Exploring Organizational Factors For The Implementation of Strategies To Reduce Door To Balloon Time

EXPERIMENTAL & CLINICAL CARDIOLOGY
Volume 20, Issue 10, 2014

Title: "Exploring organizational factors for the implementation of strategies to reduce door to balloon
time "
Authors: Sajid Haider, Carmen De Pablos Heredero and Antonio Fernandez-Ortiz
How to reference: Exploring organizational factors for the implementation of strategies to reduce
door to balloon time /Sajid Haider, Carmen De Pablos Heredero and Antonio Fernandez-Ortiz/Exp
Clin Cardiol Vol 20 Issue10 pages 6258-6270 / 2014

Exploring organizational factors for the implementation of strategies to reduce door ...
Exp Clin Cardiol, Volume 20, Issue 10, 2014 - Page 6258
Abstract
Background: Although the effectiveness of strategies to reduce door to balloon time has been well
recognized, unfortunately they remain underused. No systematic study exists to address the routine use of
these strategies.
Objective: To identify organizational factors that may facilitate the implementation of strategies to reduce
door to balloon time, as measured by STEMI care professionals opinion.
Method: Both qualitative and quantitative techniques were used. Qualitative study involved site visits,
discussion sessions, and content analysis. Quantitative analysis used summed rank orders and non
parametric statistics.
Results: Qualitative analysis identified nine organizational factors. These factors were further refined in
quantitative analysis. The highest rank was assigned to positive behaviors while the lowest rank was
given to rewards. Five most important factorspositive behaviors, teamwork, committed clinical
leadership, multidisciplinary liaison, and senior managements supportwere identified. The results
indicate that the factors under analysis were ranked significantly different from each other. Kendalls
coefficient of concordance = 0.453, Chi-square = 221.277, and the test result is significant (p-value < 0.01).
Conclusion: Knowledge of strategies to reduce door to balloon time, although important, may not be
sufficient unless they are used in routine. Some specific organizational factors can facilitate the routine use
of these strategies.
Keywords
Percutaneous Coronary Intervention, strategies to reduce door to balloon time, organizational factors

1. Introduction
Cardiovascular diseases (CVDs) are the major cause of global deaths [1]. According to WHO statistics,
CVDs were responsible for an estimated 17.3 million deaths in 2008. These deaths account for a 30% of the
global deaths. CVDs are expected to remain the leading cause of deaths worldwide. Among the CVDs,
coronary heart disease (CHD) is the leading cause of deaths worldwide [1]. In 2008, CHD was responsible
for almost 42.2 % of global deaths caused by CVDs.

Coronary heart disease (CHD) or coronary artery disease (CAD) originates in atherosclerosis, a condition
in which fatty deposits known as plaques build up along the inner wall of blood vessels. As the plaques
grow thicker, the arteries narrow down and it is difficult for heart to pump blood throughout the human
body. Acute Myocardial Infarction (AMI) or heart attack and Angina Pectoris (AP) are two leading
manifestations of coronary artery disease. A more severe type of AMI is ST-segment elevation myocardial
infarction (STEMI) which indicates a relatively large part of the heart muscle death due to complete
occlusion of coronary artery.

There has been a long debate on the optimal therapeutic approach for STEMI [2]. Fibrinolysis and
Percutaneous Coronary Intervention (PCI) are among the common and well established reperfusion
therapies for STEMI. With respect to their impact on patient mortality and morbidity, the efficiency of
these two reperfusion therapies has been well recognized in literature [3]. However, Currently, primary
percutaneous coronary intervention (PPCI) is a preferred method of reperfusion, when it is performed in a [timely
fashion] by an experienced team [4].

PCI is called to be primary PCI when it is the first reperfusion therapy applied after acute coronary
syndromes. In case PCI is performed after the application of other reperfusion therapy such as fibrinolysis,
it is called rescue PCI. After STEMI is recognized, the preference is for PPCI if it can be performed within
guideline recommended time. American College of Cardiology (ACC)/American Heart Association (AHA)
and European Society of Cardiology (ESC) guidelines recommend PPCI as the preferred method of
reperfusion over fibrinolysis, as long as it can be performed within recommended time [5].

