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A Campaign to Improve the Timeliness of Primary Percutaneous Coronary Intervention

Door-to-Balloon: An Alliance for Quality

Harlan M. Krumholz, MD, SM, FACC^_*,,1,_*, Elizabeth H. Bradley, PhD^_*,1,2, Brahmajee K. Nallamothu, MD, MPH, FACC, Henry H. Ting, MD, MBA, FACC^||, Wayne B. Batchelor, MD, MHS^¶, Eva Kline-Rogers, MS, RN, Amy F. Stern, MHS^#, Jason R. Byrd, JD^#, John E. Brush, Jr, MD, FACC^_**

^_* Section of Health Policy and Administration, Department of Epidemiology and Public Health, and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, and the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, and the Division of Cardiovascular Disease, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
Division of Cardiology, University of Michigan Health System, Ann Arbor, Michigan
^|| Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
^¶ Heart and Vascular Institute, Tallahassee Memorial Healthcare, Tallahassee, Florida
^# American College of Cardiology, Washington, DC
^_** Sentara Cardiovascular Research Institute, Norfolk, Virginia.

^_* Reprint requests and correspondence: Dr. Harlan M. Krumholz, 333 Cedar Street, Room I-456 SHM, P.O. Box 208088, New Haven, Connecticut 06520-8088. (Email: harlan.krumholz{at}yale.edu).

Objectives: We sought to describe the rationale and methods for Door-to-Balloon (D2B): An Alliance for Quality, an international effort organized by the American College of Cardiology in partnership with the American Heart Association and 37 other organizations to rapidly translate research about how best to achieve outstanding D2B times for patients with ST-segment elevation myocardial infarction (STEMI) into practice.

Background: The D2B time, the time between hospital arrival and primary percutaneous coronary intervention for patients with STEMI, is strongly associated with the likelihood of survival, yet the majority of patients are not treated within the guideline-recommended time of 90 min. Recent research has revealed key and underused strategies that are associated with achieving faster D2B times.

Methods: The D2B Alliance has enrolled approximately 1,000 hospitals. Its goal is to achieve a D2B time of 90 min for at least 75% of non-transferred patients. The key strategies chosen by the D2B Alliance include having the emergency medicine physician activate the catheterization laboratory with a single call, having the team prepared within 20 to 30 min of the call; rapid data feedback; a team-based approach; and administrative support. The use of a pre-hospital electrocardiogram by emergency medical services personnel to activate the catheterization laboratory was also noted as an additional optional strategy. The project has many approaches to promote participation and adoption of effective strategies. An evaluation component is also described.

Conclusions: The design of the D2B: An Alliance for Quality, a novel campaign to improve D2B time, is described.

Abbreviations and Acronyms   ACC = American College of Cardiology   ACTION = Acute Coronary Treatment and Intervention Outcomes Network   AHA = American Heart Association   CMS = Centers for Medicare & Medicaid Services   D2B = door-to-balloon   NCDR = National Cardiovascular Data Registry   NHLBI = National Heart, Lung, and Blood Institute   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction

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