A key player recalls the effort that went into a life-saving campaign.

In a session dedicated to the history of STEMI treatment, insider Harlan M. Krumholz, MD, SM, of Yale University School of Medicine in New Haven, Conn., told the story behind the remarkable success of the decades-long effort to achieve timely primary PCI.

In the late 1990s, primary PCI was recognized as a breakthrough, but poor implementation was compromising its effectiveness, Krumholz said. At the time it was well known that faster door-to-balloon times were associated with better outcomes, yet only about one-third of patients were being treated within 90 minutes and another third waited more than 120 minutes to be reperfused. That pattern remained unchanged for several years. Krumholz noted that in 2004, the American College of Cardiology (ACC) guidelines stated that primary PCI should be performed with 90 ± 30 minutes because the 90-minute goal was thought by many to be impossible to meet. Thus the door-to-balloon project was born, although it was not an overnight success.

It began with an NIH grant focused on implementation science that entailed identifying hospitals that were consistently outperforming others and discovering, through site visits, that these institutions had developed specific strategies that worked. Sitting down and talking to individual members of the STEMI team to understand how they achieved what they did was as important as the quantitative validation, Krumholz asserted. Moreover, the researchers came to realize that there was no single hidden delay in door-to-balloon times; instead, minutes had to be shaved off at every step of the process.

Advent of ‘power sharing’

Perhaps the most important lesson was that good performance requires teamwork, he said. With this insight, both the ACC and American Heart Association launched national campaigns (D2B Alliance, Mission: Lifeline) to promote improvement in door-to-balloon times at thousands of hospitals. A critical element of the strategy was “power sharing” — allowing EMS personnel to diagnose STEMI en route to the hospital and notify emergency department staff to activate the cath lab. As other innovative ways to save time safely were uncovered — such as using a single-call page system and requiring cath lab staff to arrive within 20 minutes of being paged — they were also incorporated into the campaign.

The success has been remarkable, Krumholz noted. Today the slowest hospitals are down to under 80 minutes, and the fastest are under 60 minutes.

The result is that greater numbers of patients and those at higher risk are now undergoing primary PCI. And with faster door-to-balloon times, overall mortality has not risen despite treatment of more complex disease. Most important, team-based care is now embedded in practice and has become a model for other areas of medicine. However, Alice K. Jacobs, MD, of Boston University Medical Center, in Boston, Mass., commented that much work remains to be done. For example, she noted, “there is a disconnect between evidence-based lifesaving guidelines-directed therapies and our ability to deliver them to all patients. So although [door-to-balloon] time is where it needs to be, there are many patients in referral hospitals, and we have no idea what’s going on in STEMI care [there].”

Disclosures:

• Krumholz reports no relevant conflicts of interest.