Given the time as a major factor in determining the success of PPCI, timely delivery has been identified as
the major barrier to the implementation of PPCI [5]. Delays are related to higher fatality rates in patients
with STEMI treated by PPCI [6]. Due to the time sensitivity associated with PPCI, American College of
Cardiologys (ACC) guidelines have set a 90 minutes gold standard for primary PCI [7]. This 90 minutes
threshold is commonly called as door to balloon time.

Door-to-balloon time is the interval from arrival of the patient at hospital to balloon angioplasty of
occluded coronary artery in cardiac catheterization laboratory (CCL). Door to balloon time is an
internationally recognized quality measure of STEMI care. Door to balloon time refers to a complex
process of STEMI care in which many professional skills are involved.

Despite the clinical importance of prompt PCI, contemporary data suggest that most patients with STEMI
exceed their door-to-balloon times [8]. In the real world phenomena treatment delays are considerably
long to reduce the benefits of this preferred reperfusion strategy [9]. Delays in access to PCI result in
greater infarct size; as the time passes the ejection fraction is reduced which increases the chances of lesser
myocardial salvage [10]. Given the time restrictions associated with PPCI, reducing door to balloon time
has become a challenge for clinicians and managers of coronary care [11].

In order to achieve the recommended door to balloon time, contemporary literature suggests some evidence
based strategies to reduce door to balloon time [12]. These strategies include: 1) Cath Lab (Cardiac
Catheterization Laboratory) activation by emergency medicine physician, 2) activating cath lab through a
single call system, 3) activation of cath lab while the patient is en route, 4) staff arrival in cath lab is
expected within 20 minutes of being paged, 4) an attending cardiologist always at hospital, 6) real time
data feedback to ED (Emergency Department) and cath lab staff.

These evidence based strategies are well recognized hospital/system based best practices for reducing
treatment delays in STEMI care process for the patients undergoing primary angioplasty. These strategies
provide many useful ideas to healthcare organizations for improving the treatment process [11]. There
exists lot evidence in literature about the effectiveness of these practices. The research evidence suggests
that using a greater number of these strategies was correlated with a shorter door to balloon time [12].

Although the effectiveness of these strategies has been well recognized in literature, unfortunately they
remain underused [13]. Bradley and colleagues also identified that the key strategies to reduce door to
balloon time were significantly underused [12]. Their results indicate that only 82 out of 365 hospitals were
using the strategy number one mentioned above. It accounts for 22.5% of the sample. Only 13.7% of the
hospitals were using strategy 2, activating cath lab through a single call system. Activation of cath lab while the
patient is en route was used by 9% hospitals only. In the same way, the use of strategy 4 to 6 was 11%, 3.8%,
and 41.5%, respectively. Their results further indicate that only 2.2% of the sample hospitals were using
four out of six strategies, and only 36% of the hospitals were using one of these strategies. These statistics
indicate that these key strategies are significantly underused.
So, the dissemination of these best practices in routine use is a well recognized challenge [13]. But little
attention has been given to understand how these strategies can be implemented, and the factors
influencing effective implementation remain poorly understood [14,15]. So, in order to enhance our
knowledge about the delivery of these best practices, a rigorous study of implementation is required [16].
We believe, an understanding of how these strategies can be successfully implemented, can provide useful
insights to the hospitals towards a routine use of these strategies.

This research seeks is to explore those factors which can facilitate the implementation of these strategies.
Since the last four decades, attitude toward the appropriate use of evidence into practice has evolved in
many phases; from the era of optimism to the era of information technology and systems engineering
[17,18]. The current era of evidence based practice (EBP) is mainly concerned with the redesigning of
service delivery systems to address the facilitators and barriers for narrowing the gap between evidence
and practice, and is mainly driven by the emphasis on describing the effective ways to change the
behavior of healthcare organizations and service providers [17,18,19]. Given the importance of studying
organizational and professional behavior for the implementation of evidence based practices, the emphasis
on studying organizational contextual factors is emerging in healthcare literature [15].

