Issue

Vol. 1 No. 2 (2024)

Date Log

Submitted
February 7, 2026
Published
December 31, 2024

Copyright (c) 2024 Faisal Ali Hakami, Ghazi Misfer M Alotaibi, Faisal Fuhaid Alshammari, Majed Fuhaid Abki AlShammari, Ayed Obaid AlShammari, Fawaz Obaid AlShammari, Abdullah Abdulkader Abdullah Al Ageel, Fatimah Mohammed Jaber Gaboli, Hussain Abdullah Hasan Zalah, Majed Fayadh Shihatah Alanazi, Hani Abdulaziz Aleudwan Alzabn, Abdulfattah Ali Ahmed Mobarki

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Optimizing the "Door-to-Balloon" (or "Door-to-Intervention") Pathway: An Interdisciplinary Review of System Bottlenecks and Solutions

https://doi.org/10.64483/202412633
Faisal Ali Hakami
Jazan , Ministry Of Health, Saudi Arabia
Ghazi Misfer M Alotaibi
Al Dawadmi General Hospital, Ministry of Health , Saudi Arabia
Faisal Fuhaid Alshammari
Maternity & Children's Hospital - Hafr Al-Batin Health Cluster,Ministry Of Health, Saudi Arabia
Majed Fuhaid Abki AlShammari
Hafr Al-Batin Health Cluster, Ministry Of Health, Saudi Arabia
Ayed Obaid AlShammari
Hafr Al Batin Central Hospital, Hafr Al Batin Governorate, Ministry Of Health, Saudi Arabia
Fawaz Obaid AlShammari
Maternity and Children's Hospital, Hafr Al-Batin Health Cluster,Ministry Of Health, Saudi Arabia
Abdullah Abdulkader Abdullah Al Ageel
PHC Alraowdah South, Ministry Of Health, Saudi Arabia
Fatimah Mohammed Jaber Gaboli
Bisha King Abdullah Hospital, Ministry Of Health, Saudi Arabia
Hussain Abdullah Hasan Zalah
Damad Hospital Jazan Health Cluster, Ministry Of Health, Saudi Arabia
Majed Fayadh Shihatah Alanazi
Taduk Maternity and Children’s Hospital, Ministry Of Health, Saudi Arabia
Hani Abdulaziz Aleudwan Alzabn
Branch of the Ministry of Health in Al-Jouf, Ministry Of Health, Saudi Arabia
Abdulfattah Ali Ahmed Mobarki
Altawal General Hospital, Ministry Of Health, Saudi Arabia

Corresponding Author(s) : Faisal Ali Hakami

f_alii91@icloud.com

Saudi Journal of Medicine and Public Health, Vol. 1 No. 2 (2024)

Abstract

Background: The Door-to-Balloon (D2B) or Door-to-Intervention (D2I) time is a critical performance metric in the treatment of ST-elevation myocardial infarction (STEMI), directly influencing myocardial salvage and mortality. Despite established guidelines targeting D2B times of ≤90 minutes, significant variability persists globally, indicating systemic inefficiencies across the entire patient pathway.


Aim: This narrative review aims to dissect the interdisciplinary bottlenecks encountered from pre-hospital contact to percutaneous coronary intervention (PCI), and to synthesize evidence-based, system-level optimization strategies for each key touchpoint.


Methods: A comprehensive literature search was conducted across PubMed, Scopus, and CINAHL for studies published between 2010 and 2024, using keywords related to STEMI, D2B, systems improvement, and specific healthcare roles. 


Results: Major bottlenecks identified include delayed field ECG acquisition, ineffective pre-notification, cath lab availability conflicts, interdisciplinary communication gaps, and administrative protocol fragmentation. Effective solutions are multifaceted, centering on pre-hospital ECG transmission, standardized activation protocols, empowering frontline staff (e.g., paramedics, emergency nurses) to activate the cath lab, dedicated inter-disciplinary STEMI teams, and real-time data feedback loops. Human factors, including family dynamics and team coordination under stress, are pivotal yet often under-addressed.


Conclusion: Optimizing the D2B pathway is an inherently interdisciplinary challenge requiring seamless integration of pre-hospital and in-hospital systems. Moving beyond a singular focus on time metrics, a holistic approach that standardizes protocols, empowers cross-disciplinary collaboration, leverages technology, and addresses human elements is essential for achieving sustained improvements in STEMI outcomes.

