Optimized STEMI Pathway for Rapid Door-to-Balloon Times: A Quality Improvement Initiative at Fortis Flt. Lt. Rajan Dhall Hospital

Abstract

ST-elevation myocardial infarction (STEMI) is a time-sensitive cardiac emergency where rapid reperfusion therapy significantly reduces morbidity and mortality. International guidelines recommend achieving a door-to-balloon (DTB) time of ?90 minutes for patients undergoing primary percutaneous coronary intervention (PCI). This clinical audit evaluated the implementation of an optimized CODE STEMI pathway at Fortis Flt. Lt. Rajan Dhall Hospital with the objective of improving DTB compliance from 60% to 100% by March 2025. The project utilized a Plan–Do–Study–Act (PDSA) quality improvement framework focusing on streamlined triage, direct emergency physician-to-cardiologist communication, rapid consent processes, faster cath lab transfer, staff training, and reduction of administrative delays. Data were collected from July 2024 to February 2025 across pre-intervention, intervention, and post-intervention phases. Post-intervention analysis demonstrated substantial reductions in treatment intervals, with DTB time decreasing from 88 minutes to 71.66 minutes. Compliance with DTB ?90 minutes improved from approximately 46% to 97%, with 100% compliance sustained for three consecutive months. The findings highlight that a structured, multidisciplinary CODE STEMI pathway significantly enhances emergency cardiac care delivery and patient outcomes.

Introduction

This study focuses on optimizing the CODE STEMI pathway at Fortis Flt. Lt. Rajan Dhall Hospital to reduce Door-to-Balloon (DTB) time for patients suffering from ST-Elevation Myocardial Infarction (STEMI). Since rapid reperfusion through primary PCI is critical for survival, the goal was to achieve the recommended DTB time of 90 minutes or less and improve emergency cardiac care outcomes.

Aim and Objectives

The primary aim was to optimize the CODE STEMI pathway so that all eligible STEMI patients receive treatment within 90 minutes. Key objectives included:

• Increasing DTB compliance from 60% to 100%.
• Reducing delays in triage, consent, cath lab transfer, and balloon inflation.
• Improving coordination among emergency, cardiology, ICU, admissions, and administrative departments.
• Enhancing patient outcomes and emergency care efficiency.

Methodology

An interventional clinical audit using the PDSA (Plan-Do-Study-Act) quality improvement model was conducted.

• Pre-intervention phase: July–October 2024
• Intervention phase: November 2024
• Post-intervention phase: December 2024–February 2025

The study monitored STEMI patients undergoing primary PCI using:

• CODE STEMI activation systems
• Performance tracking sheets
• Emergency dashboards
• Monthly audit reports

Key indicators measured:

• Door-to-ECG time
• Door-to-consent time
• Door-to-cath lab transfer time
• Door-to-balloon (DTB) time

Pre-Intervention Challenges

Several factors caused treatment delays:

• Poor triage awareness and missed atypical STEMI presentations.
• Delayed ECG and diagnosis.
• Slow consent processes.
• Lack of direct communication between ER physicians and cardiologists.
• Coordination issues between departments.
• Excessive paperwork and financial clearance delays.
• Limited accountability and workflow inefficiencies.

Interventions Implemented

The hospital introduced several improvements:

1. Triage Optimization
   • Staff training and ECG integration into early assessment.
2. Rapid CODE STEMI Activation
   • ER physicians empowered to activate CODE STEMI immediately.
   • Direct ER-to-cardiologist communication established.
3. Improved Consent Process
   • Standardized counseling and faster communication with relatives.
4. Cath Lab Coordination
   • Early cath lab alerts and simultaneous notification of relevant departments.
5. Administrative Simplification
   • Minimal documentation forms and deferred non-essential paperwork.
6. Mock Drills and Training
   • Regular emergency simulations and debriefing sessions.
7. Financial Process Changes
   • Patients transferred to the cath lab without waiting for financial approval.
8. Enhanced Accountability
   • Clear responsibilities and real-time escalation procedures.

Results

The interventions significantly improved performance:

DTB Compliance

• Before intervention: ~46%
• After intervention: ~97%
• Sustained 100% compliance from November 2024 to January 2025.

Remaining Causes of Delay

Some delays still occurred due to:

• Consent issues (25%)
• Procedural complications (10%)
• Financial delays (5%)
• Cath lab unavailability (5%)
• Patient medical instability (5%)

Impact of the Initiative

Clinical Impact

• Faster reperfusion and reduced heart muscle damage.
• Improved survival potential.
• Better patient satisfaction and care experience.

Operational Impact

• Improved coordination among departments.
• Faster emergency response.
• Reduced process variation and delays.
• Better communication and accountability.

Organizational Impact

• Stronger quality improvement culture.
• Greater adherence to evidence-based cardiac care standards.
• Enhanced reputation for emergency cardiac services.

Conclusion

The optimized CODE STEMI pathway at Fortis Flt. Lt. Rajan Dhall Hospital successfully improved door-to-balloon performance and significantly enhanced emergency cardiac care delivery. Through targeted interventions, streamlined workflows, rapid communication, and continuous monitoring, the hospital achieved near-complete compliance with the recommended DTB benchmark of ?90 minutes. This clinical audit demonstrates that structured pathway optimization and multidisciplinary collaboration can dramatically improve STEMI management outcomes, operational efficiency, and patient safety in acute cardiac care settings.

Copyright

Copyright © 2026 Jagdish Singh Negi, Dr. Dheeraj P Arya , Dr. Gurvinder Kaur. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.