the importance of time to reperfusion in primary percutaneous coronary intervention ( pci ) for stelevation myocardial infarction ( stemi ) has been clearly demonstrated with a powerful relationship between delays in doortoballoon time and increased mortality 1 . intense focus on doortoballoon time by cardiologists and hospitals has led to a substantial increase in the proportion of stemi patients with doortoballoon times 90 min from 44.2% in 2005 to 91.4% in 2010 in a medicare public reporting database 2 . the medicare public reporting database , however , only includes a small minority of patients undergoing emergency percutaneous intervention ( fig . the public reporting measure only included 13% of stemi patients as stemi patients with an initial ecg without st elevation and inhospital and transfer stemi patients are all excluded 3 . in addition , public reporting of doortoballoon time has been associated with an increase in patients excluded due to finally , many emergency percutaneous intervention patients with indications other than stelevation such as refractory unstable angina , nstemi , and cardiac arrest are not included within systems to improve doortoballoon time . in contrast to improvements in the medicare public reporting database , patients with reported nonsystem delays as well as inhospital and transfer stemi fail to achieve a median doortoballoon time 90 min and have a substantially higher mortality 4 , 5 , 6 , 7 . a comprehensive hospitalwide system to ensure timely reperfusion within 90 min in all emergency pci patients is needed and may be a novel strategy to reduce myocardial infarction mortality . therefore , we present the impact on doortoballoon time and mortality of a strategy of emergency department physician or cardiologist onecall activation of the catheterization lab combined with immediate physical transfer of the patient to an immediately available catheterization lab by inhouse nursing staff prospectively applied across the entire spectrum of emergency pci . the entire spectrum of emergency percutaneous intervention . emergency status defined as a patient of sufficient acuity that pci is to be performed immediately ( cancelling elective case ) in next available room during regular hours or activation of oncall cath lab team during offhours . this prospective study was conducted between october 1 , 2004 and december 1 , 2008 at st . francis hospital and health center ( beech grove and indianapolis , in ) , a 591bed tertiary care community hospital consisting of two campuses 7 miles apart . details of the hospital system , the protocol during the historical control period ( october 1 , 2004august 31 , 2005 ) and characteristics of the enrolled patients during the historical control period have been previously reported 8 . beginning september 1 , 2005 , we prospectively enrolled a consecutive series of patients with emergency catheterization lab activation irrespective of clinical indication , manner or timing of presentation , activating physician , or location within the hospital . we mandated the ed physicians to activate the catheterization lab for stemi in the emergency department ; cardiologists could activate the catheterization lab for any patient requiring emergent catheterization independent of indication ( i.e. , stemi , refractory unstable angina , nstemi , cardiogenic shock , or cardiac arrest ) or location ( i.e. , emergency department , inpatient floor , or intensive care unit ; fig . the emergency department physician or cardiologist contacted the hospital operator to activate the catheterization lab . the operator subsequently paged the cardiology physician assistant , catheterization lab coordinator , and a critical care unit nurse during regular hours or the oncall cardiologist , interventional cardiologist , critical care unit nurse , chest pain unit nurse , and the oncall catheterization team during offhours . four catheterization staff members take home call during offhours and are expected to arrive to the hospital within 30 min of laboratory activation . emergency department physicians or cardiologists identified all patients needing emergency cardiac catheterization / pci with subsequent immediate transfer protocol by inhouse nursing staff to catheterization lab . following catheterization lab activation , the inhouse emergency heart attack response team ( ehart ) , consisting of an emergency department nurse , a critical care unit nurse , and a chest pain unit nurse initiated a policy of immediate transfer of the patient to an immediately available catheterization lab . the critical care unit nurse proceeded to the patient 's location and initiated a standard resuscitation order set with the emergency department or bedside nurse ( if patient was not in the emergency department ) . the only exceptions to immediate transfer by the nursing staff included hemodynamic