Keywords

ST-elevation myocardial infarction, door-to-balloon time, systems improvement, interdisciplinary communication, percutaneous coronary intervention
Hakami, F. A., Ghazi Misfer M Alotaibi, Faisal Fuhaid Alshammari, Majed Fuhaid Abki AlShammari, Ayed Obaid AlShammari, Fawaz Obaid AlShammari, … Abdulfattah Ali Ahmed Mobarki. (2024). Optimizing the "Door-to-Balloon" (or "Door-to-Intervention") Pathway: An Interdisciplinary Review of System Bottlenecks and Solutions. Saudi Journal of Medicine and Public Health, 1(2), 2268–2275. https://doi.org/10.64483/202412633
Download Citation
Endnote/Zotero/Mendeley (RIS)
BibTeX
References
  1. Al-Lamee, R., Thompson, D., Dehbi, H. M., Sen, S., Tang, K., Davies, J., ... & Swallow, R. (2018). Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. The Lancet, 391(10115), 31-40. https://doi.org/10.1016/S0140-6736(17)32714-9
  2. Beygui, F., Roule, V., Ivanes, F., Dechery, T., Bizeau, O., Roussel, L., ... & Rangé, G. (2022). Indirect transfer to catheterization laboratory for ST elevation myocardial infarction is associated with mortality independent of system delays: insights from the France-PCI registry. Frontiers in Cardiovascular Medicine, 9, 793067. https://doi.org/10.3389/fcvm.2022.793067
  3. Bonow, R. O., O’Gara, P. T., Adams, D. H., Badhwar, V., Bavaria, J. E., Elmariah, S., ... & Woo, Y. J. (2020). 2019 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: operator and institutional recommendations and requirements for transcatheter mitral valve intervention: a joint report of the American Association for Thoracic Surgery, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons. Journal of the American College of Cardiology, 76(1), 96-117. https://doi.org/10.1016/j.jacc.2019.12.002
  4. Coyne, C. J., Testa, N., Desai, S., Lagrone, J., Chang, R., Zheng, L., & Kim, H. (2014). Improving door-to-balloon time by decreasing door-to-ECG time for walk-in STEMI patients. Western Journal of Emergency Medicine, 16(1), 184. https://doi.org/10.5811/westjem.2014.10.23277
  5. De Freitas, L., Goodacre, S., O’Hara, R., Thokala, P., & Hariharan, S. (2018). Interventions to improve patient flow in emergency departments: an umbrella review. Emergency Medicine Journal, 35(10), 626-637. https://doi.org/10.1136/emermed-2017-207263
  6. Demandt, J. P., Zelis, J. M., Koks, A., Smits, G. H., van der Harst, P., Tonino, P. A., ... & Vlaar, P. J. (2022). Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis. BMJ open, 12(4), e057305. https://doi.org/10.1136/bmjopen-2021-057305
  7. Ellahham, S., Aljabbari, S., Mananghaya, T. H., Raji, S. J., & Al Zubaidi, A. (2015). Reducing door to-balloon-time for acute ST elevation myocardial infarction in primary percutaneous intervention: transformation using robust performance improvement. BMJ Open Quality, 4(1), u207849-w3309. doi: 10.1136/bmjquality.u207849.w3309
  8. Evers, J. M., York, N. L., Owens, H., & Hardin-Pierce, M. G. (2022). Evaluation of Door-to-Balloon Times After Implementation of a ST-Segment Elevation Myocardial Infarction Network. Journal of Cardiovascular Nursing, 37(5), E107-E113. DOI: 10.1097/JCN.0000000000000839
  9. Hull, S. S. (2023). Communication Between Registered Nurse Leaders and Licensed Practical Nurses: A Qualitative Exploratory Case Study (Doctoral dissertation, University of Phoenix).
  10. Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., ... & Widimský, P. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Polish Heart Journal (Kardiologia Polska), 76(2), 229-313. DOI: 10.5603/KP.2018.0041
  11. Inoue, A., Mizobe, M., Takahashi, J., & Funakoshi, H. (2023). Factors for delays in door-to-balloon time≤ 90 min in an electrocardiogram triage system among patients with ST-segment elevation myocardial infarction: a retrospective study. International Journal of Emergency Medicine, 16(1), 77. https://doi.org/10.1186/s12245-023-00562-5
