1. Door-to-Balloon Time: Are there still challenges to success
Door-to-Balloon Time: Are there still challenges to success? Perspectives from the Front Line
Regina Deible, RN

2. MY DRIVEWAY FEB 2010

3. Door to Balloon Time takes on a whole new meaning in the winter!

4. WHOSE DOOR IS IT ANYWAY???

5. Does a delay impact mortality contingent on who’s door it is?
Our door to Our balloon?
Their door (at home) to our balloon?
The referring hospital door to our balloon?

6. Forge ahead … the patient always comes first

7. Perspective…circa 1999 Assigned topic for presentation @ TCT XI:
“The Impact of Primary Angioplasty, Stenting and Pharmacologic Agents in Acute Myocardial Infarction”.
Session concluded with timely debates about the value of “time is muscle” and the need for an efficient process to open the occluded vessel.
(This isn’t a new obsession)

8. No easy solution
There isn’t a single formula that will work for all cath labs…as not all cath labs are created equal; nor are all EMS systems.
Practices, referral patterns and patient population all need to be factored in for a reasonable plan.
However, there are many guidelines to build upon….

9. The D2B AllianceTM
Guidelines launched by ACC and partnered with AHA and NHLBI to save time and save lives by reducing the door-to-balloon times in U.S. hospitals performing primary PCI.
“Sustain the Gain”

10. Source- ACC : D2B Alliance http://www.d2balliance.org
Goal: D2B time ≤90 minutes >75% of patients in participating hospitals
Evidenced-based strategies:
ED physician activates the catheterization lab
One call activates the catheterization lab
Catheterization team ready in 20 – 30 minutes
Prompt data feedback
Senior hospital management commitment
Team-based approach
Optional: Activate based on pre-hospital ECG 
The D2B AllianceTM was developed to make what is current extraordinary performance ordinary by providing hospitals with key evidence-based strategies and supporting tools needed to begin reducing their D2BTM timeskey components for the D2B Alliance is to have a cath lab team ready in 20 to 30
minutes, prompt data feedback, and senior management involvement. I can't emphasize that
enough. If we are really to be successful, your hospital administration needs to empower the
physicians and the nurses, and to supply resources to make this effective. I think then the final
component is really team work. So, these components from the D2B Alliance I think have been
very effective having been applied, and PCI hospitals in the United States have done a great
Source- ACC : D2B Alliance

11. 1. 24/7 PCI capability within 30 minutes
RACE
Primary PCI Center*
1. 24/7 PCI capability within 30 minutes
2. Single number activation (immediate)
3. Accept patients regardless of bed availability
4. Ongoing data monitoring and feedback
5. STEMI Team with strong administrative support and dedicated STEMI coordinator
6. Improve STEMI care for all hospitals in region regardlessof affiliation
Duke University

12. Organization structure resilient to challenges or setbacks
Successful Themes of Top Performing Hospitals for PPCI D2B < 90 minutes)
Commitment to an explicit goal to improve D-B time
Senior management support
Innovative protocols
Flexibility in refining standardized protocols
Collaborative teams
Uncompromising individual clinical leaders
Data feedback to monitor progress, identify problems and successes
Organization structure resilient to challenges or setbacks
Source: L.Satler,

13. Recommendation for reperfusion strategies in STEMI
Source: JOINT 2010 EACTS GUIDELINES

14. THOUGHTS ON GUIDELINES…..
are not a text book.
...are the result of the scientific analysis of the available data.
...refer only to a part of the patients - due to the usually strict inclusion / exclusion criteria of the randomized trials.
...therefore do not replace medical experience.
...are recommendations what you should do or could do - but not what you must do.
...are not legally binding.
but they are more and more read and applied by health care providers and patients / relatives.
and - if you do not follow the guidelines and complications occur, you may need to justify, why you did not follow the guidelines !
Source: Dr. Sigmund Silber TCT10

15. Textbook of STEMI Interventions by Sameer Mehta, MD, FACC
Dedicated career to conquering obstacles to STEMI interventions and states there is one simple goal:
“Master the Process and Procedure”
With skilled hands and a dedicated process you can relieve CP, observe ST resolution, obtain TIMI grade III flow and have brisk myocardial perfusion.

16. Keys to success
Focus on the culprit lesion in the infarct-related vessel;
Achieve all 4 parameters of a successful pre-profusion:
relief of chest pain;
ST-segment resolution;
Restoration of TIMI grade 3 flow;
Myocardial perfusion grade 3
Sameer Mehta, M.D.

