October 30, 2008 (Chicago, Illinois) — By including emergency-physician activation in the catheterization lab, researchers from the Mayo Clinic were able to achieve door-to-balloon times (DTBTs) of less than 90 minutes for patients with ST-elevation myocardial infarction (STEMI), according to a presentation here at the American College of Emergency Physicians (ACEP) 2008 Scientific Assembly.
DTBTs for STEMI have been extensively studied during the past several years. They are correlated with patient mortality, and numerous efforts have been made to improve these times. National guidelines now recommend DTBTs within 90 minutes for at least 75% of patients with STEMI. Many sites have published studies documenting an inability to reach these goals, and no site has demonstrated durable improvements to STEMI management over the years.
“We felt that our management changes, which we named the Mayo Clinic STEMI Protocol, resulted in sustainable and durable improvements over 4 years, and that is what our data showed,” lead author David Nestler, MD, attending physician in the Department of Emergency Medicine at the Mayo Clinic in Rochester, Minnesota, told Medscape Emergency Medicine.
Pre- and postimplementation data were collected in March 2008 on consecutive, nontransferred patients with STEMI. The preimplementation group consisted of 96 patients presenting from June 2002 to March 2004, which had a median DTBT of 97 minutes, and 40% had a DTBT of less than 90 minutes. The Mayo Clinic STEMI Protocol was implemented in May 2004. The postimplementation group of 368 patients had a median DTBT of 69 minutes, and 77% had a DTBT of less than 90 minutes.
Main components of the protocol’s success were the enabling of emergency-medicine physicians to activate the cardiac-catheterization lab and the implementation of a single-call system with real-time performance feedback. Another key element of the protocol was that the emergency physician did not need approval from cardiology. With a single-group page, the entire cardiac-catheterization team was activated. Dr. Nestler and colleagues consider the time goals most important: time from door to ECG of less than 10 minutes; time from door to catheterization-laboratory activation of less than 15 minutes; and time from door to departure from the emergency department of less than 45 minutes.
There was a direct phone line between the emergency-department nurse and the cardiac-catheterization nurse for patient transfer, and an elevator control key was used for patient transfer to speed up the process. Even priority hospital parking was arranged for the cardiac-catheterization staff in off-hours. Within a 24- to 48-hour period, real-time feedback on DTBT performance was given to all providers.
“We wanted to share these data with other sites so they could consider implementing these improvements as well,” Dr. Nestler said. “Although we were not surprised by these results, other hospitals will be. This study shows these times can be achieved and are sustainable over a period of several years.”
Luis Serrano, MD, assistant professor of emergency medicine at the University of Puerto Rico, commented on the presentation for Medscape Emergency Medicine: “This study is important because it decreases door-to-door balloon times so you can decrease mortality. The protocol has been stable over time, which shows that it works.”
Brian O’Neil, MD, course director of the Research Forum at the ACEP meeting and associate chair of the Department of Emergency Medicine at Wayne State University School of Medicine, in Detroit, Michigan, said: “The American Heart Association wants every institution to have less than 90 minutes DTBT. Although [this was] not a huge study, it tried to identify factors that caused delays. Nevertheless, Mayo Clinic was one of the earliest to have this policy, and the fact that it can maintain this time over 4 years is pretty good.”
This study had internal funding from the Mayo Foundation for Education and Research. Neither Dr. Serrano nor Dr. O’Neil have disclosed any relevant financial relationships.
American College of Emergency Physicians (ACEP) 2008 Scientific Assembly: Abstract 298. Presented October 28, 2008.