compromise ( requiring vasopressors , temporary pacing , or balloon pump ) and ongoing cpr ; these patients were prepared for immediate transfer but transferred by the nursing staff with the cardiologist . the critical care unit nurse could administer dopamine or norepinephrine intravenous drips , perform defibrillation , and direct intubation by respiratory therapy all without prior physician approval in case of sustained hypotension or arrest . the critical care unit modified the work requirements for the ehart nurse by assigning the nurse one patient instead of two patients . to make the cath lab immediately available during regular hours , the catheterization lab coordinator identified a room and staff for the patient . the lab coordinator could remove an elective patient from the lab if the case had not started ( defined as cardiologist fully scrubbed at bedside obtaining access ) . if all rooms were occupied with cases in progress , then the stemi patient went to the first available room . upon patient placement on the catheterization lab table , the emergency heart attack response team members transferred the patient 's nursing care to the catheterization team . to make the cath lab immediately available during offhours , the chest pain unit nurse proceeded to the catheterization lab , activated the catheterization lab imaging equipment , and confirmed that the temporary pacemaker , balloon pump , defibrillator , and activated clotting time machine were in working order . this individual subsequently assisted the critical care unit nurse and emergency department nurse in the initial setup of the patient including placement on the catheterization table , monitoring equipment setup , prepping of groins , and assistance with the sterile catheterization lab table . the emergency department nurse and critical care nurse monitored the patient until the third and fourth catheterization staff members arrived and subsequently transferred nursing care to the catheterization team . if the patient was unstable , all staff attended to the patient until safe transfer of care was possible . for cath lab activations by emergency department ( ed ) physicians , all activities in the emergency department , during the transfer to the catheterization lab , and during initial setup in the catheterization lab did not require cardiologist presence or input . the cardiologist evaluated the patient and confirmed the appropriateness for emergency catheterization in the emergency department , en route to the catheterization lab , or in the catheterization lab . median doortoballoon time was the primary endpoint and was defined as follows : 1 doortoballoon time for primary emergency department patients , 2 first doortoballoon time for transfer patients , 3 activating ecgtoballoon time for patients without stelevation on first ecg and inhospital , and 4 activationtoballoon time for patients with activating indication other than stemi . secondary endpoints included the proportion of doortoballoon times 90 min , infarct size measured by peak creatinine kinase within the first 24 hr 9 , 10 , 11 , hospital costs ( total , direct , and indirect ) , and hospital length of stay . hospital cost data reflect the actual costs involved in the delivery of care to each patient and were determined by the hospital 's costaccounting software ( alliance for decision support , avega health systems . mortality was determined by hospital medical record review and via query of social security death index . using a national mortality database , we analyzed 30day allcause unadjusted mortality and 30day allcause riskstandardized mortality ratios for patients diagnosed with acute myocardial infarction for our hospital compared to national averages for the time periods of july 2008 and june 2008 and july 2006 to june 2009 . time values are presented as medians with interquartile ranges and were analyzed using one sample wilcoxon signed rank test against a median value of 90 min . the proportion of patients with doortoballoon 90 min was compared to the goal of 75% by the binomial test . continuous data are presented as means    standard deviation and were analyzed by two sample ttests . stata software ( version 8.2 , college station , tx ) and prism ( version 6.0d , la jolla , ca ) were used for statistical analyses . this prospective study was conducted between october 1 , 2004 and december 1 , 2008 at st . francis hospital and health center ( beech grove and indianapolis , in ) , a 591bed tertiary care community hospital consisting of two campuses 7 miles apart . details of the hospital system , the protocol during the historical control period ( october 1 , 2004august 31 , 2005 ) and characteristics of the enrolled patients during the historical control period have been previously reported 8 . beginning september 1 , 2005 , we prospectively enrolled a consecutive series