The door-to-balloon (DTB) time reduction depends largely on the chain of human specialists performing their roles with as little wasteful steps as possible, following the recommendations and best practices (CCN, 2013; American College of Cardiology Foundation & American Heart Association, 2013). However, the non-human factors can also play a significant role in reducing the time and, as an immediate consequence, mortality (Menees et al., 2014).
To identify what factors can stand in the way of reducing the DTB, one should first determine those that facilitate prompter PCI. The evidence suggests that two main conditions are improving the quality of care in this particular situation: the technology being used and the fast transportation of the patient to the cath lab (Peterson, Syndergaard, Bowler, & Doxey, 2012).
The former, however, incorporates several sub-factors since the involvement of technology is extensive in what concerns STEMI patient care. These include, namely, the ECG made before the admission and used to activate the cath lab, single-call systems to start them, record systems to gather pre- and post-operational data and provide instantaneous feedback, etc. (Lim, Wee, & Anantharaman, 2013).
While the recording systems do not appear to present issues as such, the technology being used – or the malfunction of it – can be a serious obstacle because every minute that the catheterization laboratory personnel have no access to the ECG can cost the patient their life. As to the transfer, the time it takes the emergency room staff to read the ECG and transfer the patient is another obstacle to DTB improvement, as the evidence suggests that the paramedics are oftentimes poorly instructed on acute myocardial care and are still liable to handling STEMI patients (Cantor et al., 2012). While this obstacle is, arguably, caused by the human factor, the non-human element is the delay with which the patient is transferred to the cath lab – precisely the problem to be counteracted.
The means of overcoming these issues would each involve a multi-step process, which could be summarized as follows:
- To choose the vendor of remote defibrillator/monitors equipped with features that are easy to configure and the functionality of which is guaranteed;
- To use applications for the cardiologists that would enable them to retrieve the ECGs from the electronic health record systems directly to their smartphones or tablets;
- To cross-train the paramedics to read ECGs.
The desired outcomes of each of these processes would be, respectively:
- Providing the personnel with fully functional defibrillator/monitor systems to decrease the ECG data transfer time;
- Creating a warranted alternative means of ECG retrieval for force major situation when the vendor-supplied technology is malfunctioning;
- To eliminate the time in the emergency room and transfer the patient directly to the catheterization laboratory.
The implementation of these steps can be costly as it would require forming an evidence base of its own. However, the necessity to implement these changes might not be as immediate as the change in operational conditions that lie within human control because, as it has been stated previously, the human factors bear the most significance in what concerns reducing the DTB time. Still, the issue of non-human obstacles is unquestionably grave because they, too, can play an important role in saving lives, and can be, therefore, considered as a promising direction for future research.
References
American College of Cardiology Foundation & American Heart Association. (2013). 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation, 127, e362-e425. DOI: 10.1161/CIR.0b013e3182742cf6.
Cantor, W., Hoogeveen, P., Robert, A., Elliott, K., Goldman, L., Sanderson, E.,…Miner, S. (2012). Prehospital diagnosis and triage of ST-elevation myocardial infarction by paramedics without advanced care training. American Heart Journal, 164(2), 201-206.
CCN. (2013). Recommendations for best-practice STEMI management in Ontario.
Lim, S., Wee, J., & Anantharaman, V. (2013). Management of STEMI. Current Emergency and Hospital Medicine Reports, 1(1), 29-36.
Menees, D., Peterson, E., Wang, Y., Curtis, J., Messenger, J., Rumsfeld, J… Burm, H. (2014). Door-to-Balloon Time and Mortality among Patients Undergoing Primary PCI. Survey of Anesthesiology, 58(4), 162-163.
Peterson, M., Syndergaard, T., Bowler, J., & Doxey, R. (2012). A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention. International Journal of Cardiology, 157(1), 8-23.