Time is Muscle: Improving In-House STEMI Door-to Balloon Times

Purpose:
The purpose of this evidence-based performance improvement project was to meet the American College of Cardiology (ACC) goal of <90 minutes from time of presentation to intervention for all patients suffering a ST-segment Elevation Myocardial Infarction (STEMI) within the organization.

Significance:
Current STEMI guidelines recommend patients with STEMI receive treatment with primary percutaneous coronary intervention (PCI) <90 minutes of first medical contact. The National Cardiovascular Data Registry (NCDRŽ) metric is Proportion of STEMI patients with Door-to-Balloon (DTB) of <90 minutes.

Strategy and Implementation:
Our NCDRŽ metric in Quarter 3 2008 was 81.5%. Of this STEMI population, 88% of patients presenting via the Emergency Department and 50% of hospital inpatients met the <90 minute goal. A multi-disciplinary team focused on the inpatient group, identified the main barrier in meeting the 90 minute goal as a delay in obtaining the 12-lead ECG and activating the cardiac catheterization lab. A practice change was proposed that adult 12-lead ECGs ordered stat, meeting trigger criteria, are screened by the Cardiac ICU charge nurse for ST segment elevation. When noted, the cardiology fellow reads the ECG. The fellow notifies the interventional cardiologist and the patient's primary team of STEMI. If there are no contraindications, patient is prepared for immediate cardiac catheterization. The Cardiac ICU nurses demonstrated competency in screening 12-lead ECGs. The ECG technicians were educated on the trigger criteria. The process was piloted for 4 weeks and then became expected practice.

Evaluation:
During the pilot, 2 successful cases were identified, with time to intervention <90 minutes and minimal burden on the nurses or fellows. The process continues with routine case and data review, and follow-up as indicated. Fifteen-month metric reveals 98% of STEMI patients with PCI in <90 minutes.

Implications for Practice:
In reaching the quality metric of <90 minutes to PCI for STEMI inpatients, system processes can be impedimentary. Utilizing a multi-disciplinary approach and competent nursing staff to screen 12-lead ECGs was paramount in reaching the goal in our academic medical center.