of patients with emergency catheterization lab activation irrespective of clinical indication , manner or timing of presentation , activating physician , or location within the hospital . we mandated the ed physicians to activate the catheterization lab for stemi in the emergency department ; cardiologists could activate the catheterization lab for any patient requiring emergent catheterization independent of indication ( i.e. , stemi , refractory unstable angina , nstemi , cardiogenic shock , or cardiac arrest ) or location ( i.e. , emergency department , inpatient floor , or intensive care unit ; fig . the emergency department physician or cardiologist contacted the hospital operator to activate the catheterization lab . the operator subsequently paged the cardiology physician assistant , catheterization lab coordinator , and a critical care unit nurse during regular hours or the oncall cardiologist , interventional cardiologist , critical care unit nurse , chest pain unit nurse , and the oncall catheterization team during offhours . four catheterization staff members take home call during offhours and are expected to arrive to the hospital within 30 min of laboratory activation . emergency department physicians or cardiologists identified all patients needing emergency cardiac catheterization / pci with subsequent immediate transfer protocol by inhouse nursing staff to catheterization lab . following catheterization lab activation , the inhouse emergency heart attack response team ( ehart ) , consisting of an emergency department nurse , a critical care unit nurse , and a chest pain unit nurse initiated a policy of immediate transfer of the patient to an immediately available catheterization lab . the critical care unit nurse proceeded to the patient 's location and initiated a standard resuscitation order set with the emergency department or bedside nurse ( if patient was not in the emergency department ) . the only exceptions to immediate transfer by the nursing staff included hemodynamic compromise ( requiring vasopressors , temporary pacing , or balloon pump ) and ongoing cpr ; these patients were prepared for immediate transfer but transferred by the nursing staff with the cardiologist . the critical care unit nurse could administer dopamine or norepinephrine intravenous drips , perform defibrillation , and direct intubation by respiratory therapy all without prior physician approval in case of sustained hypotension or arrest . the critical care unit modified the work requirements for the ehart nurse by assigning the nurse one patient instead of two patients . to make the cath lab immediately available during regular hours , the catheterization lab coordinator identified a room and staff for the patient . the lab coordinator could remove an elective patient from the lab if the case had not started ( defined as cardiologist fully scrubbed at bedside obtaining access ) . if all rooms were occupied with cases in progress , then the stemi patient went to the first available room . upon patient placement on the catheterization lab table , the emergency heart attack response team members transferred the patient 's nursing care to the catheterization team . to make the cath lab immediately available during offhours , the chest pain unit nurse proceeded to the catheterization lab , activated the catheterization lab imaging equipment , and confirmed that the temporary pacemaker , balloon pump , defibrillator , and activated clotting time machine were in working order . this individual subsequently assisted the critical care unit nurse and emergency department nurse in the initial setup of the patient including placement on the catheterization table , monitoring equipment setup , prepping of groins , and assistance with the sterile catheterization lab table . the emergency department nurse and critical care nurse monitored the patient until the third and fourth catheterization staff members arrived and subsequently transferred nursing care to the catheterization team . if the patient was unstable , all staff attended to the patient until safe transfer of care was possible . for cath lab activations by emergency department ( ed ) physicians , all activities in the emergency department , during the transfer to the catheterization lab , and during initial setup in the catheterization lab did not require cardiologist presence or input . the cardiologist evaluated the patient and confirmed the appropriateness for emergency catheterization in the emergency department , en route to the catheterization lab , or in the catheterization lab . median doortoballoon time was the primary endpoint and was defined as follows : 1 doortoballoon time for primary emergency department patients , 2 first doortoballoon time for transfer patients , 3 activating ecgtoballoon time for patients without stelevation on first ecg and inhospital , and 4 