Achieving Rapid Door-To-Balloon Times How Top Hospitals Improve Complex Clinical Systems

• Published in: Circulation (New York, N.Y.) Vol. 113; no. 8; pp. 1079 - 1085
• Main Authors: Bradley, Elizabeth H., Curry, Leslie A., Webster, Tashonna R., Mattera, Jennifer A., Roumanis, Sarah A., Radford, Martha J., McNamara, Robert L., Barton, Barbara A., Berg, David N., Krumholz, Harlan M.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 28.02.2006
• Subjects: Angioplasty, Balloon, Coronary - standards; Arterial hypertension. Arterial hypotension; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Clinical manifestations. Epidemiology. Investigative techniques. Etiology; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Fundamental and applied biological sciences. Psychology; Guideline Adherence; Health Services - standards; Hospitals - standards; Humans; Interviews as Topic; Lymphatic system; Medical sciences; Myocardial Infarction - mortality; Myocardial Infarction - therapy; Quality of Health Care - statistics & numerical data; Time Factors; Vertebrates: cardiovascular system; Myocardial infarction; health services research; Cardiovascular disease; Myocardial disease; Heart disease; quality
• ISSN: 0009-7322; 1524-4539; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.105.590133

Background— Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999–2002. Methods and Results— We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of ≤90 minutes during 2001–2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals’ experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts. Conclusions— Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.