Looking at this trend in literature, the specific objective of this research is to explore organizational factors
that can influence the implementation of strategies for reducing door to balloon time. Existing literature on
the implementation of evidence based practice explains dozens of organizational factors which explain the
implementation of different EBPs in different contexts. But, unfortunately there exists no research on the
identification of organizational factors for the implementation of strategies to reduce door to balloon time.
So, in order to specify organizational factors that can influence the implementation of these strategies, we
used both qualitative and quantitative techniques. Accordingly, we selected STEMI professionals from five
PCI capable hospitals in Madrid Community of Spain.
2. Methodology
In order to explore organizational factors for the implementation of strategies to reduce door to balloon
time we used both qualitative and quantitative techniques.
2.1. Participants
The participants of the study were sixty one STEMI care professionals from five PCI capable hospitals. The
sample includes heads of interventional cardiology (5), interventional cardiologists (7), senior CCL nurses
(6), CCL supervisors (5), heads of coronary unit (5), clinical cardiologists (6), senior CU nurses (5), CU
supervisors (5), heads of emergency departments (5), emergency physicians (5), and senior emergency
nurses (7). The sample represents experienced healthcare professionals involved in STEMI care.
2.2. Qualitative Analysis
Initially the idea was to invite all participants in a one-day session so that the initial qualitative data on
organizational factors could be collected. However, due to some administrative and time constraints, it
was not possible to call people from all organizations on the same day. Looking at this difficulty, the
participants were approached at their work place. Before visiting a specific healthcare organization, it was
assured that all the participants should be present on that specific day. Average time for each discussion
was about 60 minutes, and there was one discussion session on each site. A brief introduction of the
strategies to reduce door to balloon time was given to the participants. The focus question in all
discussions was what kind of organizational factors can facilitate a routine use of the strategies to reduce
door to balloon time? The original version of this question was in Spanish language. The discussion was
also conducted in Spanish language. All the necessary translations from Spanish to English were
performed by two experts in both languages.
In case of all visits, two researchers were participating for collecting data. Both the researchers were well
trained in all steps involved in AMI care process. One of these researchers played the role of facilitator.
The facilitators task was to generate and facilitate group discussion on the identification of organizational
factors to reduce door to balloon time. The other researcher took important notes and added the discussion
where necessary. All the discussions were summarized on flip chart by highlighting the most
prominent/key factors. As a feedback, the key points of each discussion were shared verbally with the
participants. Any final thoughts from the participants were also included in the flip chart notes.

It took about three months to collect initial data from all selected healthcare professionals. On the
completion of this process, a content analysis was performed. For the purpose of content analysis flip chart
notes were transcribed by an independent transcriptionist. In order to assure accuracy, we compared the
transcribed notes against flip chart notes.
2.2.1. Content analysis
After their accuracy and consistency was checked, the transcribed notes were entered into Atlas.ti for
examining the emerging themes in data. Taking insight from existing research we fulfilled the requirement
of the objectivity of analysis for developing precise categories [20,21]. In this regard we followed a three
step process by using insights from literature [22]. First, we identified some general themes applicable to
the implementation of strategies to reduce door to balloon time. In order to define categories we used
single word descriptors from the data. Each category was determined after capturing all possible but
idiosyncratic interpretations. This step helped to confirm that the discussion question was appropriate for
deriving themes. Second, we tested the consistency and objectivity of categories through sample judgment
process. In this process, we used a random number generator to obtain three samples of responses
generated in the discussion. Based on the general themes derived by the authors, two independent
researchers (judges) categorized these sample responses. In other words, the judges were asked to define a
number of words which could explain a category. The final categories and their corresponding definitions
have been shown in table 1.
Categories Definition
What kind of organizational factors can facilitate a routine use of the strategies to reduce door to
balloon time?
Monitoring and evaluation Evaluation | monitoring | examine | assessment
Rewards Rewards | incentives | recognition
Multidisciplinary liaison Liaison | Networks | linkages | other organizations | other
departments
Teamwork Teamwork | joint effort | collaboration
Positive behaviors Positive behavior | attitude | citizenship | norms
Committed clinical leadership Committed clinical leaders | champions | physician leaders
Flexibility Flexible protocols | decision autonomy
Resources Financial resources | equipment | human resources
Senior managements support Administrative support | senior managements commitment |
senior managements engagement
Table 1. Categories of organizational factors for the implementation of strategies to reduce door to balloon time
Third, we entered each final category into Atlat.ti, and used Wildcards for category search. We used
wildcards by using the definition list compiled by judges. In category search through wildcards a search
expression such as teamwork* | joint effort | collaboration* finds all passages with these words. The
outcomes of this search are the quotations which are also called as category hits [23]. These hits constitute
passages related to a specific category. So, we used paragraphs for examining category hits.
Once the search results were gathered we reviewed them to avoid any misplacement of quotations in a
category. We found only four quotations which were not properly placed. These misplaced category hits
were removed from the corresponding category, and were placed in a suitable category.
2.2.2. Results of content analysis
In content analysis nine final categories were used (see table 2). The central question of discussion was:
What kind of organizational factors can facilitate a routine use of the strategies to reduce door to balloon time? A
total of 167 hits were identified for this question. Table 2 shows that teamwork was discussed the most (15
%) while rewards were mentioned the least (7%). The hit closer to teamwork was positive behaviors (14%). The
next closest hits are clinical leadership (13%), multidisciplinary liaison (12%), and senior managements
support (12%). The content analysis helped identify some initial organizational factors for the
implementation of strategies to reduce door to balloon time.

