New Haven, CT - Hospitals wishing to achieve PCI door-to-balloon times within the guideline-recommended 90-minute window may wish to take their cue from institutions that have managed to radically improve their median door-to-balloon times within the past few years, researchers say [1]. In a paper published online February 21, 2006 in Circulation, Dr Elizabeth Bradley (Yale University, New Haven, CT) and colleagues say that eight specific hospital characteristics may be the key to improved care for STEMI patients undergoing PCI.

Bradley et al performed a qualitative analysis of 11 hospitals participating in the National Registry of Myocardial Infarction that had demonstrated substantial improvement in terms of shorter door-to-balloon times between 1999 and 2001-2002. Through in-depth interviews with emergency-room physicians, cardiologists, nurses, and administrators, the investigators were able to identify eight common themes that were consistently associated with improved delay times:

• Setting the explicit goal of reducing door-to-balloon times.
• Active, visible senior-administrator support.
• Innovative protocols, based on creative identification of delays and how to reduce them.
• Flexibility in refining standardized protocols.
• Driven, highly respected individual clinical leaders who pushed persuasively for improvement.
• Collaborative, interdisciplinary teams made up of people equally committed to the goal.
• Nonblaming data-feedback mechanisms for identifying problems and successes and conveying these to team members.
• An organization "that fosters resilience to challenges or setbacks."

Commenting on the study to heartwire, senior author Dr Harlan Krumholz (Yale University) emphasized that the biggest barrier to implementing coordinated improvements was "the power of inertia."

"What we noticed at the top hospitals was that they recognized that they needed to change—that the status quo was not acceptable—and that they could improve. Once that commitment was manifest and spread throughout the organization, they refused to fail, even as they hit bumps."

Bradley, likewise, observed that hitting "bumps" along the way was a characteristic of every successful hospital. "These could have been processes that went wrong, people that were resistant, changes in the marketplace that took attention away from door-to-balloon time, etc. Not having adequate preparation for and processes in place to work through the "bumps" is a barrier to improvement," she added.

What we noticed at the top hospitals was that they recognized that they needed to change—that the status quo was not acceptable—and that they could improve.

In an accompanying editorial [2], Drs Mauro Moscucci and Kim Eagle (University of Michigan Health System, Ann Arbor) write: "Taken together, [these] results summarize and apply to the specific issue of door-to-balloon time the elements that have previously been shown to play an important role in improving overall quality of care for patients with acute coronary syndromes."

While the eight themes can be used to judge institutional preparedness, they add, actual improvement requires moving "beyond preparedness to action," perhaps by identifying specific steps that can be targeted and implemented.

"Achieving the 90-minute gold standard is possible, but it will require sustained investment on the part of institutions and caregivers alike," Moscucci and Eagle conclude.

To heartwire, Bradley emphasized that no single factor represents more of an obstacle than the others to hospitals and teams wishing to improve door-to-balloon times; rather it was committing to all of the areas identified in the study that led to success.

"What I think is the most challenging is not any single aspect but rather allowing what may be conflicting aspects to coexist," she said. "For instance, supporting in-depth, detailed data-monitoring and still fostering a blame-free environment. Or having intense, individualist clinical leaders and still leadership through broad-based teams. It is the ability to nurture and allow for these potentially conflicting approaches to simultaneously exist in an organization, what we termed 'balancing paradox,' that is, I think, at the heart of sustained improvement, but is also the most challenging aspect of organizational change."