New Haven, CT - Prehospital electrocardiograms and interdisciplinary collaboration are two key ingredients for reducing door-to-balloon times in patients with ST-segment-elevation MI (STEMI), a new study shows [1]. Writing in the October 4, 2005 issue of the Journal of the American College of Cardiology, Dr Elizabeth H Bradley (Yale University School of Medicine, New Haven, CT) and colleagues report that hospitals with the fastest door-to-balloon time, as recorded in the National Registry of Myocardial Infarction, likely also have these types of practices in place.

Dr Elizabeth H Bradley (Source: Yale University School of Medicine)

"Some of the things are easier to implement than others, but in general, we really found things that were much more about reorganizing the way you're doing something than about adding new resources," Bradley told heartwire. "We really have found, and believe, that these are not the kinds of things that are impossible to accomplish. Even in the hospitals where we studied it, often it was a question of everybody getting around the table to decide, is this something that we are going to accomplish? And then having the will to do it."

Often it was a question of everybody getting around the table to decide, is this something that we are going to accomplish? And then having the will to do it.

Bradley and colleagues chose 11 "top-performing" hospitals based on whether they had achieved door-to-balloon times of <90 minutes for their 50 most recent PCI cases. After interviewing 122 health professionals at these hospitals, Bradley et al were able to draw up a flowchart for expediting acute reperfusion in STEMI patients undergoing PCI. Paramount in their observations was the performance of an ECG by the paramedic, who then called the emergency department (ED) operator, who in turn paged the cath-lab staff and interventionalist on call.

"The issue of prehospital ECGs has been in the guidelines and recommendations for some time, and there are a number of areas around the country in which this can be achieved," Bradley told heartwire.

In situations where the patient arrived at the emergency department without an ECG, the best door-to-balloon times were in patients whose ED nurses expedited the ECG process and made sure the results were seen swiftly by an attending ED physician, who then activated the catheterization team, rather than first having the patient reviewed by a cardiologist, as is typical in most EDs today.

In the process proposed by Bradley et al, the emergency-medicine physicians are given the responsibility to activate the cath lab. "This is really not what is done now. Even in the hospitals we studied, they described what the challenges were and how difficult it was to transfer that responsibility from a cardiologist to emergency-medicine physicians."

In the beginning, Bradley acknowledged, there were situations in which the cath-lab staff was activated, then not needed. "But the response to those situations and the learning and quickness with which hospitals recovered from that were amazing," Bradley said. "It might happen a couple of times, but then it stopped, and you've cut out a good amount of time. It takes a lot of feedback, collaboration, and training to be sure that this is working, but it was amazing to see, in this study, how a cardiologist and emergency-medicine physicians really thought: let's put the patient first and what do we need to do? How do we learn to collaborate?"

Hopefully somebody takes it up and has the passion to make the right kinds of changes.

Bradley and colleagues believe their study should give hospitals wanting to improve their door-to-balloon times the evidence they need to move forward, although Bradley is quick to agree that deciding on the concrete changes can be difficult. She and her colleagues have presented the results of their study to various hospitals and have found that the hospital leadership needs to make it a priority for the necessary changes to occur.

"Nothing is as simple as it looks, but [this study] has been a tremendous motivator for some leaders who see that it can be done and appreciate that some of the changes are not that expensive," Bradley explained. "I do think in a large institution, fundamentally the leadership taking it on as a key role is probably the first thing that has to happen. Hopefully somebody takes it up and has the passion to make the right kinds of changes."