Categories Total hits Percentage
What kind of organizational factors can facilitate a routine use of the strategies to reduce door to balloon
time?
Monitoring and evaluation 17 10
Rewards 12 7
Multidisciplinary liaison 20 12
Teamwork 25 15
Positive behaviors 23 14
Committed clinical leadership 21 13
Flexibility 15 9
Resources 14 8
Senior managements support 20 12
Total 167 100
Table 2. Frequencies of codes (in number and percentage)
2.3. Quantitative analysis
Taking insights from existing research [22], we administered quantitative analysis by using summed rank
order and a non parametric test. The respondents evaluated nine organizational factors, and ranked each
factor in relative terms with respect to its influence on the implementation of strategies to reduce door to
balloon time. We analyzed these rankings by using Kendalls W or Kendalls coefficient of concordance; a
non parametric test for overall rank differences among different factors in a group of variables. The results
have been shown in table 3.
2.3.1. Results of quantitative analysis
The results in table 3 indicate that the factors under analysis have been ranked significantly different from
each other. Kendalls coefficient of concordance = 0.453, Chi-square = 221.277, and the test result is
significant (p-value < 0.01). Positive behaviors and teamwork have been ranked as first and second
respectively (summed ranks = 139 and 200, respectively). These two factors have been ranked significantly
different from each other. Clinical leadership, feedback, and senior managements support have been
ranked as third, fourth, and fifth, respectively (summed ranks = 214, 232, and 258, respectively). There is
not a significantly high difference between ranks from second to fifth, which indicates that the
respondents consider these factors equally important with a small difference. However, the results
indicate that the relative importance of the factors ranked sixth to ninth is significantly less than the factors
ranked first to fifth. The results suggest that the difference between the factors ranked as first five and last
four is large enough to ignore the factors ranked as sixth, seventh, eighth, and ninth. In other words, it can
be stated that the respondents believe that positive behaviors, teamwork, clinical leadership,
multidisciplinary liaison, and senior managements support are the most important organizational factors
for the implementation of strategies to reduce door to balloon time.
Kendall's Coefficient of Concordance for rank differences among organizational factors
Kendall's coefficient of
concordance (W)
Chi-square df Sig.
0.453 221.277 8 0.000