  12. Jacobs, A. K., Ali, M. J., Best, P. J., Bieniarz, M. C., Bufalino, V. J., French, W. J., ... & American Heart Association Advocacy Coordinating Committee. (2021). Systems of care for ST-segment–elevation myocardial infarction: a policy statement from the American Heart Association. Circulation, 144(20), e310-e327. https://doi.org/10.1161/CIR.0000000000001025
  13. Kaddoura, R., Mohamed Ibrahim, M. I., Al-Badriyeh, D., Omar, A., Al-Kindi, F., & Arabi, A. R. (2022). Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials. Plos one, 17(5), e0263270. https://doi.org/10.1371/journal.pone.0263270
  14. Karkabi, B., Meir, G., Zafrir, B., Jaffe, R., Adawi, S., Lavi, I., ... & Shiran, A. (2021). Door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary angioplasty. European Heart Journal-Quality of Care and Clinical Outcomes, 7(4), 422-426. https://doi.org/10.1093/ehjqcco/qcaa037
  15. Kennedy-Metz, L. R., Barbeito, A., Dias, R. D., & Zenati, M. A. (2022). Importance of high-performing teams in the cardiovascular intensive care unit. The Journal of thoracic and cardiovascular surgery, 163(3), 1096-1104. https://doi.org/10.1016/j.jtcvs.2021.02.098
  16. Krumholz, H. M., Bradley, E. H., Nallamothu, B. K., Ting, H. H., Batchelor, W. B., Kline-Rogers, E., ... & Brush, J. E. (2008). A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality. JACC: Cardiovascular Interventions, 1(1), 97-104. https://doi.org/10.1016/j.jcin.2007.10.006
  17. Kunadian, B., Morley, R., Roberts, A. P., Adam, Z., Twomey, D., Hall, J. A., ... & de Belder, M. A. (2010). Impact of implementation of evidence-based strategies to reduce door-to-balloon time in patients presenting with STEMI: continuous data analysis and feedback using a statistical process control plot. Heart, 96(19), 1557-1563. https://doi.org/10.1136/hrt.2010.195545
  18. Lange, D. C., Larson, D. M., Hildebrandt, D., & Henry, T. D. (2017). Creating Networks for Optimal STEMI Management. Manual of STEMI Interventions, 299-314. https://doi.org/10.1002/9781119095446.ch18
  19. Lee, C. K., Meng, S. W., Lee, M. H., Chen, H. C., Wang, C. L., Wang, H. N., ... & Wu, C. C. (2019). The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One, 14(9), e0222019. https://doi.org/10.1371/journal.pone.0222019
  20. León‐Salas, B., González‐Hernández, Y., Infante‐Ventura, D., de Armas‐Castellano, A., García‐García, J., García‐Hernández, M., ... & Trujillo‐Martín, M. M. (2023). Telemedicine for neurological diseases: a systematic review and meta‐analysis. European journal of neurology, 30(1), 241-254. https://doi.org/10.1111/ene.15599
  21. Namdar, P., YekeFallah, L., Jalalian, F., Barikani, A., & Razaghpoor, A. (2021). Improving door-to-balloon time for patients with acute ST-elevation myocardial infarction: a controlled clinical trial. Current Problems in Cardiology, 46(3), 100674. https://doi.org/10.1016/j.cpcardiol.2020.100674
  22. Nathan, A. S., Raman, S., Yang, N., Painter, I., Khatana, S. A. M., Dayoub, E. J., ... & Fanaroff, A. C. (2020). Association between 90-minute door-to-balloon time, selective exclusion of myocardial infarction cases, and access site choice: insights from the cardiac care outcomes assessment program (COAP) in Washington State. Circulation: Cardiovascular Interventions, 13(9), e009179. https://doi.org/10.1161/CIRCINTERVENTIONS.120.009179
  23. Nowbar, A. N., Rajkumar, C., Foley, M., Ahmed-Jushuf, F., Howard, J. P., Seligman, H., ... & Al-Lamee, R. K. (2022). A double-blind randomised placebo-controlled trial of percutaneous coronary intervention for the relief of stable angina without antianginal medications: design and rationale of the ORBITA-2 trial. EuroIntervention, 17(18), 1490. https://doi.org/10.4244/EIJ-D-21-00649
  24. O'gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., De Lemos, J. A., ... & Zhao, D. X. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American college of cardiology, 61(4), e78-e140. https://doi.org/10.1016/j.jacc.2012.11.019
