Improving Door-to-Balloon Time through Operational Efficiency and Patient Safety Culture in STEMI Patients
A Hospital-Based Quality Improvement Study
DOI:
https://doi.org/10.69855/laceri.v2i2.565Keywords:
Door-to-Balloon Time, STEMI, Quality ImprovementAbstract
Background: Timely reperfusion is critical for reducing myocardial damage and mortality in ST-elevation myocardial infarction (STEMI). In many Indian settings, door-to-balloon (DTB) time remains prolonged due to operational and system-level barriers. Objective: To evaluate whether recommended DTB timelines can be achieved in a tertiary care hospital and to identify and address key delay factors. Methods: A prospective study was conducted in a 400-bed tertiary care hospital in South India (Oct 2018–Oct 2019), followed by an intervention phase (Nov 2019–Jan 2020). Phase I (n=282) identified delays using process mapping and Fishbone analysis. Phase II implemented Lean principles and the Plan–Do–Check–Act (PDCA) cycle. Statistical comparison of means was performed, with p < 0.05 considered significant. Results: Mean DTB time reduced from 372 minutes to 208 minutes (p < 0.05). The proportion achieving DTB <120 minutes increased from 24% to 47%. Shorter DTB times were associated with lower mortality. Conclusion: Structured protocols, early activation systems, and continuous quality improvement can significantly reduce DTB time. However, achieving global benchmarks requires sustained system-level strengthening.
References
Alexander, T., Mehta, S., Mullasari, A., & Nallamothu, B. K. (2012). Systems of care for ST-elevation myocardial infarction in India. Heart, 98(1), 15–17. https://doi.org/10.1136/heartjnl-2011-300681
Armstrong, P. W., Westerhout, C. M., & Welsh, R. C. (2009). Duration of symptoms is not always the key modulator of the choice of reperfusion for ST-elevation myocardial infarction. Circulation, 119(8), 1133–1135.
Authors/Task Force Members. (2008). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. European Heart Journal, 29(23), 2909–2945.
Bradley, E. H., Roumanis, S. A., Radford, M. J., Webster, T. R., McNamara, R. L., Mattera, J. A., Barton, B. A., Berg, D. N., Portnay, E. L., Moscovitz, H., Holmboe, E. S., & Krumholz, H. M. (2006). Achieving door-to-balloon times that meet quality guidelines: How do successful hospitals do it? Journal of the American College of Cardiology, 47(6), 1236–1241.
Foo, C. Y., Bonsu, K. O., Nallamothu, B. K., Reid, C. M., Dhippayom, T., Reidpath, D. D., & Chaiyakunapruk, N. (2018). Coronary intervention door-to-balloon time and outcomes in ST-elevation myocardial infarction: A meta-analysis. Heart, Lung and Circulation, 27(3), 291–298.
Graham, K. J., Strauss, C. E., Boland, L. L., Mooney, M. R., Brush, J. E., & others. (2012). Has the time come for a national cardiovascular emergency care system? Circulation, 125(16), 2035–2044.
Huber, K., Gersh, B. J., Goldstein, P., Granger, C. B., & Armstrong, P. W. (2014). The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: Current state, unmet needs and future directions. European Heart Journal, 35(23), 1526–1532. https://doi.org/10.1093/eurheartj/ehu125
Kushner, F. G., Hand, M., Smith, S. C., King, S. B., Anderson, J. L., Antman, E. M., Bailey, S. R., Bates, E. R., Blankenship, J. C., Casey, D. E., & others. (2009). 2009 focused updates: ACC/AHA guidelines for the management of ST-elevation myocardial infarction. Circulation, 120(22), 2271–2306.
McNamara, R. L., Wang, Y., Herrin, J., Curtis, J. P., Bradley, E. H., Magid, D. J., Blaney, M., Frederick, P. D., & Krumholz, H. M. (2006). Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. Journal of the American College of Cardiology, 47(11), 2180–2186.
O’Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., de Lemos, J. A., Ettinger, S. M., Fang, J. C., Fesmire, F. M., Franklin, B. A., Granger, C. B., Krumholz, H. M., Linderbaum, J. A., Morrow, D. A., Newby, L. K., Ornato, J. P., Ou, N., Radford, M. J., Tamis-Holland, J. E., … Zhao, D. X. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Journal of the American College of Cardiology, 61(4), e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
Reimer, K. A., Lowe, J. E., Rasmussen, M. M., & Jennings, R. B. (1977). The wavefront phenomenon of ischemic cell death: 1. Myocardial infarct size versus duration of coronary occlusion in dogs. Circulation, 56(5), 786–794.
Steg, P. G., James, S. K., Atar, D., Badano, L. P., Blömstrom-Lundqvist, C., Borger, M. A., Di Mario, C., Dickstein, K., Ducrocq, G., Fernandez-Aviles, F., Gershlick, A. H., Giannuzzi, P., Halvorsen, S., Huber, K., Juni, P., Kastrati, A., Knuuti, J., Lenzen, M. J., Mahaffey, K. W., … Zahger, D. (2012). ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 33(20), 2569–2619. https://doi.org/10.1093/eurheartj/ehs215
Terkelsen, C. J., Sørensen, J. T., Maeng, M., Jensen, L. O., Tilsted, H. H., Trautner, S., Vach, W., Johnsen, S. P., Thuesen, L., Lassen, J. F., & others. (2010). System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA, 304(7), 763–771. https://doi.org/10.1001/jama.2010.1139
Xavier, D., Pais, P., Devereaux, P. J., Xie, C., Prabhakaran, D., Reddy, K. S., & Yusuf, S. (2008). Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. The Lancet, 371(9622), 1435–1442. https://doi.org/10.1016/S0140-6736(08)60623-6
Zhang, Q., Zhang, R. Y., Qiu, J. P., Zhang, J. F., & others. (2011). One-year clinical outcome of interventionalist-versus patient-transfer strategies for primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction. Circulation: Cardiovascular Quality and Outcomes, 4(1), 33–38.
Zhang, Y., & Huo, Y. (2011). Early reperfusion strategy for acute myocardial infarction: A need for clinical implementation. Journal of Zhejiang University Science B, 12(9), 629–632.
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