This paper will discuss the various ways of reducing the Door-to-Balloon (D2B) period for ST-elevation myocardial infarction (STEMI) patients. The paper is backed by different studies that have established a strong link between D2B time and mortality incidence for STEMI patients. D2B refers to the interval between the arrival of a STEMI patient in the hospital and the commencement of treatment, specifically, the insertion of a catheter into the patient’s body. Reducing D2B time is likely to result in a positive outcome for patients to a given degree (Mehta et al., 2014).
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The current standards for D2B time require less than 90 minutes between the arrival of patients in the catheterization lab (cath lab) and the initiation of reperfusion. This paper is addressed to the stakeholders of Kendall Regional Medical Center, Miami. It seeks to convince them of the need for improved D2B as a major step toward the effective combating of STEMI.
Hard and Soft Elements of the Change
Successful reduction of D2B time calls for proper coordination among all stakeholders (Mehta et al., 2014). Such stakeholders range from the patient’s family to the STEMI team. A well-guided intervention protocol may result in improved timelines for each step or process that a STEMI patient goes through before reperfusion is finally administered at the cath lab. For instance, Swaminathan et al. (2013) established that a delay occasioned by non-system factors such as the failure by a patient to offer consent on time might greatly influence the treatment procedure.
Mathews et al. (2011) also found that only about 60% of STEMI patients use an ambulance to access hospitals. This situation denies the patient an opportunity to receive the attention of paramedics in the event of cardiac arrest. For the above illustrations, it is apparent that all stakeholders must be actively engaged to achieve the desired D2B times for each patient’s case. The next section will discuss the aspects that are likely to have a direct or indirect impact on the proposed change regarding improved D2B for STEMI patients at the Kendall Regional Medical Center.
STEMI Patient and Family
The patients and their immediate families play a major role in determining aspects such as the arrival time at the hospital and timely consent. Delays may be occasioned when patients take longer to give consent to the emergency team to commence reperfusion (Swaminathan et al., 2013). The situation increases the D2B time to beyond the recommended 90 minutes, hence raising chances of mortality (Swaminathan et al., 2013). This problem may be addressed by obtaining permission from an immediate family member of the patient whenever he or she (patient) is not able to give timely consent.
Where it is impossible to obtain the approval of the patient or an immediate family member, any two physicians should sign the consent on the grounds of medical necessity. Another problem associated with non-system delays in the D2B time is caused by patients’ failure to use Emergency Medical Service (EMS) transport.
Bansal et al. (2014) observed how walk-in patients experience longer treatment duration when compared to those who arrive in ambulances. Failure to use EMS by patients may result from a lack of knowledge on the need for rapid access to STEMI PCI-capable centers. This problem may be solved by engaging the patients and their families on the importance of using EMS for STEMI patients.
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Emergency Department Physicians
Physicians in the emergency department respond to disaster calls that require the activation of the cath lab. ED physicians are also responsible for the transfer of STEMI patients into the emergency room. The duration taken by ED physicians to activate the cath lab and/or transfer patients for emergency treatment has a direct impact on the D2B period. The American Heart Association (AHA) recommends fast response by ED physicians to emergency calls, not exceeding 30 minutes (Langabeer et al., 2015).
Langbeer et al. (2015) also found a strong link between field activation of the cath lab and mortality incidence for pre-hospital treatment. The evidence provided above points to the need for the ED to be ready at all times to attend to STEMI patients. Peterson, Syndergaard, Bowler, and Doxey (2012) also found that the D2B meantime was often increased where ED physicians had to consult an internist who then consults a cardiologist. In contrast, direct consultation between the ED physicians and cardiologists will considerably decrease the D2B time (Peterson et al., 2012).
Emergency Department Paramedics
Paramedics interact with STEMI patients before they can receive specialized treatment at the hospital. This strategy provides paramedics with an early opportunity to diagnose and hence attend to STEMI patients. Stowens, Sonnad, and Rosenbaum (2015) have found that paramedics who are trained to diagnose STEMI using the electrocardiogram (EKG) may help to reduce the D2B meantime.
