Your centre's audit shows the proportion of STEMI patients achieving door-to-balloon within 90 minutes has fallen from 82% to 61% over six months. You have been asked to lead the response. Outline your approach.

Question

You are the cardiology registrar. The regional network has flagged your centre as an outlier. The consultant lead has asked you to investigate and lead a quality improvement response, reporting to the departmental governance meeting in three months.

Accepted Answer

I would resist the temptation to intervene immediately and start with a diagnostic phase, because a fall of this size usually has a specific cause rather than a general decline in effort. I would process map the whole pathway from first medical contact through to balloon inflation, and then segment the data — in-hours against out-of-hours, ambulance pre-alert against self-presenters, direct admissions against inter-hospital transfers, and by day of week. That segmentation usually localises the problem quickly; in my experience the delay is concentrated in one segment rather than spread evenly. I would talk to the people who do the work: the ambulance crews, the emergency department nurses, the cath lab team and the on-call registrars, because they will name the cause faster than the data will. My aim would be SMART — for example, to return the proportion achieving door-to-balloon within 90 minutes to above 80% within six months. My measures would be the outcome of door-to-balloon time plotted as a run chart, process measures such as time from first ECG to cath lab activation, and a balancing measure of inappropriate lab activations, because pushing on speed can generate false-positive calls that exhaust the team. I would then test changes in small, fast PDSA cycles rather than launching one large intervention, favouring changes that make the right thing the easy thing — single-call activation, ambulance pre-alert taking patients directly to the lab, a pre-populated activation checklist — over education alone, which decays. I would engage the network and a consultant sponsor, report at governance, and before I rotate I would embed the change in the standard operating procedure and induction with a named owner, so it survives me.

Falling Door-to-Balloon Times

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