The decisions made by hospital staff in the first few minutes following an acute myocardial infarction (MI) often determine whether a patient lives or dies. Studies have shown that MI outcomes improve if a patient receives reperfusion treatment no more than 90 minutes after arriving at the hospital. But despite the evidence, few U.S. hospitals meet this quality standard.
In November 2006, the New England Journal of Medicine published a study examining strategies for improving door-to-balloon times. The authors surveyed 365 hospitals over a six-month period to find out how they were trying to expedite MI care and which methods were most effective. Of the 28 strategies evaluated, six saved a substantial amount of time, from eight minutes to almost 20 minutes each. Only a small percentage of hospitals, however, were using those strategies. Many were following protocols that had no effect at all.
To put this new knowledge into practice, the American College of Cardiology launched the D2B Alliance: An Alliance for Quality (d2balliance.org), a national campaign to help hospitals reduce door-to-balloon times. Hospitals sign up at the campaign's Web site and pledge to try to implement the designated core strategies, as well as share their successes and failures with other participating facilities.
Harlan M. Krumholz, MD, is the senior author of the NEJM study, professor of medicine at Yale University in New Haven, Conn., and the chair of the D2B Alliance's Door-to-Balloon Work Group. He recently spoke with ACP Hospitalist.
Q: Your article in the New England Journal of Medicine laid the groundwork for the D2B Alliance. Is the campaign based directly on your results?
A: It's pretty close. We were very interested in not only generating this knowledge but having it disseminated and applied throughout the country. Two of the strategies from the study were relatively complex: obtaining [and transmitting data from] an ECG [electrocardiogram] in the ambulance en route to the hospital and having an attending cardiologist always on site. Those might not be possible in all places. The things from the study that we want to push are activating [the catheterization lab] from the ED, doing it with a single call, expecting staff to arrive within 20 to 30 minutes and providing real-time feedback. We also added two other things that came up from other studies: strong administrative support and a team approach.
Q: Why do you think more facilities aren't meeting the national standard for MI care of 90 minutes or less?
A: I think there are two reasons. The first has to do with inertia and will. Often, no matter what you're doing, you think you're doing the best you can and sometimes cannot imagine that you can do better. The second part of it is that, in medicine, we've had so much focus on what to do but not so much focus on how to do it. Studies like ours are providing an evidence base for how best to meet quality standards.
Q: Your study found that some strategies hospitals were using to improve door-to-balloon time actually had no effect at all. Were you surprised by any of the things that didn't work? Were there any that you thought should work but didn't?
A: People put a lot of emphasis on how quickly you get the electrocardiogram in the emergency room, but that didn't turn out to be quite so important. Where the most time was wasted, in general, was after the recognition that a [patient with a] heart attack needed to go to the cath lab and have angioplasty. Minutes would be lost in a wide variety of ways.
Q: The study mentioned false alarms as one risk associated with activating the catheterization lab early. How significant a problem is that?
A: I think it was a bigger problem in perception than in reality. In general, the fastest places would get a couple of false alarms over six months. One of the things that was evident in the very best places was a sense of shared mission. Once these places were able to achieve a team mentality, they deconstructed every case to try to figure out what they could have done better. They recognized that there were going to be false-positives, and if there weren't, they probably weren't reacting quickly enough. It was very collaborative and avoided blame. That's the model that we should be striving for in the future.
Q: Another interesting effective intervention was the practice of giving real-time feedback to staff. Why do you think that's effective?
A: The feedback brings about accountability and raises awareness. The posting of data signals that there's reason to celebrate when people do a really good job. When times do not meet targets, feedback allows staff to unravel the processes and figure out what could have been done better. It also provides people the opportunity to talk about things when they're fresh, and it creates anticipation for the result when people are in the midst of providing care. They recognize the sense of urgency. People who work hard trying to achieve a certain goal like immediate feedback about whether they hit that goal. It's been a very useful way to energize people involved in the project and to sustain it.
Q: How has the response been to the D2B Alliance?
A: It's been wonderful. Our goal is to get as many hospitals as possible signed up by the end of February. We're trying to bring everybody together and say, “We can solve this problem.” To me, the real paradigm shift here is that we're finding ways to translate the research into action immediately. We're optimistic that we're going to have maybe 500 or 600 hospitals involved and that each one is going to make a promise to their community that patients who come in with this kind of heart attack are going to get rapid care, that they're going to achieve the target, and that they're going to meet the standard.
Q: Are you collecting data from participating hospitals at this point?
A: We're collecting modest data at baseline and at the end through an easy survey. Almost all of these hospitals are also submitting data to CMS [Centers for Medicare & Medicaid Services] as part of the public reporting effort, but that data is not available yet. Our first evaluation will be based on the data that people provide from their experience at the start and then approximately a year later, and another evaluation will be based on what we see from the national data from CMS.
It is important to note that this is not a project just for hospitals having trouble. For those who are doing really well, we're trying to take advantage of their expertise and point to them as examples of what can be achieved. For hospitals that see opportunities to improve, we want to help them do so. We're going to promote publicly the hospitals that have joined the effort as committed to high-quality, rapid treatment. It is essential for hospitals to sign up by March 1 to be included in the first announcement of the list. We're trying to create a community that's making this commitment.