activationtoballoon time for patients with activating indication other than stemi . secondary endpoints included the proportion of doortoballoon times 90 min , infarct size measured by peak creatinine kinase within the first 24 hr 9 , 10 , 11 , hospital costs ( total , direct , and indirect ) , and hospital length of stay . hospital cost data reflect the actual costs involved in the delivery of care to each patient and were determined by the hospital 's costaccounting software ( alliance for decision support , avega health systems . mortality was determined by hospital medical record review and via query of social security death index . using a national mortality database , we analyzed 30day allcause unadjusted mortality and 30day allcause riskstandardized mortality ratios for patients diagnosed with acute myocardial infarction for our hospital compared to national averages for the time periods of july 2008 and june 2008 and july 2006 to june 2009 . time values are presented as medians with interquartile ranges and were analyzed using one sample wilcoxon signed rank test against a median value of 90 min . the proportion of patients with doortoballoon 90 min was compared to the goal of 75% by the binomial test . continuous data are presented as means    standard deviation and were analyzed by two sample ttests . stata software ( version 8.2 , college station , tx ) and prism ( version 6.0d , la jolla , ca ) were used for statistical analyses . the proportion undergoing diagnostic catheterization was slightly higher in the stemi activation group compared to indications other than stemi ( 98.6% vs. 94.7% , p  =  0.0194 ) while the proportion undergoing pci was markedly higher in the stemi group ( 83.4% vs. 52.6% , p  <  0.0001 ) . summary of 679 consecutive emergency catheterization lab activations according to indication and origin of patient . stemi patients had lower rates of prior cabg and peripheral vascular disease compared to patients with indications other than stemi ( table 1 ) . patient with indications other than stemi were more likely to have offhours cath lab activations , selftransportation , and left circumflex involvement as the infarctrelated artery . emergency department physicians accounted for 81.1% of cath lab activations for stemi but only 11.7% of activations for indications other than stemi . demographics , initial presentation characteristics , and treatment outcomes in stemi and emergent activation patients undergoing pci values are expressed as mean    sd or n ( % ) . ed , emergency department ; chd , coronary heart disease ; copd , chronic obstructive pulmonary disease ; pci , percutaneous intervention ; cabg , coronary artery bypass grafting ; pvd , peripheral vascular disease ; ecg , electrocardiogram ; cpr , cardiopulmonary resuscitation ; lbbb , left bundle branch block ; cath lab , catheterization laboratory ; iabp , intraaortic balloon pump ; and drg , diagnosisrelated group . compared to historical controls , the clinical profile of stemi patients undergoing pci originating from the primary emergency department and in transfer ( groups a1 and a3 from fig . the proportion treated within 90 min increased from 28.3% to 85.3% ( p  <  0.0001 ; table 2 ) . there was a 10fold increase in the treatment within 45 min and a nearly 10fold reduction in treatment requiring > 120 min ( p  <  0.0001 ) . mean infarct size , hospital length of stay , total and direct hospital costs all decreased . doortoballoon time , infarct size , hospital length of stay , costs , and allcause mortality before and after process change in primary and transfer ed patients for all patient types , median doortoballoon time was 68 min with 85.7% of patients treated within 90 min ( table 3 ) . for stemi patients presenting to the primary emergency department ( fig . 3 , group a1 ) , a median doortoballoon time less than 90 min was achieved overall and in every subgroup . similarly , the goal of 75% of patients to be treated within 90 min was achieved except in patients with prior cabg and patients presenting without chest pain . furthermore , all emergency pci patient subgroups achieved a median doortoballoon time 90 minute ; nearly all achieved the goal of 75% of patients within 90 min except for stemi transfer patients and those with stemi inhospital . median doortoballoon and proportion of doortoballoon times within 90 min doortoballoon defined ( 1 ) conventionally for primary ed patients , ( 2 ) first doortoballoon for transfer patients , ( 3 ) activating ecgtoballoon for 1st ecg without st elevation , and ( 4 ) activation to balloon for emergency activations for indications other than stemi . compared to national averages , there were substantially lower unadjusted 30day allcause mortality for acute myocardial infarction and 30day allcause riskstandardized mortality ratios for the time periods of july 2008 and june 2008 and july 2006 to june 2009 ( fig . 