Achieving rapid door-to-balloon times: How top hospitals improve complex clinical systems

Mar 1 2006

Some of the key elements for success in the rapid treatment of heart attacks have been identified by researchers at Yale School of Medicine in a recent issue of Circulation: Journal of the American Heart Association.

Eleven hospitals consistently delivered therapy to restore blood flow to heart attack patients in 90 minutes or less. The researchers studied how staff at these hospitals, including Yale-New Haven Hospital, regularly delivered such speedy treatment, which can save lives.

The authors write that many of the nation's hospitals do not respond as quickly as national guidelines suggest, even though speed is important in restoring blood flow to reduce the amount of damage to heart muscle. Faster "door-to-balloon" time--time elapsed from a patient's arrival to treatment with angioplasty--translates into better survival and less disability.

The researchers visited each of the 11 hospitals and conducted extensive interviews with staff--from the top administrators to technical support staff-- and identified a set of common themes.

"We found that success involved much more than skilled individual doctors and nurses," said lead author Elizabeth Bradley, associate professor in the Department of Epidemiology and Public Health at Yale. "What distinguished these hospitals was how well they were organized, how teams functioned together, how the culture rewarded quality improvement and how they dealt with setbacks."

Bradley added, "The themes also reflect the ability of the top performing hospitals to pursue simultaneously contrasting approaches and balance the tensions between them. For example, having standardized protocol but retaining flexibility to refine them continuously, or having intense and individualized data feedback but a no-blame culture. The ability to balance these paradoxes may be a critical aspect of bouncing back from the speed bumps in the process of improvement."

"All of these top hospitals share eight common characteristics that drive their ability to deliver fast, effective treatment to patients with ST-elevation acute myocardial infarction (STEMI)," said senior author Harlan M. Krumholz, M.D., the Harold H. Hines, Jr. Professor of Medicine. "This study has direct and important information for hospitals around the country."

Each of the hospitals had explicit commitment to reduce delays throughout the process, senior management support for quality improvement efforts, innovative protocols and flexibility in refining those protocols and collaborative teams across nursing, cardiology and emergency services, real-time data feedback to measure success, and an organizational culture that made hospitals resilient to setback.