for patients."
Quality Is in the Drinking Water Here
"Everything we do
is aimed at improving patient care, and raising the bar in treatment of STEMI
patients," said Dr. Paige. "This extends to providing a level of service to
referring physicians that they won't get at other places, to do whatever we can
to keep them informed, including real-time feedback from the Cath Lab. We review
every STEMI case to evaluate DTB times and outcomes, and we're happy to meet
with referring doctors to talk and troubleshoot."
"The focus on quality is in the drinking water here," affirmed Mr. Cyr.
"We've been doing this for three years now, and everyone involved believes the
things we do make a difference in patient outcomes. We measure and monitor
everything and provide feedback - both positive and negative - about results.
People respond to that, especially to good results, and feel committed to making
things even better. There's no resting on laurels here."
In fact, UMass Memorial is earning national recognition for its excellent
results in reducing DTB time for STEMI patients. Three major medical
organizations accepted abstracts for presentation this year, including the
American Society of Chest Pain Centers, the American College of Emergency
Physicians Scientific Assembly and the American College of Cardiology.
The real prize, however, continues to be optimal patient care. "We're willing
to do whatever we can to ensure optimal care for patients," reiterated Dr.
Paige. "Our goal is service to the community and, ultimately, to create better
outcomes for patients. That's why we're here."