4 ) . allcause 30day mortality rate during the time period of this study compared to national averages . the protocol led to a substantial reduction in unadjusted mortality and riskstandardized mortality ratios for allcause 30day mortality compared to national averages in both 20052008 and 20062009 . our study is the first description of a hospitalwide systems approach to achieve rapid doortoballoon time by implementing a uniform strategy across the entire spectrum of emergency pci . this consistent performance in doortoballoon time was evident in patients at high risk for delayed doortoballoon time , transfer patients , and patients requiring emergency pci for indications other than stemi ( fig . important secondary benefits included a 35% reduction in myocardial infarct size , a decrease in hospital length of stay by 2 days , and a more than $ 7,000 reduction in total costs for the hospital admission . most importantly , although pcirelated mortality did not change , both unadjusted and riskadjusted mortality for all acute myocardial infarction patients at 30 days were dramatically lower than national averages . achieving rapid doortoballoon time across the entire spectrum of emergency percutaneous intervention . ecg  = electrocardiogram , iabp  =  intraaortic balloon pump , nstemi  =  nonstelevation myocardial infarction , pci  = percutaneous coronary intervention , stemi  =  stelevation myocardial infarction , usa  =  unstable angina . delays in doortoballoon time can be ascribed to either systemcentered delays or patientrelated reasons 12 . systemcentered delays , such as delay in cath lab staff arrival , are believed to be amenable to process improvement . patientrelated reasons , such as cardiac arrest or the need for additional procedures , are believed to be appropriate justifications for delayed doortoballoon times . however , our data indicate that virtually every patient subgroup including cardiorespiratory arrest , cardiogenic shock , and the need for additional procedures , can have pci performed within a median doortoballoon 90 min and even the more stringent criteria of 75% within 90 min . these findings refute the belief that delays in doortoballoon time are inevitable in highrisk patients for patientrelated reasons . the applicability of our protocol extends beyond the focused population of patients who present to emergency departments with stemi and underscores the heterogeneity of clinical presentations of patients needing emergency pci ( fig . the inhospital development of stemi is also an important source of patients needing emergency pci with a very high mortality rate 6 , 12 , 14 . in fact , our study is the first study to demonstrate the ability to provide reperfusion to inhospital stemi within 90 min from detection . we also included patients who require emergency catheterization for reasons other than stemi including unstable angina / nonstelevation myocardial infarction complicated by refractory angina , hemodynamic or electrical instability , cardiac arrest , and cardiogenic shock . attention to all of these patients extends the focus of timely reperfusion from the emergency department stemi populations to the broader population of all patients who require emergency catheterization and revascularization . a michigan study revealed that the decrease in doortoballoon time led to no improvement in pci inhospital mortality 15 . furthermore , at a national level , improvements in doortoballoon time also led to no temporal improvement in pci inhospital or 30day mortality 16 . current public reporting criteria and national clinical registries allow for exclusion of patients for cpr , defibrillation , and intubation within 90 min of arrival or those with clinical reasons documented within the medical record ( i.e. , difficulty with access , the need for additional workup or procedures prior to pci , or time required for patient ) . erosion of the denominator  of the public reporting doortoballoon metric as the number of patients excluded for nonsystem delays has increased from 3.7% to 8.1% between the years 2005 and 2010 2 . the potentially excluded populations account for only 18.1% of patients but 54% of deaths 4 . similarly , in the united states cathpci registry , inhospital mortality for patients without reported nonsystem delays was 2.5% compared with 15.1% for those with a reported nonsystem delay 5 . as the benefits of improved doortoballoon time are concentrated in highrisk subgroups 17 , public reporting and clinical registries should require reporting of doortoballoon times for all patients undergoing emergency pci . hospitals typically require stemi patients to wait in the emergency department until a certain number of catheterization staff have arrived and for the catheterization lab to be ready prior to transfer 18 . time spent within the emergency department