17. Back to the question: Are there still challenges to success
Back to the question: Are there still challenges to success? Perspectives from the Front Line

18. A Bit of Perspective…circa 1970
Dr. Kelly Brackett M.D.: [into transmitter link] 51, go. Paramedic Roy DeSoto: [over biophone] We have a male, tunnel worker, approximate age 60, was trapped under a digging machine. Patient had a cardiac history. He is now diaphoretic. Vital signs: 80 over 50; rate: 100 and irregular; respirations: 12 and shallow. Dr. Kelly Brackett M.D.: Do you have your EKG hooked up? Paramedic Roy DeSoto: Affirmitive, doctor. Dr. Kelly Brackett M.D.: Send me something so I can get a reading. [turns on EKG printer] Paramedic Roy DeSoto: This will be Lead 2. [turns on ELG transmitter] Dr. Kelly Brackett M.D.: [reads EKG strip] Multiple PVC's. [sees reading change] V-Tac. [reading changes again] He's starting to fibrillate. [to DeSoto] Defibrillate! 400 watt/seconds! Nurse Dixie McCall: Kell! They're not authorized to... Dr. Kelly Brackett M.D.: [into link] Are you receiving? Come on, 51! You've got a dying man on your hands

19. So, how can we save some time?

20. Tracking Form makes a difference!

21. Top Myths about Pre-hospital 12 lead EKG’s
If you’re close to the hospital, performing a PH12ECG is a waste of precious time.
PH12ECG monitors are incapable of capturing diagnostic quality 12 leads.
It’s important for the ED staff to perform another 12 lead ECG to confirm that it’s really a STEMI.
If ST segment elevation resolves by the patient’s arrival at the hospital, then it’s not a STEMI, and the patient doesn’t need an emergent cath.

22. It’s easy to identify STEMI on the PH12ECG.
If the hospital ignores the PH12ECG, then there’s no point in performing one
It’s easy to identify STEMI on the PH12ECG.
It’s impossible to identify STEMI in the presence of LBBB
Source:

23. Current versus ideal processes to integrate prehospital ECGs into systems of care
Ting, H. H. et al. Circulation 2008;118:
Copyright ©2008 American Heart Association

24. American Heart: Mission Lifeline
Prehospital electrocardiograms (ECGs) in patients with ST-elevation myocardial infarction (STEMI) are associated with a reduction in door-to-needle time of 10 minutes, and a reduction of minutes in door-to-balloon time.
Emergency medical service (EMS) systems serving over 90% of the 200 largest cities in the United States have 12-lead ECG equipment available in their ambulance systems.
Trained paramedics can identify STEMI with high sensitivity (71-97%), specificity (91-100%), and with good agreement between paramedics and emergency department physicians.

25. Studies using wireless transmission of ECG have demonstrated a reduction in time to reperfusion. Systems for prehospital wireless transmission are commercially available from Medtronic ,Welch Allyn , Zoll Medical and Phillips Healthcare
Appropriate training and ongoing quality assurance for EMS providers and medical control physicians is a key requirement for an effective prehospital ECG-based STEMI care system

26. EMS providers or the emergency physician should activate the catheterization laboratory while the patient is en route to the hospital.
Hospitals providing percutaneous coronary intervention (PCI) need to organize reliable wireless networks and technologies, have protocols in place for advanced preparation to receive and evaluate the patient with STEMI, and streamline emergency department evaluation or bypass emergency department evaluation altogether.
Communities need to develop prehospital triage so that the EMS can bypass non-PCI hospitals when a patient is diagnosed with STEMI

27. http://www. montgomerycountymd. gov/firtmpl. asp 

28. Technological help..
Web based integration
Web based / phone

29. iPhone 4G STEMI Alert System
STEP 1
STEP 2
ECG acquired by EMS iPhone live camera and transmitted to receiving hospital’s ED
ECG sent from ED or ambulance to Cardiologist’s smartphone
Internet application in ED
Internet applicaation
Or iPhone 4Gs

30. All Phone Carriers are jumping on apps

31. LIFENET
The LIFENET® STEMI Management Solution from Physio-Control. Using the latest broadband technology,this all-digital system enables paramedics to transmit 12-leadECGs from the LIFEPAK® 12 defibrillator/monitor in the field to a secure web-based system. The system then relays the information securely via the Internet to hospital care teams and cath labs, or directly to a cardiologist’s handheld device. The LIFENET STEMI
Management Solution bridges the gap between prehospital assessment and in-hospital care, ensuring critical patients receive the right treatment at the right place and at the right time.

