Matthew E. Fitzgerald, DrPH, American College of Cardiology


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  • As can be seen by the green bars, in 1999, only 46% of the patients in the fibrinolytic cohort were treated within the recommended 30 minute door-to-drug time, and only 35% of the patients in the PCI cohort were treated within the recommended 90 minute door-to-balloon time. These numbers are humbling. Even more humbling is the fact that these proportions did not change significantly over the next three years.
  • Door-to-ECG 8 9 ECG-to-lab 47 68 Lab-to-balloon 29 41 TOTAL 94 128
  • Submissions identified point in process when tool is used Submissions identified function of person responsible for completing the tool QI stories provided lessons learned from implementation associated with the tool
  • Hospital Site Reviewers 19 total hospitals D2B times ranging from 55 – 152 min Peer Reviewers 13 total peer reviewers Representatives from: ACC Quality Strategic Directions Committee ACC Board of Governors ACC Cardiac Care Associate Membership American College of Emergency Physicians American Heart Association Institute for Healthcare Improvement Society for Cardiovascular Angiography and Interventions
  • Matthew E. Fitzgerald, DrPH, American College of Cardiology

    1. 1. The D2B Quality Alliance Matthew E. Fitzgerald, DrPH Sr. Director, Science & Quality American College of Cardiology
    2. 2. Evidence-base Review Subgroup <ul><li>Betsy Bradley, PhD – Chair </li></ul><ul><ul><li>Yale School of Public Health </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Jeptha Curtis, MD </li></ul><ul><ul><li>Yale University </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Chris Granger, MD </li></ul><ul><ul><li>Duke Clinical Research Institute </li></ul></ul><ul><ul><ul><li>North Carolina </li></ul></ul></ul><ul><li>Mauro Moscucci, MD </li></ul><ul><ul><li>University of Michigan </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>Brahmajee Nallamothu, MD </li></ul><ul><ul><li>University of Michigan </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>Harlan Krumholz, MD </li></ul><ul><ul><li>Yale University </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul>
    3. 3. Evaluation and Research Subgroup <ul><li>Brahmajee Nallamothu, MD – Chair </li></ul><ul><ul><li>University of Michigan - Michigan </li></ul></ul><ul><li>Wayne Batchelor, MD </li></ul><ul><ul><li>Southern Medical Group - Florida </li></ul></ul><ul><li>Betsy Bradley, PhD </li></ul><ul><ul><li>Yale School of Public Health -Connecticut </li></ul></ul><ul><li>Jeptha Curtis, MD </li></ul><ul><ul><li>Yale University - Connecticut </li></ul></ul><ul><li>Chris Granger, MD </li></ul><ul><ul><li>Duke Clinical Research Institute </li></ul></ul><ul><ul><ul><li>North Carolina </li></ul></ul></ul><ul><li>Harlan Krumholz, MD </li></ul><ul><ul><li>Yale University - Connecticut </li></ul></ul><ul><li>Mauro Moscucci, MD </li></ul><ul><ul><li>University of Michigan - Michigan </li></ul></ul><ul><li>April Simon, RN, MSN </li></ul><ul><ul><li>Cardiac Data Solutions - Indiana </li></ul></ul><ul><li>Kalon Ho, MD </li></ul><ul><ul><li>Beth Israel Deaconess Medical Center </li></ul></ul><ul><li>- Massachusetts </li></ul><ul><li>David Janicke, MD </li></ul><ul><ul><li>SUNY at Buffalo - New York </li></ul></ul><ul><li>Fred Masoudi, MD, MPH </li></ul><ul><ul><li>Denver Health Medical Center - Colorado </li></ul></ul>
    4. 4. Toolkit Subgroup <ul><li>Wayne Batchelor, MD - Chair </li></ul><ul><ul><li>Southern Medical Group </li></ul></ul><ul><ul><ul><li>Florida </li></ul></ul></ul><ul><li>Ralph Brindis, MD, MPH </li></ul><ul><ul><li>Oakland Kaiser Medical Center </li></ul></ul><ul><ul><ul><li>California </li></ul></ul></ul><ul><li>Jeptha Curtis, MD </li></ul><ul><ul><li>Yale University </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Eva Kline-Rogers, RN, MS </li></ul><ul><ul><li>University of Michigan </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>Harlan Krumholz, MD </li></ul><ul><ul><li>Yale University </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Peter