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Innovations in Care

Sustaining Improvement in Door-to-Balloon Time Over 4 Years

The Mayo Clinic ST-Elevation Myocardial Infarction Protocol

David M. Nestler, MD, MS; Amit Noheria, MBBS, SM; Luis H. Haro, MD; Latha G. Stead, MD; Wyatt W. Decker, MD; Lori N. Scanlan-Hanson, RN; Ryan J. Lennon, MS; Choon-Chern Lim, MS; David R. Holmes, Jr, MD; Charanjit S. Rihal, MD, MBA; Malcolm R. Bell, MBBS and Henry H. Ting, MD, MBA

From the Department of Emergency Medicine (D.M.N., L.H.H., L.G.S., W.W.D., L.N.S.-H.), the Department of Medicine, Division of Cardiovascular Diseases (A.N., D.R.H., C.S.R., M.R.B., H.H.T.), the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics (R.J.L.), and the Department of Health Sciences Research, Division of Health Care Policy & Research (C.-C.L.), Mayo Clinic College of Medicine, Rochester, Minn.

Correspondence to David M. Nestler, MD, MS, Mayo Clinic, Department of Emergency Medicine, 200 1st St SW, Rochester, MN 55905. E-mail nestler.david{at}mayo.edu

Received November 28, 2008; accepted June 26, 2009.

Background— American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) <90 minutes for nontransferred patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention. Systems of care to achieve and sustain this DTB performance over several years have not been previously reported.

Methods and Results— The Mayo Clinic STEMI protocol was implemented in April 2004 and included activation of the cardiac catheterization laboratory by the emergency medicine physician; a single call system to activate the catheterization laboratory; catheterization laboratory staff arrival within 20 to 30 minutes of activation; and real-time performance feedback within 24 to 48 hours. Data were collected on nontransferred STEMI patients. The preimplementation group (June 2002 to March 2004) comprised 96 patients with a median DTB of 97 (interquartile range, 82, 130) minutes, and 40% had a DTB <90 minutes. The postimplementation group (May 2004 to March 2008) comprised 322 patients with a median DTB of 67 (interquartile range, 55, 82) minutes, and 81% had a DTB <90 minutes. Postimplementation DTB was significantly shorter than preimplementation DTB (P<0.001). In the 4-year follow-up after protocol implementation, the DTB performance remained stable over time (P=0.41).

Conclusions— The Mayo Clinic STEMI protocol implemented strategies to reduce DTB for nontransferred patients with STEMI. DTB was significantly reduced, and the results were sustained over the 4-year follow-up period. Our experience demonstrates the effectiveness and durability of process changes targeting timeliness of primary percutaneous coronary intervention.

Key Words: diagnosis • myocardial infarction

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