Parma Community General Hospital, a 348-bed community hospital in the largest suburb of Cleveland, has cut door-to-balloon times in half — from 119 minutes to 60 minutes — through an ongoing team approach. Physician champions from emergency medicine and cardiology joined with nursing leaders and quality specialists to form a “Code ST-elevation myocardial infarction (STEMI)” team. That collaboration, coupled with a 30-minute response time by catheterization laboratory (cath lab) staff, even during off hours, and the transmission of 12-lead electrocardiograms (ECGs) by the emergency medical service (EMS) squads, have made a critical difference for Parma Hospital patients.

The Code STEMI process has been hardwired into Parma Hospital’s care delivery system, allowing the hospital to achieve and sustain average door-to-balloon times that consistently surpass the American College of Cardiology goal of 90 minutes.

Developing the Process

During 2005, a multidisciplinary quality initiative team was formed to improve door-to-balloon times. Initially, each department defended its own area. As the process progressed, a Code STEMI team concept emerged and the focus became the patient. Goals and accountability for each step in the process were established.

The following key action steps were identified and resolved during the development process:

• The board-certified emergency department (ED) physicians have the authority to initiate a Code STEMI without waiting for a cardiologist to confirm the ECG.
• Independent physician groups of cardiologists designate on-call interventionists.
• Internal medicine/family practice physicians support having the ED contact the interventionist first.
• The cardiac cath lab is committed to a 30-minute clock-in arrival time for on-call staff.

The cath lab on-call teams are comprised of members who live in close proximity to the hospital to ensure quicker readiness for cases (more than half of the staff members live within 15 minutes of the hospital).

• Clinical departments are committed to providing staff on an immediate basis 24 hours a day.
• With one call, the ED physician can simultaneously mobilize a team that includes an ED nurse, the on-call interventionalist, cardiac cath lab staff, respiratory thearpy and an RN and surgical interventionalist form the post-intervention/open-heart surgery unit (The Heart Center).

The Code STEMI team was activated on January 1, 2006. If a patient arrives with chest pain via an EMS squad, the process begins prior to the patient’s arrival in the ED, as a 12-lead ECG is transmitted via wireless technology from the field to the ED. This allows early mobilization of the Code STEMI team prior to the patient’s arrival. If a patient arrives via private means with complaint of chest pain, an ECG is done within 10 minutes of arrival.

In either instance, if indicated, the ED physician activates the Code STEMI team with one call. Cath lab and Heart Center staff members arrive to assist the ED staff and transport the patient down the hall to the cath lab.

Refining the Process: Touch-and-Go STEMIs

The Code STEMI process continues to evolve and produce outstanding door-to-balloon times through effective partnerships and communication. The “Touch-and-Go STEMI” is a phrase that has been used to describe the process by which a patient is brought directly to the ED by the EMS squad for confirmation of the 12-lead ECG results by the ED physician, then is immediately transported to the cath lab (while still on the EMS stretcher). This method has allowed our center to achieve 15- and 16-minute door-to-balloon times.

In a Touch-and-Go STEMI, the cath lab inherits many of the ED’s responsibilities such as blood draws and administration of medications. The Heart Center RN gathers data, including the patient’s name, height, weight and allergies. The hand-off is completed with direct communication between the ED physician and the cardiologist and the ED and cath lab nursing staff.

Communication Enhances Treatment

Real-time feedback is provided to the Code STEMI team and departments. The most recent median door-to-balloon time is 56 minutes (Q1 2008 AMI Core Process Performance Measures).

The Code STEMI process and performance measures are reviewed at committee meetings, and revisions to the process are implemented.
Door-to-balloon time feedback is provided to the fire chiefs to share with the EMS squads to demonstrate how their actions in the field directly save heart muscle and improve patient outcomes.

Physician and nursing leaders have presented this striking data to local EMS departments to provide continuing education on the current guidelines and to reinforce that our center is the best in the area for treatment of STEMI patients.

Advice to Other Cath Labs

Cath labs must be aggressive in establishing a team response to STEMIs by finding ways to overcome delayed responses. Collaboration among physicians and staff from the departments involved is critical, as it allows the members of the various disciplines involved to rise above politics and focus on the patient’s best interests. Partnership with local EMS providers who have 12-lead ECG transmission equipment, utilization of a coordinated one-step notification process, and establishment of well-defined roles and performance measures with feedback have significantly improved door-to-balloon times at Parma Community General Hospital.

The authors can be contacted via csheppard@parmahospital.org