32. EMS
    Training and ongoing quality assurance for EMS providers and medical control physicians
    Acquiring prehospital ECG as early as possible during initial scene evaluation
    Minimize scene time when STEMI is diagnosed
    Advanced notification of destination hospital
    Activation of catheterization laboratory by EMS providers or emergency physician while patient is en route to hospital
PCI Hospital
    Organize reliable wireless networks and technologies
    Advanced preparation to receive and evaluate patient
    Activation of catheterization laboratory by emergency physician while patient is en route to hospital
    Streamline emergency department evaluation or bypass emergency department
    Prehospital triage for regional hospital networks to bypass non-PCI hospitals
Research and Quality Assurance
    Monitor quality measures, including first medical contact to drug/balloon
    Monitor false-positive and false-negative rates
    Evaluate whether EMT-basic and EMT-intermediate can acquire prehospital ECG reliably and efficiently
    Promote systematic and routine feedback of performance to all stakeholders, including EMS, emergency department, and cardiology
Requirements for an Integrated Prehospital ECG System of Care

33. Angina or Anginal Equivalent Chest Pain No
Yes
ECG Diagnosis of STEMI or “New” LBBB No
STOP
Yes
STEMI-Referral Hospital ED Physician
STAT Code Heart Program Activation
Assess bleeding Risk
Low
High
Rapid Air-Ground Transport Availability
Yes No
Contraindication Protocol
PCI
Protocol
Fibrinolytic
Protocol
Direct Inter-hospital Transport to STEMI-Accepting Hospital Cath Lab

34. Barriers Only 50% of STEMI in US use EMS
Lack of integrated healthcare system
Lack of well organized inter-hospital transfer systems
Hospital bed capacity issue
Source: Tim Henry, MD

35. Institutional help: Establishing Core Measures
Door – EKG time : < 10 minutes (direct admits)
EKG – Activation Time: < 10minutes
Activation Time – Cath lab: < 45 minutes
Door to Cath lab: < 60 minutes
Cath lab to Perfusion: < 30 minutes
Door to Perfusion: < 90 minutes

36. Ways to streamline process
Empower EMT’s for pre-hospital activation.
“One call does all” team activation
Bypass ER…go directly to cath lab
Program Pyxis for STEMI patient
Have call teams either on site or ready within 30 minutes
Maximize your resources (Use in-house resource team for after hours)

37. Treatment Worksheet – Handover Report
Emergency Department
(Not part of medical record) S.T.E.M.I.
Treatment Worksheet – Handover Report
Criteria: Patient presenting with symptoms consistent with and confirmed on EKG for ST elevation M.I.
A. Initial Nursing Intervention  EKG Done ­­ ≤10min  Shown to ED Attending ___________(name)
 Patient placed on monitor/alarms on  Pulse Oximetry and Vitals q15 min
 Oxygen 2-4 L NC or alternative O2 source  STAT portable CXR (diagnosis CP)
 2 Large Bore IV’s (at least 1 AC line)  STEMI Labs drawn  Labs sent
(cbc, compmet, cardiac enzymes, PT/INR PTT, magnesium, lipids, Type and Screen, dig level when applicable)
B. Initial Medication
 ASA 81mg x 4 (chew and swallow) (HOLD if allergic and or has taken with in 1 hour PTA)
 Plavix 300mg PO x 1
 NTG 0.4 SL x 1 now (hold for SBP<100)  Nitro drip titrate to CP free and or SBP>120
Lopressor 5mg IV x 1 if vitals are: Pulse >100 and SBP>130 on NTG drip
C. Secondary Medication
 Normal Saline Bolus  250cc  500cc  1000cc  1000cc x _____
 Morphine Sulfate IVP _______ mg x 1  Morphine Sulfate IVP _______ mg may repeat x _____
 Lopressor 5 mg IV q _____min x _____ Time _____/Initials _____ Time _____/Initials _____
 Heparin 3000 unit bolus Time _____/Initials _____
 Heparin 4000 unit bolus Time _____/Initials _____
 Heparin 5000 unit bolus Time _____/Initials _____
 GIIb/IIIa Inhibitor _____________ per protocol Time _____/Initials _____
D. Additional Orders
 Repeat EKG  Right Sided EKG  I-Stat
 Consent for “Cardiac catheterization with possible percutaneous coronary intervention”
to be done by DR. _____________________(Cardiologist Name).
Other _________________________________
Emergency Physician ________________________________ (Signature) revised

38. Questions Does your site have 24/7 ON SITE coverage?
Site meeting D2B goals?
Mandate for time for on-call team?
Who activates the team?
Does EMS always give Aspirin?
Does EMS fax EKG for activation of team?
Is there a resource RN to help call team?
Heparin w/ IIb/IIIa or Angiomax for STEMI?

39. Take home message: Create a “Code Heart” STEMI Team
Educate the team & streamline your process: Every minute counts.
Involve EMS, ED, Cath lab Staff and resource staff to perfect the process. Feedback is key!
Communication and Teamwork are critical components of any successful program
Who knows where the clock will be geared soon….

40. No Better reason to smile than after a record breaking D2B during a bliizzard in D.C.!
Suburban Hosp
January ‘11

42. References Dr. Sigmund Silber , Munich Germany
/ Duke University
ACC : D2B Alliance
Dr. Lowell Satler, Washington Hospital Center
Dr. Tim Henry, Minneapolis Heart
Brodie, B, Gersh, B et al: Analysis from the Horizons-AMI and Cadillac Trials.

43. Thanks for your attention