Using quality improvement methods to improve door-to-balloon time at an academic medical center.

Huang RL, Donelli A, Byrd J, Mickiewicz MA, Slovis C, Roumie C, Elasy TA, Dittus RS, Speroff T, Disalvo T, Zhao D
J Invasive Cardiol. 2008 20 (2): 46-52

PMID: 18252966

OBJECTIVES - 1) Describe a quality improvement (QI) process to decrease door-to-balloon time (D2B); 2) Explain implementation of evidence-based strategies to improve D2B.

BACKGROUND - The ACC/AHA 2006 guideline target for ST-elevation myocardial infarction (STEMI) is a D2B of 90 minutes (min). QI methods can be used to identify areas for improvement, measure current processes, and provide rapid-cycle feedback about which strategies are effective.

METHODS - We studied all STEMI patients presenting to Vanderbilt University Medical Center from July 2005 through November 2006. A process flow chart was created and all D2B process steps were analyzed. In February 2006, evidence-based strategies were implemented to address bottlenecks and decrease D2B. Statistical process control (SPC) was used to monitor D2B time in real-time.

RESULTS - Targeted changes led to a 44 min decrease (p < 0.001) in overall median D2B time from 108 min (interquartile range [IQR] = 94-122 min) to 64 min (IQR = 56-94 min). Subinterval time periods for emergency department (ED)-to-electrocardiogram (ECG) time decreased by 7 min (p = 0.008), ECG-to-cardiac catheterization laboratory (CCL) time decreased by 18 min (p = 0.01), and CCL-to-balloon time decreased by 4 min (p = 0.19). After implementation, SPC charts revealed a 50% decrease in the central mean line and narrower control limits indicating more reliable performance.

CONCLUSIONS - Using QI methods of flow-charting, identifying bottlenecks, targeting strategies to bottleneck areas, and real-time monitoring with SPC and rapid-cycle feedback, D2B processes can be systematically redesigned for improvement. QI methods can be used by individual institutions to customize and implement strategies for their particular context.

MeSH Terms (14)

Aged Angioplasty, Balloon, Coronary Electrocardiography Evidence-Based Medicine Female Hospitals, University Humans Male Middle Aged Myocardial Infarction Tennessee Time and Motion Studies Time Factors Total Quality Management

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