Ask the Experts: Door-to-Balloon Time: 47 Minutes!

Kevin Wehrle

Kevin Wehrle, RN, AAC
Accreditation Review Specialist

Kevin has a solid background in cardiac nursing and a passion for the community hospital setting. He has a strong desire to improve the ACS and Early Heart Attack Care education that is needed for the public. During his extensive nursing career, he developed a strong commitment for the critical care patient while working in the Intensive Care Unit and the Catheterization Lab. While at the hospital he advanced from a staff nurse into a leadership role as a Manager, then on to Cardiovascular Service Line Director with the added responsibility of being on the Steering Committee for developing an Interventional Angioplasty program with Open Heart surgery. Since joining us, he has reviewed a multitude of hospitals and truly appreciates the great things that are being done to improve ACS patient care processes.

Read the Q&A with Kevin Wehrle, who talks about PCI, our process, and how one hospital reduced door-to-balloon times!

Q: Many of our accredited hospitals have the PCI designation … what does that mean?
A: PCI or Percutaneous Coronary Intervention is a non-surgical procedure to restore blood flow to a stenotic (narrowed) area within the affected coronary artery. PCI designation is treated a little differently when reviewing the documentation in that the hospital must have a written reperfusion strategy and support this process throughout the manual. In order to achieve PCI designation, a hospital must have on-site 24/7 emergent cath lab capabilities as well as having successfully performed 36 primary PCIs for STEMI over the last 12 months prior to the site visit.

Q: Is it a differentiator for hospitals in terms of treating STEMI patients?
A: When it comes to treating the STEMI patient, the only difference is where the interventional procedure takes place — either on-site at that specific hospital or at a facility that has the capability to perform the interventional procedure. In that case, the original facility would have to arrange for a patient transfer to the PCI-capable hospital. Now, please take into consideration that there are hospitals across the country that have an on-site cath lab and will utilize the PCI procedure as their primary reperfusion strategy; however they may not have the Accredited Chest Pain Center with PCI designation. The only thing holding back the "PCI" designation would be the fact that they have not met the minimum number of 36 primary PCIs for STEMI over the previous 12 months.

Q: When facilities have that kind of volume — 36 or more — what are the keys you focus on for process improvement at the cath lab?
A: If they do meet the criteria of more than 36 primary PCIs for STEMI over that period, we will look at their percentage that the door-to-balloon (D2B) time is under 90 minutes. For the current Cycle IV criteria, we want hospitals to have a D2B time under 90 minutes 85% of the time for the previous 6 consecutive months. Areas that directly affect the overall D2B time in the cath lab include but are not limited to the following: response time of the interventional team from first notification, cardiology response time, time spent in the ED prior to being delivered to the cath lab, and arrival in the cath lab to reperfusion.

Q: D2B time is critical, we know. What are some simple things your organization recommends to reduce that critical time?
A: There are a couple of basic things that we recommend to every facility. They are early activation processes, and a collegial/collaborative relationship between all departments working on the ACS patient. Early activation processes can be initiated from the EMS providers in the field by the ECG or report and will allow for staff to get prepared for the patient prior to arrival. A collegial/collaborative relationship will help eliminate the duplicated steps and increase the awareness for a seamless transition of care. Research has shown that steps done prior to the cath lab will help save 5-8 minutes of procedure time.

Q: Some things sound like simple math — taking time off the clock if you will — but others just seem to be communication issues, or getting everyone on the same frequency. Can you give an example of how that applied out in the field for you?
A: During a site visit in Florida, I had the opportunity to meet a patient who was admitted after experiencing a heart attack a couple of days prior. He relayed to me that he had experienced chest pain over the weekend and called 911 when the pain wouldn't subside after taking Nitroglycerin. When the EMS providers arrived on the scene, they immediately acquired an ECG and transmitted it to the hospital. He stated that the EMS crew was "very knowledgeable" about what was going to happen and reassured him that the staff would be waiting for them when they got to the hospital. He went on to tell me that he stopped in the ED for a "quick look" by the ED physician and they delivered him straight to the cath lab where the staff and cardiologist were waiting to "do their thing." As he stated to me on that day "they never slowed down and took great care of me without any interruptions." The subsequent door-to-balloon time was 47 minutes, and the patient has become an advocate for early recognition and activation for the local community.

Q: 47 minutes! Isn't that a little more than half of the recommended 90 minutes?
A: Yes, it is and the entire staff attributed their success to the concepts and best practice ideas that they had learned from the accreditation process and the collegial/collaborative approach we offer to facilities. My partner and I left that hospital with huge smiles on our faces and knowing we are directly affecting ACS patient care across the country.