Feature | December 13, 2010| Vinit Lal, M.D.

Cutting Door-to-Balloon Times

Cross-training ER staff and use of the latest in medical imaging technology can help shave minutes

An angiographic view from an Infinix-i angiography X-ray system shows a left coronary injection with multiple stents that are visible in a totally occluded left anterior descending artery.

When it comes to interventional cardiology, increasing diagnostic confidence and reducing exam time are paramount to improving overall patient care. The American College of Cardiology and American Heart Association’s national standard for treating ST segment elevation myocardial infarction (STEMI) with emergency percutaneous coronary intervention (PCI) within 90 minutes of the patient entering the hospital is crucial in addressing cardiac emergencies.

This door-to-balloon time measurement of 90 minutes is calculated as soon as a patient enters a hospital’s emergency room with symptoms of a heart attack and ends once the balloon catheter is inflated into the coronary artery causing the heart attack. As “time is muscle” for heart attack patients, the faster this procedure is completed, the less damage is done to the heart muscle. These door-to-balloon times truly demonstrate the efficiency of cardiac care in healthcare facilities and the ability to improve patient outcomes.

HeartPlace, our dedicated group of cardiologists in the greater Dallas metropolitan area, took on the challenge of ensuring that the institutions we practice at could meet and exceed these national standards. Implementing a truly cross-functional department approach at our facilities, as well as acquiring and utilizing the latest in medical imaging technology, have allowed us to dramatically reduce our door-to-balloon times. Since committing to these new standards, we have achieved a 36 percent decrease in our door-to-balloon times, from about 100 minutes down to an average of 64 minutes per patient.

Departmental Efficiencies and Streamlined Process

To facilitate efficiencies and meet the STEMI program goals, we have implemented numerous departmental changes that have helped in improving our door-to-balloon times. When a patient arrives at an emergency room with chest pain, there are multiple departments involved in the patient’s pathway to the cath lab. First, the patient undergoes an electrocardiogram (ECG) to confirm the heart attack. Once the need for angioplasty is determined, the radiology department activates the cath lab, the interventional cardiologist is called and the patient is brought in for the procedure. At HeartPlace, we improved our door-to-balloon times by making changes to the way our department worked together to handle these patients.

We developed a more streamlined process and hired additional staff to better move the patients between the emergency department and the cath lab. In the past, we spent time waiting for the staff needed for cardiac catheterization to arrive. To improve this issue, we trained emergency room (ER) and radiology staff to assist in the cath lab, further increasing the number of people with the ability to work in this environment.

This cross-department training creates a team environment within the ER, radiology and cardiology teams, who can now all work together to quickly prepare the patient and perform the catheterization. We are now starting procedures much sooner, as the overall process of transporting from the ER and prepping the patient for the cath lab is more streamlined.

Advancements in Cath Lab Technology to Improve Times

Acquiring the latest in medical imaging technology also plays a major role in lowering our door-to-balloon times. The design mechanics, system reliability and start-up sequences of new equipment reduce set-up times, which is helpful in preparing the room for urgent cases and reduces overall door-to-balloon times. Additionally, the improved image quality of newer systems limits image retakes and allows us to treat patients more accurately and safely.

To accomplish this goal, my facility acquired two Toshiba America Medical Systems Infinix-i cardiovascular X-ray systems to help improve our times. One of the new systems features a five-axis floor-mounted positioner and a cardiac flat panel detector (FPD). The system is equipped with numerous mechanical design features to improve cath lab efficiencies, including an easy-to-adjust C-arm for quick patient loading and unloading. The flexibility of the 270-degree C-arm positioning provides unprecedented access to the patient, ancillary equipment and fellow clinicians. It accommodates easy access, regardless of the approach needed, which is particularly helpful in urgent cases.

The second system has two independent C-arms and two different-sized FPDs, providing the ability to perform cardiac or vascular procedures on the same patient in the same room. One C-arm, with an 8” by 8” FPD imaging chain, is optimized for cardiac work, while the other C-arm, with a 12” by 16” FPD imaging chain, is optimized for peripheral work outside the heart, such as carotids, renals and legs.

The patient-friendly design of these systems and the five-axis positioner provide clinical benefits as well as improved exam efficiencies. For example, it is common to insert the catheter through the femoral artery, and at times this access is blocked. The five-axis system, with its liberal C-arm rotation and transverse travel, can easily be positioned for a transradial or brachial access. The design features of new imaging equipment greatly contribute to quicker exams, faster start-up times and reduced door-to-balloon times.

The X-ray equipment also includes features to improve image quality for quicker diagnosis and limit exam retakes. One of these technologies is next-generation advanced image processing (AIP) that supports interventionalists during procedures while utilizing fluoroscopic and fluorographic imaging. The AIP imaging innovation is a combination of proprietary hardware and software working in concert with the image chain to optimize image quality.

This feature improves patient care by increasing the quality, sharpness and image contrast during interventional procedures. The proprietary technology has virtually eliminated image lag, benefitting us while guiding and deploying devices during fluoroscopy. Next-generation AIP further increases image clarity, creating a safer, more time-efficient exam by reducing the possibility of having to re-image the patient.

Studies have shown that improving door-to-balloon times and the speed in which heart attack patients receive treatment dramatically changes patient outcomes and prevents major damage to the heart. With a combination of the latest in medical imaging technology and a cross-department commitment to improving door-to-balloon times, these times can be reduced and patient care improved.

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