Although the change did not translate to decreases in postprocedural 48-hour mortality, the results now exceed the national and state average of 94% to 96% of patients receiving PPCI within 90 minutes. 4 In this study, we demonstrate successful customization of the generalized recommendations for STEMI DTBT reduction in the community setting using a Six Sigma approach. No differences were observed in 48-hour postprocedure mortality or need for intra-aortic balloon pump.ĭTBT has 3 key intervals-time from door to electrocardiogram (ECG), time from ECG to catheterization laboratory, and time from laboratory arrival to device-all of which are dependent on system factors that vary across institutions. These interventions led to an overall reduction in DTBT from a mean (SD) of 79 (52) minutes in group 1 to 57 (19) minutes in group 3 ( P <.0001), with 99.4% of patients in group 3 (vs 76.2% in group 1 P <.0001) achieving a DTBT of less than 90 minutes. The individual steps, specific interventions targeting them, and their impact with reductions in mean and SD are noted in the Table. Overall, the baseline demographics, comorbidities (including cardiovascular risk factors), and cardiac catheterization data were similar in group 1 and group 3. The mean age of patients was 63 years 69% were male and 50% were black. All analyses were conducted using IBM SPSS Statistics for Windows version 22.0 (IBM Corp Armonk, New York). A Six Sigma approach was used for the primary end point of reduction in DTBT and the proportion of patients with DTBT less than 90 minutes and secondary end points of improvement in the time duration of each of the 7 steps mentioned in the Table. 3 The patients were divided into 3 groups: group 1 (preintervention group n = 63 October 1, 2013, to September 30, 2014), group 2 (transition group n = 14 October 1, 2014, to Decemexcluded from analysis), and group 3 (postintervention group n = 166 January 1, 2015, to December 31, 2017). These data were collected using the CathPCI registry of the National Cardiovascular Data Registry after approval by the Institutional Review Board at Sinai Hospital of Baltimore in Baltimore, Maryland. In addition to the total DTBT, data were collected on time durations for several steps as outlined in the Table. We collected data on 243 consecutive adult patients (≥18 years) who presented with out-of-hospital STEMI between October 1, 2013, and December 31, 2017. Here, we report the specific interventions and their impact on the DTBTs specific to the community setting. Interventions were then designed based on the Six Sigma ideology to improve performance at each step by reducing SD. 2 Subsequently, several individual steps from the emergency department arrival of a patient to deployment of the balloon in the catheterization lab were identified. 1 In a community-based hospital, we observed that only 76% of patients had a DTBT of less than 90 minutes despite CMS reporting a national average of 96%. Primary percutaneous coronary intervention (PPCI) is the gold standard for these patients, with a recommended door-to-balloon time (DTBT) of less than 90 minutes.
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