O’Brien, MD </li></ul><ul><ul><li>Lynchburg General Hospital </li></ul></ul><ul><ul><ul><li>Virginia </li></ul></ul></ul><ul><li>Art Riba, MD </li></ul><ul><ul><li>Oakwood Hospital and Medical Ctr </li></ul></ul><ul><li> - Michigan </li></ul><ul><li>April Simon, RN, MSN </li></ul><ul><ul><li>Cardiac Data Solutions </li></ul></ul><ul><ul><ul><li>Indiana </li></ul></ul></ul><ul><li>Charles Chambers, MD </li></ul><ul><ul><li>Penn State Milton Hershey Med Ctr </li></ul></ul><ul><ul><ul><li>Pennsylvania </li></ul></ul></ul><ul><li>David Magid, MD, MPH </li></ul><ul><ul><li>Kaiser Permanente </li></ul></ul><ul><ul><ul><li>Colorado </li></ul></ul></ul>
    5. 5. Change Package Subgroup <ul><li>Eva Kline-Rogers, RN, MS - Chair </li></ul><ul><ul><li>University of Michigan – </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>Wayne Batchelor, MD </li></ul><ul><ul><li>Southern Medical Group </li></ul></ul><ul><ul><ul><li>Florida </li></ul></ul></ul><ul><li>Chris Granger, MD </li></ul><ul><ul><li>Duke Clinical Research Institute </li></ul></ul><ul><ul><ul><li>North Carolina </li></ul></ul></ul><ul><li>Harlan Krumholz, MD </li></ul><ul><ul><li>Yale University </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Mauro Moscucci, MD </li></ul><ul><ul><li>University of Michigan </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>Ivan Rokos, MD </li></ul><ul><ul><li>UCLA – Olive View </li></ul></ul><ul><ul><ul><li>California </li></ul></ul></ul><ul><li>Aaron Kugelmass, MD </li></ul><ul><ul><li>Henry Ford Health System </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>Barry Uretsky, MD </li></ul><ul><ul><li>University of Texas – Galveston </li></ul></ul><ul><ul><ul><li>Texas </li></ul></ul></ul>
    6. 6. Partnership and Communications Subgroup <ul><li>John Brush, MD – Chair </li></ul><ul><ul><li>Sentara Hospital </li></ul></ul><ul><ul><ul><li>Virginia </li></ul></ul></ul><ul><li>Ralph Brindis, MD, MPH </li></ul><ul><ul><li>Oakland Kaiser Medical Center </li></ul></ul><ul><ul><ul><li>California </li></ul></ul></ul><ul><li>Harlan Krumholz, MD </li></ul><ul><ul><li>Yale University </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Peter O’Brien, MD </li></ul><ul><ul><li>Lynchburg General Hospital </li></ul></ul><ul><ul><ul><li>Virginia </li></ul></ul></ul><ul><li>Art Riba, MD </li></ul><ul><ul><li>Oakwood Hospital and Medical Ctr </li></ul></ul><ul><ul><ul><li>Michigan </li></ul></ul></ul><ul><li>April Simon, RN, MSN </li></ul><ul><ul><li>Cardiac Data Solutions </li></ul></ul><ul><ul><ul><li>Indiana </li></ul></ul></ul><ul><li>Ivan Rokos, MD </li></ul><ul><ul><li>UCLA – Olive View </li></ul></ul><ul><ul><ul><li>California </li></ul></ul></ul><ul><li>Barry Uretsky, MD </li></ul><ul><ul><li>University of Texas – Galveston </li></ul></ul><ul><ul><ul><li>Texas </li></ul></ul></ul><ul><li>Henry Ting, MD </li></ul><ul><ul><li>Mayo Clinic </li></ul></ul><ul><ul><ul><li>Minnesota </li></ul></ul></ul>
    7. 7. PIM Subgroup <ul><li>Eric S Holmboe, MD </li></ul><ul><ul><li>American Board of Internal Medicine </li></ul></ul><ul><ul><ul><li>Pennsylvania </li></ul></ul></ul><ul><li>Henry Ting, MD </li></ul><ul><ul><li>Mayo Clinic </li></ul></ul><ul><ul><ul><li>Minnesota </li></ul></ul></ul><ul><li>Ivan Rokos, MD </li></ul><ul><ul><li>UCLA – Olive View </li></ul></ul><ul><ul><ul><li>California </li></ul></ul></ul><ul><li>Janet Parkesovich </li></ul><ul><ul><li>Yale New Haven Hospital </li></ul></ul><ul><ul><ul><li>Connecticut </li></ul></ul></ul><ul><li>Patrick O’Gara, MD </li></ul><ul><ul><li>Brigham & Women’s Hospital </li></ul></ul><ul><ul><ul><li>Massachusetts </li></ul></ul></ul><ul><li>John Spertus, MD, MPH </li></ul><ul><ul><li>Mid America Heart Institute </li></ul></ul><ul><ul><ul><li>Missouri </li></ul></ul></ul><ul><li>Martha Radford, MD </li></ul><ul><ul><li>New York University Hospitals Ctr </li></ul></ul><ul><ul><ul><li>New York </li></ul></ul></ul>
    8. 8. <ul><li>Relationship Between Delay in PTCA and 30-day Mortality </li></ul>Primary PTCA in the Era of Balloon Angioplasty GUSTO IIb Substudy Berger et al. Circulation 1999;100:14.
