Six Sigma Process Utilization in Reducing Door-to-Balloon Time at a Single Academic Tertiary Care Center
Section snippets
Six Sigma methodology in D2B times
In April 2004, our institution, Wake Forest University Baptist Medical Center (WFUBMC), determined that a reduction in D2B times for our STEMI patients was a quality assurance priority. Six Sigma methodology was applied with full administrative support provided by the hospital administrative leadership and chief executive officer. The Six Sigma leader was the cardiac catheterization laboratory (CCL) director, but membership of the Six Sigma Task Force was truly multidisciplinary, with
Results
Individual data were available for 457 patient encounters from June 2002 through June 2009. Before implementation of the Six Sigma process, mean (SD) D2B time at WFUBMC was 128 (41) minutes, and 83% of patients did not meet the 90-minute D2B goal (Fig 5). During the 6 months of initial Six Sigma data definition and analysis (July 1–December 31, 2004), D2B times decreased to a mean (SD) of 99 (33) minutes. After initiation of the project, mean (SD) D2B time decreased during the pilot phase to 90
Discussion
The research evidence related to hospital strategies that are effective in reducing D2B time is limited and mostly has been generated from large observational studies, but in practice, these studies are pertinent for understanding effective and practical interventions for hospitals attempting to reduce D2B times. We have implemented processes recommended by several of these evidence-based studies and also have generated our own strategies that have helped produced continued D2B reductions at
Conclusion
Six Sigma methodology and real-time quality assurance feedback has resulted in significant reductions in D2B times in patients with STEMI at our tertiary care primary PCI institution. The lessons learned may be extrapolated to other primary PCI centers to improve the care of STEMI patients.
Statement of Conflict of Interest
All authors declare that there are no conflicts of interest.
References (36)
- et al.
2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2008) - et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)
J Am Coll Cardiol
(2004) - et al.
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials
Lancet
(2003) - et al.
Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry
J Am Coll Cardiol
(2009) - et al.
Treatment delay in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a key process analysis of patient and program factors
Am Heart J
(2008) - et al.
Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006
Am Heart J
(2008) - et al.
An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction
Am J Cardiol
(2007) - et al.
Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE): study design
Am Heart J
(2006) - et al.
Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?
J Am Coll Cardiol
(2005) - et al.
The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4
J Am Coll Cardiol
(2006)
The prehospital electrocardiogram in acute myocardial infarction: is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators
J Am Coll Cardiol
Effect of audit on door-to-inflation times in primary angioplasty/stenting for acute myocardial infarction
Am J Cardiol
Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts
Circulation
Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction
JAMA
Disparities in use of same-day percutaneous coronary intervention for patients with ST-elevation myocardial infarction in Florida, 2001-2005
Am J Cardiol
Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis
Circulation
Emergency department physician activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction
Circulation
Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems
Circulation
Cited by (18)
Sharing and Teaching Electrocardiograms to Minimize Infarction (STEMI): reducing diagnostic time for acute coronary occlusion in the emergency department
2021, American Journal of Emergency MedicineCitation Excerpt :Audit and feedback has been recognized as a strategy to reduce delays to reperfusion [47,48] and added to AHA/ACC STEMI guidelines. [2] But audit and feedback initiatives, either as part of multiple strategies [49-54] or in isolation [55-58] have restricted themselves to classic STEMI criteria, provided feedback to the entire healthcare team, and focused on overall door-to-balloon times. Our study was novel in that it directed feedback exclusively to emergency physicians as a group, provided education beyond classic STEMI criteria to include newer ECG insights into acute coronary occlusion, and assessed ETA time as the quality metric.
Quality Improvement and Public Reporting in STEMI Care
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2020, Health PolicyReply: Time to start implementing lean and six sigma in the catheterization laboratory
2016, Cardiovascular Revascularization MedicineTime to start implementing Lean and Six Sigma in the catheterization laboratory
2016, Cardiovascular Revascularization Medicine
Statement of Conflict of Interest: see page 225.