Streamlined STEMI Protocol Slashes Door-to-Balloon Times

Case vignette

While visiting neighbors on a Sunday, a 56-year-old man collapsed, lost consciousness and began seizing. 911 was called. By the time the fire department arrived, the man’s seizures had stopped, but he had no pulse. He was defibrillated twice. EMS arrived and shocked the patient three more times before transporting him to Cleveland Clinic.

In the emergency department (ED), the patient’s jaw remained clenched, preventing access to his airway and requiring administration of resuscitation medications by intraosseous cannulation. The patient opened his eyes on command, but he remained unresponsive to pain and continued thrashing. A broken dental appliance lodged in his airway was removed with hemostats, and the airway was secured. With medications and CPR, the patient’s pulse was restored and an ECG was performed, revealing ST-segment elevation myocardial infarction (STEMI).

The ED activated the cath lab, where an interventional cardiologist performed an angiogram of the right coronary artery via radial artery access, revealing 100 percent occlusion. Because the patient was hemodynamically and electrically unstable, aspiration thrombectomy was performed, followed by angioplasty and stenting, before further exploration of the coronaries.

Time from ED arrival to device placement: 37 minutes.

One efficient case among many

This case illustrates some key payoffs of an enhanced STEMI protocol recently adopted by Cleveland Clinic to standardize care, eliminate unnecessary steps and maximize teamwork. The result has been a substantial, sustained reduction in door-to-balloon time (i.e., from ED arrival to percutaneous coronary intervention [PCI]) during the nearly two years since the protocol revisions.

“The changes were prompted by an organizational commitment to take our STEMI program from good to exceptional by standardizing the process to reduce variability,” explains cardiologist Umesh N. Khot, MD, Chief Quality Officer for Cleveland Clinic’s Miller Family Heart & Vascular Institute, who spearheaded the efforts by drawing on years of experience designing systems of care for MI, a topic on which he has published1,2 and presented extensively.

Four main process improvements

The protocol revisions involved about a year of research and preparatory work that resulted in the following key process improvements designed to reduce variability in STEMI care:

1) Standardization of criteria by which ED physicians can activate the cath lab, enabling ED and interventional cardiology teams, located in different buildings, to work in a more coordinated way. “Although we had used ED physician activation previously, standardizing the criteria made it much tighter,” explains Travis Gullett, MD, Quality Improvement Officer in Cleveland Clinic’s Emergency Services Institute.

2) Development of a STEMI handoff checklist delineating distinct roles for all caregivers involved: ED physicians, cardiologists, and nurses in both the ED and the cath lab. The checklist also provides instructions and key phone numbers, assigns accountability, and calls for a short “time out” to ensure all tasks have been completed. Handoff signatures are required. “Use of this checklist has greatly increased compliance with required medications and fostered a sense of partnership between the ED and cardiology,” notes Kathleen Kravitz, MBA, BSN, RN, Quality Director for the Miller Family Heart & Vascular Institute, who served as project manager for the STEMI protocol initiative.

3) Facilitation of immediate transfer to the cath lab. For both self-transport patients and those transported by EMS, the decision to activate the cath lab lies with the ED attending physician, with a cardiovascular medicine fellow available to advise as needed. If a patient has an EMS-obtained diagnostic ECG and meets criteria for activation, the ED attending will activate the cath lab and the patient will bypass the ED.

4) Round-the-clock cath lab readiness through use of an in-house transfer team. The protocol ensures 24/7/365 STEMI treatment availability by giving cath lab priority to STEMI patients during the day and by using an in-house team at night consisting of two cath lab nurses along with a critical care nurse. All three are ready to tend to an incoming patient whenever needed. “We previously had two nurses available at night, but the protocol changes added the third nurse and organized everyone in a more effective way,” explains Kravitz. The cath lab is assumed to be available to receive a patient 24/7/365 unless cath lab personnel call the ED to indicate an issue. Nursing reports are given to cath lab nurses in person either by EMS or by ED nurses.

“Together these process changes were designed to fundamentally structure STEMI management so that patients receive the same care every time with clear consistency,” says Dr. Khot.

“Importantly, the process was complemented by skilled interventional cardiologists being available at all times and being prepared to support failing hearts 24/7,” adds Samir Kapadia, MD, Director of the Cardiac Catheterization Laboratory and Section Head of Invasive and Interventional Cardiology.

Treatment times speak for themselves

The revised protocol was implemented on Cleveland Clinic’s main campus in July 2014, “and within days we saw improvement in door-to-balloon times,” Dr. Khot notes. Here are a few subsequent care statistics:

• 35 percent of STEMI patients treated in the first year after protocol revision had a door-to-balloon time of 45 minutes or less, nearly double the percentage during the prior six months. Multiple patients were treated in as little as 21 or 22 minutes. “That level of performance is largely unheard of,” says Dr. Khot. “It’s a testament to the exceptional coordination between the emergency department and the catheterization lab.”
• Median door-to-balloon time during the first year after protocol revision was 52 minutes.
• 100 percent of STEMI patients have had a door-to-balloon time within the American College of Cardiology-recommended 90 minutes for each of the past six quarters (through the first quarter of 2016).

Preliminary data suggest these treatment time reductions may be resulting in significant improvements in patient mortality and other outcomes. The team plans to share outcomes data on that front in upcoming months.

“Effective treatment of STEMI is a team approach,” notes interventional cardiologist Stephen Ellis, MD, who serves as Chief Academic Officer for Cleveland Clinic’s Department of Cardiovascular Medicine. “Organizing an efficient and capable team with appropriate processes is key to optimal care.”

The revised STEMI protocol is now being deployed in all hospital EDs across the Cleveland Clinic health system. “We want to bring this same consistent delivery of fast, standardized treatment to all STEMI patients,” Dr. Khot explains.

References

1. Khot UN, Johnson ML, Ramsey C, et al. Emergency department physician activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction. Circulation. 2007;116:67-76.
2. Khot UN, Johnson-Wood ML, VanLeeuwen R, et al. A hospital-wide system to ensure rapid treatment time across the entire spectrum of emergency percutaneous intervention. Catheter Cardiovasc Interv. 2015 Dec 23 [Epub ahead of print].

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