  25. Overmann, K. M., Wu, D. T., Xu, C. T., Bindhu, S. S., & Barrick, L. (2021). Real-time locating systems to improve healthcare delivery: A systematic review. Journal of the American Medical Informatics Association, 28(6), 1308-1317. https://doi.org/10.1093/jamia/ocab026
  26. Paradossi, U., Palmieri, C., Trianni, G., Ravani, M., Vaghetti, M., Rizza, A., ... & Berti, S. (2010). Door-to-balloon time and in-hospital mortality in patients with ST-evaluation myocardial infarction: A network experience in a province in northwest Tuscany, Italy. Giornale Italiano di Cardiologia (2006), 11(5), 386-392.
  27. Patel, M. R., Calhoon, J. H., Dehmer, G. J., Grantham, J. A., Maddox, T. M., Maron, D. J., & Smith, P. K. (2017). ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology appropriate use criteria task force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic .... Journal of the American College of Cardiology, 69(17), 2212-2241. https://doi.org/10.1016/j.jacc.2017.02.001
  28. Peterman, M. J., & Bisgaard, S. (2010). Door-to-balloon time: performance improvement in the multidisciplinary treatment of myocardial infarction. The Journal for Healthcare Quality (JHQ), 32(4), 14-23. DOI: 10.1111/j.1945-1474.2010.00079.x
  29. Rajkumar, C. A., Foley, M. J., Ahmed-Jushuf, F., Nowbar, A. N., Simader, F. A., Davies, J. R., ... & Al-Lamee, R. K. (2023). A placebo-controlled trial of percutaneous coronary intervention for stable angina. New England Journal of Medicine, 389(25), 2319-2330. DOI: 10.1056/NEJMoa2310610
  30. Rodríguez-Pardo, J., Fuentes, B., de Leciñana, M. A., Campollo, J., Castaño, P. C., Ruiz, J. C., ... & Tejedor, E. D. (2020). Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. Neurología (English Edition), 35(4), 258-263. https://doi.org/10.1016/j.nrleng.2020.04.007
  31. Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433. https://psycnet.apa.org/doi/10.1037/amp0000298
  32. Satou, G. M., Rheuban, K., Alverson, D., Lewin, M., Mahnke, C., Marcin, J., ... & Sable, C. A. (2017). Telemedicine in pediatric cardiology: a scientific statement from the American Heart Association. Circulation, 135(11), e648-e678. https://doi.org/10.1161/CIR.0000000000000478
  33. Savage, M. L., Hay, K., Murdoch, D. J., Doan, T., Bosley, E., Walters, D. L., ... & Raffel, O. C. (2022). Clinical outcomes in pre-hospital activation and direct cardiac catheterisation laboratory transfer of STEMI for primary PCI. Heart, Lung and Circulation, 31(7), 974-984. https://doi.org/10.1016/j.hlc.2022.01.008
  34. Savage, M. L., Hay, K., Vollbon, W., Doan, T., Murdoch, D. J., Hammett, C., ... & Raffel, O. C. (2023). Prehospital Activation of the Cardiac Catheterization Laboratory in ST‐Segment–Elevation Myocardial Infarction for Primary Percutaneous Coronary Intervention. Journal of the American Heart Association, 12(14), e029346. https://doi.org/10.1161/JAHA.122.029346
  35. Stone, G. W., Selker, H. P., Thiele, H., Patel, M. R., Udelson, J. E., Ohman, E. M., ... & Ben-Yehuda, O. (2016). Relationship between infarct size and outcomes following primary PCI: patient-level analysis from 10 randomized trials. Journal of the American College of Cardiology, 67(14), 1674-1683. https://doi.org/10.1016/j.jacc.2016.01.069
  36. Wallace, L. A., Schuder, K. K., Loeslie, V., Hanson, A. C., Ongubo, C., Chiarelly, E., ... & Springer, D. (2023). Improving communication in the medical intensive care unit through standardization of handoff format: a quality improvement project. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 7(4), 301-308. https://doi.org/10.1016/j.mayocpiqo.2023.05.006
  37. Wong, G. C., Welsford, M., Ainsworth, C., Abuzeid, W., Fordyce, C. B., Greene, J., ... & So, D. (2019). 2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion. Canadian Journal of Cardiology, 35(2), 107-132. https://doi.org/10.1016/j.cjca.2018.11.031
  38. Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6, 606445. https://doi.org/10.3389/fcomm.2021.606445
Read More
Author biographies is not available.
Download
PDF
Statistic
Read Counter : 60 Download : 254