    9. 9. National Trend in Door-to-Balloon Time 1999-2003
    10. 10. Percent of Hospitals Meeting Median Door-to-Balloon Times Guidelines McNamara et al., JACC 2006
    11. 11. Hospital-Level Variation in Median Door-to-Balloon Times
    12. 12. D2B Quality Alliance Goal <ul><li>Goal: </li></ul><ul><ul><li>To improve door-to-balloon (D2B) times at participating hospitals in non-transfer patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). </li></ul></ul><ul><li>Outcome Measure: </li></ul><ul><ul><li>The proportion of hospitals with at least 75 percent of all their non-transfer patients undergoing primary PCI with D2B times of 90 minutes or less. </li></ul></ul>
    13. 13. Evidence Base <ul><li>Synthesis of existing literature (13 studies) </li></ul><ul><li>- Pre/post interventional studies </li></ul><ul><li>- Qualitative studies of top performers </li></ul><ul><li>- National cross-sectional studies </li></ul><ul><li>Together, these data provide insights about specific interventions that work </li></ul>
    14. 14. Time Intervals in Fastest and Slowest Quintiles of Hospitals Bradley et al., AHJ 2006
    15. 15. Strategies that Work (10-15 minutes saving in some cases) <ul><li>1. ED activation of cath lab </li></ul><ul><li>2. Single-call system </li></ul><ul><li>3. Cath team target 20-30 minute assembly time </li></ul><ul><li>4. Prompt data feedback to ED and cath lab staff </li></ul><ul><li>5. Senior management commitment </li></ul><ul><li>6. Team-based approach </li></ul><ul><li>7. Pre-hospital ECGs activate cath lab team </li></ul>
    16. 16. Room for Improvement <ul><li>Emergency medicine activation </li></ul><ul><li>22% of hospitals on days </li></ul><ul><li>27% of hospital on nights and weekends </li></ul><ul><li>Single-call system </li></ul><ul><li>14% of hospitals </li></ul><ul><li>Expectation for cath lab team arrival after page </li></ul><ul><li>11% of hospitals within 20 minutes </li></ul><ul><li>77% of hospitals within 21-30 minutes </li></ul>
    17. 17. Interaction Among EMS, ED, and Cath Lab <ul><li>EMS routinely calls in or transmits ECGs </li></ul><ul><li>40% of hospitals </li></ul><ul><li>Hospital activates while patient is still en route </li></ul><ul><li>9% of hospitals </li></ul>
    18. 18. Reported False Alarm Rates <ul><li>Hospitals where cardiology activates cath lab  1 (range: 0-3) in 6 months </li></ul><ul><li>Hospitals where emergency medicine activates  2 (range: 1-4) in 6 months </li></ul><ul><li>Hospitals that activate while patient en route </li></ul><ul><li> 2 (range: 1-4) in 6 months </li></ul>
    19. 19. Organizational Context <ul><li>Explicit goal of improving door-to-balloon time </li></ul><ul><li>Senior management support </li></ul><ul><li>Uncompromising clinical champions (and teams) </li></ul><ul><li>Organizational culture that fostered resilience to challenges and setbacks (non-blame) </li></ul><ul><li>Data feedback to trend, motivate, and reward </li></ul>
    20. 20. Summary <ul><li>The literature supports a set of specific strategies associated with faster door-to-balloon time </li></ul><ul><li>These are underutilized currently </li></ul><ul><li>Changes require organizational commitment and cooperation among disciplines and departments </li></ul><ul><li>National GAP-D2B campaign can help foster needed organizational visibility and commitment </li></ul>
    21. 21. D2B Tool Kit Subgroup <ul><li>Developed by experts in the field and in D2B research </li></ul><ul><li>Included representatives of D2B Team across disciplines and specialties: </li></ul><ul><ul><li>Nurses </li></ul></ul><ul><ul><li>Emergency physicians </li></ul></ul><ul><ul><li>Interventional cardiologists </li></ul></ul><ul><ul><li>Quality improvement professionals </li></ul></ul>
    22. 22. Development Process Tool Kit Development Tools from other facilities are compiled, assessed, and modified for D2B Tool Kit development. Hospital Site Review D2B Work Group Review Peer Review <ul><li>Three-part review process to ensure a high-quality tool kit </li></ul>
