Achieving Door-to-Balloon Times That Meet Quality Guidelines

Bradley, Elizabeth H.; Roumanis, Sarah A.; Radford, Martha J.; Webster, Tashonna R.; McNamara, Robert L.; Mattera, Jennifer A.; Barton, Barbara; Berg, David N.; Portnay, Edward L.; Moscovitz, Harry; Parkosewich, Janet; Holmboe, Eric S.; Blaney, Martha; Krumholz, Harlan M.

doi:10.1016/j.jacc.2005.07.009

Cited by 186 publications

(57 citation statements)

References 16 publications

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“…16 Pre-hospital ECG transmission enables on-call cardiologists to be notified before the patient arrives in the emergency department and reduces PCI-related delays, with earlier activation of the catheterization laboratory. [17][18][19] We believe that pre-hospital ECG transmission and analysis contributed substantially to the higher rate of a DTB within 90 min at the TEC in our study.…”

Section: Circulation Journal Vol73 March 2009mentioning

confidence: 74%

Current Status of Emergency Care for ST-Elevation Myocardial Infarction in an Urban Setting in Japan

Nakayama

Kimura

Endo

et al. 2009

Circ J

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he time from hospital admission to reperfusion is an important predictor of the outcome for patients with ST-elevation myocardial infarction (STEMI). 1-3 Guidelines for the management of STEMI issued by the American College of Cardiology/American Heart Association and the European Society of Cardiology recommend primary percutaneous coronary intervention (PCI) for reperfusion therapy when it can be performed in a timely manner (ie, door-to-balloon time (DTB) or first medical contact-to-balloon time within 90 min) by experienced operators at high-volume centers. 4,5 However, emergency primary PCI is not always feasible, and treatment is frequently delayed. In Japan, PCI can be performed at many hospitals, and the predominant strategy for reperfusion therapy is primary PCI, 6-9 but how rapidly reperfusion is achieved in Japanese hospitals that routinely perform PCI remains unclear. Drugs, devices, and techniques for primary PCI have been actively debated, whereas shortening the time to reperfusion has only recently received attention. This study evaluated DTB and analyzed its components in patients with STEMI who were admitted to emergency hospitals in an urban setting in Japan and examined differences in DTB according to the type of hospital. Methods Study PopulationWe retrospectively studied 369 patients (283 men, 86 women; mean age, 65 years) with STEMI who were admitted to 12 emergency hospitals in an urban setting in Japan and underwent emergency coronary angiography within 12 h after symptom onset. Patients with out-of-hospital cardiac arrest were excluded. All subjects had to have typical chest pain lasting for 20 min or more and ST-segment elevation in at least 2 adjacent leads (>0.1 mV in leads II, III, aVF, aVL, V4-6 and >0.2 mV in leads V1-3) on the admission electrocardiogram (ECG). The diagnosis of acute myocardial infarction (AMI) was confirmed by an increase in the creatine kinase level to more than twice the upper limit of normal. Another 20 patients with STEMI within 12 h after symptom onset were hospitalized during the study period, but did not undergo urgent cardiac catheterization because of advanced age or comorbidity. No patient Background: The door-to-balloon time (DTB) is an important predictor of the outcome for patients with STelevation myocardial infarction (STEMI). In Japan, percutaneous coronary intervention (PCI) can be performed at many hospitals, and the predominant strategy for reperfusion therapy is primary PCI. However, it remains unclear how rapidly reperfusion is achieved at these hospitals. Current Status of Emergency Care for ST-Elevation Myocardial Infarction in an Urban Setting in Japan

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Section: Circulation Journal Vol73 March 2009mentioning

confidence: 74%

Current Status of Emergency Care for ST-Elevation Myocardial Infarction in an Urban Setting in Japan

Nakayama

Kimura

Endo

et al. 2009

Circ J

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“…662,663 Twelve studies demonstrated that emergency physician activation of the catheterization laboratory was associated with significant reductions in door-to-balloon time intervals (20 to 68 minutes) (LOE 2 664 -666 ; LOE 3 [667][668][669][670][671][672][673] ; LOE 5 663,674 ). Falsepositive activation rate in these studies ranged from 0% to 15%.…”

Section: Consensus On Science Emergency Physician or Prehospital Actimentioning

confidence: 99%

“…Falsepositive activation rate in these studies ranged from 0% to 15%. 674,[663][664][665][666][667][668][669][670][671][672][673] Prehospital Activation of the Catheterization Laboratory. Seven studies demonstrated the effectiveness of prehospital activation on reducing door-to-balloon time intervals (22 to 69 minutes) (LOE 2 656,675 ; LOE 3 676,677 ; LOE 4 660,678 ).…”

Section: Consensus On Science Emergency Physician or Prehospital Actimentioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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“…These may include a delay in acquiring and interpreting ECGs, delays in patient transport to the catheterization lab, delays in activating the interventional cardiology team, delays in preparing the catheterization lab, or the unavailability of the catheterization lab due to patient overload. Additionally, efforts to reduce the delay in patient arrival to the ED should be made (9)(10)(11)(12).…”

Section: Discussionmentioning

confidence: 99%

The Effect of Direct Communication Between Emergency Physicians and Interventional Cardiologists on Door-to-Balloon Times in STEMI

Kwak¹,

Kim²,

Lee³

et al. 2007

Academic Emergency Medicine

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We developed an institutional protocol mandating emergency physicians to contact the interventional cardiologist directly in all cases of ST-segment elevation myocardial infarction (STEMI) and hypothesized that this would reduce door-to-balloontimes (DTBT). From January 2004 to July 2006, 208 patients with STEMI were treated with primary percutaneous coronary intervention (PCI). A total of 144 patients were treated before implementing the new protocol (''before'') and 64 patients were treated after the implementation (''after''). The DTBT was significantly reduced from 148± ±101 min to 108± ±56 min (p<0.05). While only 25% of the ''before'' patients received PCI within 90 min after arrival, 50% of the ''after'' patients received PCI within 90 min (p<0.05). There were no significant differences between two groups in other outcomes (postprocedural TIMI flow, mortality, subsequent stroke, heart failure, shock, reinfarction, length of stay in intensive care unit, and the total hospital length of stay). In conclusion, mandating emergency physicians to directly notify interventional cardiologists of all STEMI patients reduces DTBT.

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Achieving Door-to-Balloon Times That Meet Quality Guidelines

Cited by 186 publications

References 16 publications

Current Status of Emergency Care for ST-Elevation Myocardial Infarction in an Urban Setting in Japan

Current Status of Emergency Care for ST-Elevation Myocardial Infarction in an Urban Setting in Japan

Part 9: Acute Coronary Syndromes

The Effect of Direct Communication Between Emergency Physicians and Interventional Cardiologists on Door-to-Balloon Times in STEMI

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