Improvement Report: Reduce Door-to-Balloon Time for Primary Angioplasty in Emergency Department Patients

Singapore Health Services
Auckland, Singapore


The workgroup members comprised of cardiologists, Emergency Department physicians, nurses and quality management staff:
Kadir HA, Ling ML - Quality Management, Singapore Health Services
Wong P, Kwok B, Chua T, Kwok V, Amat Z, Koh TH - Cardiology, National Health Centre
Rabind AC, Lim SH - Department of Emergency Medicine, Singapore General Hospital

Our hospital offers 24-hour primary angioplasty for patients with acute myocardial infarction. A working committee was set up to identify time taken for individual steps and to institute measures to reduce the door-to-balloon time.
  • To evaluate prospectively the causes of delay for patients with acute myocardial infarction requiring primary angioplasty upon arrival at the emergency department (ED)
  • To institute recommendations to reduce delays and analyse the impact of recommendations to reduce the door-to-balloon time

  • Analysis of individual delay points in the workflow from ED to Cardiac Catheterisation Laboratory (CCL) 
  • Focal group discussion on measures to eliminate delay points to reduce door-to-balloon time


A prospective survey of the door-to-balloon time was undertaken from Oct to Dec 2002. The survey covered 43 patients. Data collected was analysed and the following corrective measures were taken to improve door-to-balloon time:

  • Educated staff on importance of quick response on good clinical outcome.
  • Screened patients for chest pain at ED registration counter.
  • Used clipboard with digital clock for event log from time of diagnosis at ED to arrival at CCL.
  • Synchronised digital clock with clock at CCL.
  • Developed flowchart with timelines for each step of the process to achieve American College of Cardiology/ American Heart Association (ACC/AHA) guidelines for median door-to-balloon time of 90 minutes.
  • Revised survey form to add remark column.



Graph_Median door-to-balloon time (Oct 02 to Apr 03).jpg 


Summary of Results / Lessons Learned / Next Steps
After recommendations were instituted, a survey was conducted from January to April 10, 2003, using revised survey form covering 74 patients. Median door-to-balloon time was reduced from 146 (pre-intervention) to 104 minutes (p<0.01). Primary angioplasty was suspended due to SARS outbreak.

Primary angioplasty for acute myocardial infarction is a multidisciplinary process requiring cooperation and communication between ED and Cardiology staff. Identification of individual delay points by a multidiscipline workgroup using an improved workflow process to improve speed of reperfusion of the infarct-related artery.

Contact Information

Halimahton Kadir


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