ACC/AHA Launch D2B Initiative; New Study Highlights Key Ingredients for Closing the Gaps

Shelley Wood

November 14, 2006

November 14, 2006 (Chicago, IL) - The American Heart Association (AHA), American College of Cardiology (ACC), and other health organizations launched their "Door to Balloon (D2B): An Alliance for Quality" campaign during a press conference here on the first day of the American Heart Association (AHA) 2006 Scientific Sessions. As previously reported by heart wire , the D2B initiative is a Guidelines Applied in Practice (GAP) program that aims to improve the timeliness of lifesaving therapy for MI patients at all US hospitals that perform emergency angioplasty. Specifically, the project has the goal of increasing the percentage of AMI patients who receive primary angioplasty within 90 minutes of hospital presentation to 75%; currently, only 35% of patients are treated within the recommended 90-minute window.

"This won't be easy. Changing what happens on a national scale isn't something that is very often tried," ACC president Dr Steve Nissen (Cleveland Clinic, OH) said during the press conference.

Two hundred hospitals have already signed up and, according to Dr Harlan Krumholz (Yale University, New Haven, CT), one of the pioneers of the project, all of the major hospital organizations are in the process of joining. Those who sign on receive an "implementation manual" and tool kit to help them institute specific changes identified as key to improving door-to-balloon times. The information also includes tips for constructing the team that will need to make the changes and how to single out the point person for the project within each participating hospital.

Simple changes; lives saved

Dr Wayne Bachelor (Southern Medical Group, Tallahassee, FL), who is heading up the development of the D2B tool kit, described it as "simple, easy to implement and concise, and it spans a number of basic processes in the hospital that we need to improve."

As Bachelor explained during the press conference, there are six evidence-based strategies that represent the core of the D2B program:

• Having emergency medicine physicians activate the cath lab.

• Using a single call to activate the cath lab.

• Having the cath-lab team arrive and be ready within 20 to 30 minutes.

• Providing real-time data feedback in the emergency department and the cath lab.

• Having commitment from senior management.

• Using a team-based approach spanning multiple departments.

An optional recommendation, for hospitals/community health systems that are capable of doing so, the D2B program recommends using results from prehospital ECGs to activate the cath lab.

As Krumholz commented previously to heartwire , "These are things that for some hospitals will be old hat, but other hospitals are saying, give it to us very clearly: What are the steps needed to get this done? We've tried to scale this down to the essentials, to make it very clear and easy and to ultimately make this something that could be implemented anywhere."

New study corroborates D2B recommendations

The D2B recommendations were compiled after extensive review of the research in this field, much of it conducted at Yale by Krumholz, Dr Elizabeth Bradley, and colleagues. In fact, one such study by Bradley et al was presented today at the AHA meeting by coauthor Dr Jeptha P Curtis (Yale University) and is published simultaneously in the New England Journal of Medicine [ 1].

Bradley et al surveyed 365 hospitals to identify hospital factors associated with reduced door-to-balloon times, looking specifically at 28 strategies for streamlining the process. They then looked to see which strategies were most strongly associated with reduced door-to-balloon times and the time saving these incurred. Their findings largely corroborate the recommendations set forth in the D2B recommendations.

In all, Curtis reported today, six strategies were most strongly associated with faster door-to-balloon times, and the time savings ranged from eight minutes to almost 20 minutes.

Mean reduction in door-to-balloon times by strategy


Mean reduction in door-to-balloon time (min)

Having emergency medicine physicians activate the cath lab


Having a single call to a central page operator activate cath lab


Having the ED activate the cath lab while patient still en route


Expecting staff to arrive at cath lab within 20 minutes after page


Having an attending cardiologist always on site


Having staff in ED and cath lab use and receive real-time feedback


As Bradley et al point out, despite the considerable time savings of these measures, very few hospitals were using them. For example, only 23% of hospitals had an emergency physician activate the cath lab during weekdays, a percentage that rose to 27% at night and on weekends. Similarly, only 14% used the strategy of a single call to a central page operator to activate the cath lab.

In a press conference, Krumholz, the senior author on the study, emphasized that there is "no magic place where an hour is hiding," and Bradley, likewise, stressed that time can be saved at each step along the way. "There are a lot of intervals between the door and getting the artery open, and there are a lot of pieces to that, and in each piece, you can wring out minutes, there's no question about that," she said.

False alarms uncommon

An important finding in Bradley et al's study was that so-called false alarms were uncommon: one of the barriers to adopting the types of recommendations set forth in the D2B initiative has been the fear that having emergency department physicians activate the cath lab would lead to cath-lab staff being called in unnecessarily.

In an editorial accompanying the published study, Drs Mauro Moscucci and Kim A Eagle (University of Michigan, Ann Arbor) point out that the expectation that staff be able to arrive within 20 minutes and that an attending cardiologist always be on site are factors that might be too costly or impractical for most hospitals [ 2]. "However, all the other strategies that worked in this study should be achievable by most hospital systems," they write.

In the press conference, Bradley and Krumholz acknowledged that only a slim minority of hospitals will ever meet the criteria of having an attending cardiologist on site, and this is one of the reasons it is not one of the recommendations of the D2B program. The importance of having cath-lab staff be ready to get to work within half an hour, however, is a key component and represents one of the largest potential time-savers.

"The fact is, you do have an alternative [to primary PCI]: you can treat someone with a drug," Krumholz reminded members of the press. "All things being equal, emergency angioplasty is better, but if you're really going to be delayed, you've got a drug that breaks up blood clots that can open up the artery again. If you've got people who say, we live an hour away and we're not moving, then I think it's up to the hospital to start thinking, maybe we shouldn't be providing this if we can't do so within this time frame. We owe it to our patients."

The D2B program intends to track hospitals that implement the changes to see how much they are able to trim down their door-to-balloon times. Over time, the recommendation of 90 minutes or less may seem generous, Bachelor hinted. At his hospital, the D2B team saw their times fall from approximately 110 minutes, on average, to 85 minutes within the first few months of implementing changes. Over the past two to three months, average door-to-balloon times have been closer to 75 to 80 minutes. Strikingly, Bachelor's team has also seen a drop in mortality among STEMI patients of about 36% in one year.

More information about the D2B initiative is available online at or by contacting Jason Byrd at or phone 202-375-6653.

  1. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006; DOI: 10.1056/NEJMsa063117. Available at:

  2. Moscucci M, Eagle KA. Reducing the door-to-balloon time for myocardial infarction with ST-segment elevation. N Engl J Med 2006; DOI: 10.1056/NEJMe068255. Available at:

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