13 November 2006

Door to Dilation

There was an AP Report today on a major initiative to reduce the time from the moment a patient hits the door with a heart attack, more precisely known as an acute coronary thrombosis, to the inflation of a balloon in the blocked coronary artery which restores blood flow to the affected heart muscle.

The full text of the report can be found here.

I do know that we are already doing the most important things listed as recommendations:

  • We call in the cath lab based on a reliable EMS report of a STEMI
  • We call in the cath lab based on the ER doc's interpretation of the EKG
  • The call-in is a single phone call
We don't have a cardiologist in-house 24/7 (yet?), and I have no clue how long the team has to arrive.

The results? Based on the current data, our facility, in 2006, has a median door-to-dilation time of 69 minutes, with the national median being 90 minutes, and the 90th percentile being about 75 minutes. Our total number of cases is about 140 for the year, which I perceive as being reasonably high, and certainly statistically significant.

I can't take too much credit on this one. We have great leadership, great administration, and great cardiologists. They have identified this as a major goal for the hospital, and put systems in place to generate this type of success. It is satisfying to see that it can be done, and that it makes a difference.

(Side note: I have been at this facility for six years and have never once given thrombolytics. Amazing.)


  1. Seeing how in the future you will need to admit everybody who presents with signs and symptoms consistent (or even resembling) an MI, is it not in your best interest to clear your waiting room of folks who don't friggin' need to be there?

    Please, please please teach your mouth to say "Ma'am, Sir, your child is not sick enough to be in an Emergency Department."

    You've got a valuable life-saving job to do. Some day, God forbid, it'll be my life you are saving. I'm doing my part to keep the non-emergently ill kids out. Please help me.



  2. I've been a nurse 30 years and I could never work in the ER because I have difficulty with my brain/mouth censor button. I get upset when people with boo-boos clog up the ER. Having the sniffles doesn’t constitute an emergency, and keeps docs and nurses from seeing really sick people in a timely manner.

  3. We will likely never do primary PCI for acute MIs as we do not have CT back up. Its either thrombolytics or ambulance to the local teaching facility.

    Curious how long it takes your facility to get back troponin results (realize this does not affect door to balloon for STEMIs).

    I work at a VA hospital and one of the P4P criteria for ACS/MI is that troponin needs to be drawn and results available within an hour. Our lab is notoriously slow and we rarely achieve >75% on this benchmark. We don't use point of care testing.
    So, since the goals were not achieved, the cardiology staff did not get bonuses this year. Very frustrating as it is a system problem and not related to issues controlled by cardiology staff.

  4. A missed case of meningitis or an inadequately evaluated case of croup in a kid is potentially a lot more expensive than a delayed door to balloon time (or even a missed MI)in a retiree.

    So Flea, your proposal would be difficult to implement.

    Nonurgent cases don't really delay the care of patients with life-threatening problems. If they want to wait 8 hours to be seen while sicker patients keep going ahead of them, then I don't mind if they stay in the waiting room. As long as they don't cause a fuss.

  5. Jan, we used to take ~45 minutes, but it's more like ten now, since we got a bedside troponin meter. Oh my god is it wonderful. I can get an admit to the chest pain unit in about 30 minutes from presentation, now.

    I have heard that CT surgery as a prerequisite for PCI is being re-examined, but I do not know where it currently stands.

    Flea, I know this is your biggest pet peeve. While I do appreciate all you and other community docs do to filter the non-emergent cases, once they are in the ED I have to see them, and being a jerk (which is how such an admonition is perceived) only increases my liability while doing little to act as a deterrent. You might think putting the febrile 3-year old in the hallway bed next to the withdrawing homeless alcoholic would be deterrent enough, wouldn't you? But it's not, and I have learned to accept that I am not going to be able to prevent anxious and unsophisticated parents from coming in at 3AM. Keep up the good work, though.

    (If nothing else, the 3 year old might be insured and offset some of the free care gven to the homeless alcoholic.)

  6. Must say I'm with Scalpel - I've no problem with people sitting in waiting rooms all night, constantly getting punted until the end of the shift when things quiet down and they can be "Seen in 10 minutes, they just gave me painkillers"

    I think, as EMS staff, I have a responsibility to discourage certain cases from travelling. If the condition would be better treated with OTC meds or a visit to the GP, I'll press that option.


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