and transferring to the catheterization lab is the largest component of doortoballoon time . immediate transfer to an immediately available cath lab by an inhouse nursing staff is one of the most effective steps to reduce doortoballoon time . this process has now been validated by our experience , in academic medical settings , and outside the united states 8 , 19 , 20 . however , only 36% of emergency pci patients in our study were eligible for prehospital identification and treatment . of note , selftransportation is a common mode of presentation by stemi patients occurring approximately 50%70% of the time  a figure which is consistently seen worldwide 21 . thus , systems of care like ours that ensure equally rapid treatment for patients presenting via ambulance or selftransportation should be instituted . although the historical and process improvement cohorts were clinically similar , baseline differences can not be completely accounted for because of our study 's nonrandomized nature . our before and after outcome and cost comparisons ( table 2 ) are limited to primary and transfer ed stemi patients ; data from the other emergency pci patient populations in this study ( i.e. , initial ecg without stelevation , inhospital , and activation indications other than stemi ) were not collected during the historical time period . however , these primary and ed transfer patients did account for more than 70% of the patients treated with pci . our study describes a cohort of patients from 2004 to 2008 ; however , we believe that the system design remains relevant today particularly given ongoing challenges with rapid treatment of inhospital and transfer stemi . our study reflects a single center united states experience and may not be applicable outside the united states . we could not analyze mortality data prior to july 2005 as it is not available from the centers of medicare and medicaid services . the start date of the public reporting mortality data ( july 2005 ) do not identically match the start date for our process improvement ( september 2005 ) as the two projects were performed independently . our mortality findings were statistically and clinically significant , but the study was not primarily designed to measure mortality . optimal doortoballoon times can be achieved across a hospital system by broad implementation of ed physician or cardiology onecall activation of the catheterization lab and immediate transfer protocol by an inhouse nursing staff . the strategy can be further extended to patients who do not have stelevation on initial ecg , to inhospital stemi , and to patients who undergo emergency catheterization for clinical indications other than stemi . ultimately , this system can align improvements in doortoballoon time with reduced myocardial infarction mortality rates . widespread adoption of this comprehensive strategy can substantially improve the care of a broad population of patients undergoing emergency pci worldwide .
objectivesthis study 's aim was to describe a hospitalwide system to deliver rapid doortoballoon time across the entire spectrum of emergency percutaneous intervention.backgroundmany patients needing emergency pci are excluded from doortoballoon public reporting metric ; these groups do not achieve doortoballoon times 90 min and have increased mortality rates . 
 methods : we prospectively implemented a protocol for patients with stemi or other emergency indication for catheterization mandating ( 1 ) emergency department physician or cardiologist activation of the catheterization lab and ( 2 ) immediate patient transfer to an immediately available catheterization lab by an inhouse nursing transfer team.resultsfrom september 1 , 2005 to december 31 , 2008 , 526 consecutive patients underwent emergency pci . 
 median doortoballoon time was 68 min with 85.7% 90 min overall . 
 important subgroups included primary emergency department ( 62.5 min ) , cardiorespiratory arrest ( 71 min ) , cardiogenic shock ( 68 min ) , need for temporary pacemaker or balloon pump ( 67 min ) , initial ecg without stelevation ( 66.5 min ) , transfer from another ed ( 84 min ) , inhospital ( 70 min ) , and activation indications other than stemi ( 68 min ) . 
 patients presenting to primary ed and in transfer were compared to historical controls . 
 treatment 90 min increased ( 28%85% , p  <  0.0001 ) . 
 mean infarct size decreased , as did hospital lengthofstay and admission total hospital costs . 
 acute myocardial infarction allcause 30day unadjusted mortality and riskstandardized mortality ratios were substantially lower than national averages.conclusiona hospitalwide systems approach applied across the entire spectrum of emergency pci leads to rapid doortoballoon time , reduced infarct size and hospitals costs , and low myocardial infarction 30day allcause mortality . 
 2015 wiley periodicals , inc .