    23. 23. Development Process <ul><li>Step 1 - Call for D2B Tools </li></ul><ul><li>Requested all hospitals performing primary PCI to submit tools and QI stories </li></ul><ul><li>Step 2 – Assess Tools Received </li></ul><ul><li>Identified tools from the existing collection that support Tier 1 strategies </li></ul><ul><li>Step 3 – Modify/Develop Tools </li></ul><ul><li>Modified existing tools and/or developed new tools to support Tier 1 strategies </li></ul>
    24. 24. Development Process <ul><li>Step 4 – Finalize Draft #1 </li></ul><ul><li>Finalize D2B Tool Kit (Draft #1) by incorporating D2B Tool Kit Subgroup comments </li></ul><ul><li>Step 5 – Initiate Review Process </li></ul><ul><li>Initiate Review Process by releasing Draft #2 to hospital reviewers and peer reviewers </li></ul>
    25. 25. D2B Tool Kit <ul><li>How to use D2B toolkit </li></ul><ul><li>Strategies Checklist </li></ul><ul><li>Process Flow Chart </li></ul><ul><li>“ STEMI Alert” Checklist </li></ul><ul><li>Cath Lab Activation Protocol </li></ul><ul><li>Team Roles and Responsibilities </li></ul><ul><li>Time Entry Form with Target Times </li></ul><ul><li>Data Collection Form </li></ul><ul><li>Standard Order Set </li></ul><ul><li>Pre-hospital ECG Checklist </li></ul>
    26. 26. Take Home Messages <ul><li>The D2B Tool Kit… </li></ul><ul><li>is based on practical tools from the field </li></ul><ul><li>is intended to be easily implemented </li></ul><ul><li>applies evidence-based strategies for D2B improvement </li></ul><ul><li>is constantly improving based on user feedback </li></ul>
    27. 27. D2B: An Alliance for Quality <ul><li>International quality improvement campaign to reduce door-to-balloon times in STEMI patients </li></ul><ul><li>200+ hospitals, 27 strategic partners (and growing!) </li></ul><ul><li>Participating hospitals asked to commit to following: </li></ul><ul><li>• Implement as many of 6 evidence-based strategies as possible • Allow ACC to publicize their good efforts </li></ul><ul><li>• Complete three surveys to let ACC know what the hospital is doing to improve D2B times </li></ul><ul><li>• Participate in the D2B online community to share experiences and learn from others </li></ul>
    28. 28. D2B: An Alliance for Quality <ul><li>Reasons for joining D2B: </li></ul><ul><ul><li>Improve on CMS/JCAHO core measure results </li></ul></ul><ul><ul><li>ABIM and CME credit for participation </li></ul></ul><ul><ul><li>Publicity for your efforts </li></ul></ul><ul><ul><li>No cost to hospitals to join </li></ul></ul><ul><ul><li>It’s the right thing to do! </li></ul></ul><ul><li>March 1, 2007 – deadline for hospitals to join D2B and be included in initial public release of participating hospitals at ACC ’07 (hospitals are permitted to join after March 1) </li></ul><ul><li>More information: </li></ul>
    29. 29. How can hospitals join D2B? By visiting
    30. 30. D2B Manual and Tool Kit
    31. 31. D2B Tool Kit The D2B Tool Kit is located about midway down the “D2B Implementation Manual” web page. Hospitals can access each tool to determine whether it is appropriate for their facility and are encouraged to modify tools to fit their needs.
    32. 32. How to Participate and What is Expected of Hospitals <ul><li>Complete a Participation Agreement and Join the D2B Alliance! </li></ul><ul><li>Commit to implementing the evidence-based strategies. </li></ul><ul><li>Allow D2B Alliance to use hospital name in D2B promotional materials. </li></ul><ul><li>Help contribute to the learning community by sharing stories, successes and obstacles. </li></ul><ul><li>And it’s FREE - No cost to join. </li></ul>
    33. 33. Where can I get more information? <ul><li> </li></ul><ul><li>* website for information on D2B, download tools and resources, sign up your hospital and participate in the online D2B community </li></ul><ul><li>D2B Staff Email – </li></ul>