Stowens et al. (2015) reveal how early communication of the diagnosis to the hospital through 9-1-1 dispatchers promotes early cardiac catheterization lab (CCL) activation. In turn, early CCL leads to reduced D2B. This finding is further backed by a study carried out by Cantor et al. (2012) who shows how pre-hospital management of STEMI might greatly reduce mortality. Additionally, Lim, Wee, and Anantharaman (2013) suggest EKG be extended to patients being transported to STEMI care facilities in personal vehicles.
STEMI Team, PBX Operator, and Intervention Cardiologists
The STEMI team is responsible for administering the PCI procedure on a patient. Proper training is essential to ensure that reperfusion is initiated within a reasonably short period. The STEMI team consists of CVL nurses, a cardiologist, and cardiovascular and perfusion technicians. Currently, Kendall Medical Center faces a unique challenge occasioned by the high turnover of nurses working in the ED.
Additionally, many interventional cardiologists and cath lab technicians are relatively new. There is a need to train the new staff on the hospital’s intervention procedures for STEMI cases. Menees et al. (2014) observe that proper coordination of the STEMI team can result in reduced D2B time. This coordination can only be achieved through efficient training accompanied by teamwork.
All health facilities strive to offer the best quality services to the various categories of patients. Nevertheless, several factors determine the rate of mortality for these patients. For instance, mortality incidence for STEMI patients is influenced by the D2B time. Based on the expositions made in the paper, it is clear that patients who receive early attention are more likely to recover easily as compared to those with a longer D2B meantime.
Therefore, there have been efforts to reduce this time interval. Researchers suggest that all stakeholders involved in the treatment of STEMI have a role to play in improving D2B. Additionally, the STEMI team must work in coordination to ensure minimal time is lost between the diagnosis of STEMI patients and the initiation of the PCI.
Bansal, E., Dhawan, R., Wagman, B., Low, G., Zheng, L., Chan, L.,…Shavelle, D. (2014). Importance of hospital entry: Walk-in STEMI and primary percutaneous coronary intervention. Western Journal of Emergency Medicine, 15(1), 81-87.
Cantor, W. J., Hoogeveen, P., Robert, A., Elliott, K., Goldman, L. E., 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.
Langabeer, J., Alqusairi, D., DelliFraine, J., Fowler, R., King, R., Segrest, W., & Henry, T. (2015). Reassessing after-hour arrival patterns and outcomes in ST-elevation myocardial infarction. Western Journal of Emergency Medicine, 16(3), 388-394.
Lim, S. H., Wee, J., & Anantharaman, V. (2013). Management of STEMI. Curr Emerg Hosp Med Rep, 1(1), 29-36.
Mathews, R., Peterson, E. D., Li, S., Roe, M. T., Glickman, S. W., Wiviott, S. D.,… Wang, T. Y. (2011). Use of emergency medical service transport among patients With ST-segment-elevation myocardial infarction: Findings from the national cardiovascular data registry acute coronary treatment intervention outcomes network registry-get with the guidelines. Circulation, 124(2), 154-163.
Mehta, S., Botelho, R., Rodriguez, D., Fernandez, F. J., Ossa, M. M., Zhang, T.,… Pena, C. (2014). A tale of two cities: STEMI interventions in developed and developing countries and the potential of telemedicine to reduce disparities in care. Journal of Interventional Cardiology, 27(2), 155-166.
Menees, D. S., Peterson, E. D., Wang, Y., Curtis, J. P., Messenger, J. C., Rumsfeld, J. S., & Burm, H. S. (2014). Door-to-balloon time and mortality among patients undergoing primary PCI. Survey of Anesthesiology, 58(4), 162-163.
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Peterson, M. C., 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.
Stowens, J., Sonnad, S., & Rosenbaum, R. (2015). Using EMS dispatch to trigger STEMI alerts decreases door-to-balloon Times. Western Journal of Emergency Medicine, 16(3), 472-480.
Swaminathan, R. V., Wang, T. Y., Kaltenbach, L. A., Kim, L. K., Minutello, R. M., Bergman, G.,… Feldman, D. N. (2013). Nonsystem reasons for delay in door-to-balloon time and associated in-hospital mortality. Journal of the American College of Cardiology, 61(16), 1688-1695.