Rank orders

Organizational Factors
Summed
Rank order
a

Percent
ranked (1)
Percent ranked
in top 3
Percent ranked
in top 5
Positive behaviors 139 (1) 48 84 92
Teamwork 200 (2) 10 66 92
Committed clinical leadership 214 (3) 15 55 84
Multidisciplinary liaison 232 (4) 9 38 87
Senior managements support 258 (5) 10 27 82
Monitoring and evaluation 382 (6) 3 10 26
Flexibility 423 (7) 2 5 11
Resources 424 (8) 2 7 10
Rewards 439 (9) 2 9 16
Table 3: Descriptive statistics and rankings of organizational factors
a
Summed rank order is calculated as follows: (Frequency Rank) for each factor. The total lowest score results in the
highest-ranking (1), while the highest total score results in the lowest ranking (9).
3. Discussion
Our qualitative and quantitative analysis identified several organizational factors which can facilitate the
implementation strategies to reduce door to balloon time. Now we discuss the importance of the most
important five factors.
3.1. Positive behaviors
Among the most important organizational factors, a considerably high rank has been assigned to positive
behaviors of professionals involved in STEMI care. Positive behaviors reflect the organizational members
relationship and the degree of commitment with their organization [24].
Successful implementation of evidence based practices requires the organizational members to fully
participate and put extra efforts [25]. Positive behaviors have the ability to affect clinical staffs willingness
to fully engage in the process of implementation or the use of an intervention [26, 27]. These insights from
literature suggest that positive behaviors of professionals can be very helpful for achieving a routine use of
strategies to reduce door to balloon time.
Achieving door to balloon time requires the participants to adopt a problem solving rather than blaming
behavior [28]. Helping behaviors result in problem solving behaviors in organizations [29]. Helping
behavior makes a worker prevent work related problem of co-workers. Implementation of evidence based
practices requires the participants to exhibit altruism because many problems occur during
implementation that require problem solving efforts [30]. If the there exist helping behaviors in
organizational members, problem solving efforts are expected to take place for successful implementation
of these strategies.
Another form of positive behaviors is conscientiousness which reflects discretionary behaviors of the
employees who are available to go beyond minimum task requirements in obeying rules and regulations,
punctuality, and hard work [31, 32]. This behavior is especially important for cardiac catheterization team
to implement the strategy such as CCL team arrival within 20 minutes. According to clinical implication of
an existing research Patients presenting with AMIs after hours are more likely to be treated with
fibrinolytic therapy than PCI [10]. Some other studies also demonstrated the similar views [33,34,35]. This
is perhaps due to poor response from the cath lab team or delays in hospital arrival that the patient cannot
benefit from PCI whose benefits are well documented [10]. AMI care literature is evident that many times
there comes the need for CCL team during off working hours. CCL team members with conscientiousness
are more likely to respond positively to off duty calls.
3.2. Teamwork
Teamwork has been considered as the second most important organizational factor for the implementation
of strategies to reduce door to balloon time. Teamwork is defined as the ability of a group of people to
work together. Empirical research suggests that strategies to reduce door to balloon time have a
substantial effect on door to balloon time. However, the implementation of these strategies does not take
place in a vacuum. Healthcare professionals from different specialties participate in a complex,
multidisciplinary, and time sensitive process of care which requires a collaborative teamwork between
various care-providers [28,36].
Knowledge sharing is an important element of teamwork [37,38]. In STEMI care of patients undergoing
PPCI, knowledge sharing is important among the participants involved in reperfusion process. For
example; in order to decide for implementing pre hospital triage, knowledge sharing is necessary about
acute coronary syndromes, infarct size, ischemic time, patient history etc. After the implementation of pre
hospital triage EMS members knowledge sharing with coronary unit, emergency department, or CCL
staff about the patient conditions mentioned above will make possible the effective implementation of the
practices like; single call activation, CCL activation while patient is en route, and the activation of CCL
team within 20 minutes. Further, during catheterization the CCL members need to share knowledge about
selection of appropriate artery i.e. catheterization via radial artery, or via femoral or brachial artery [39].
Moreover, catheterization process often requires knowledge sharing on the complications such as
bleeding, pseudoaneurysms, arteriovenous fistula, nerve damage, and arterial occlusion etc. So, teamwork
is expected to enhance the quality of care through successful implementation of strategies to reduce door
to balloon time.
Another important element of teamwork is goal sharing. Goal sharing refers to the members priority to
teams common task over other obligations [37,40,41]. Effective implementation of evidence based
healthcare practices is dependent on the sharing of common goal among all involved [42]. From an
organizational culture perspective, organizations with a culture of sharing common values and goals are
more likely to succeed in their implementation efforts [43].
Mutual respect is another important component of teamwork. Mutual respect is especially important for
teams with highly specialized skills, and different occupational identities and status [44]. Mutual respect in
this case is important because the differences in status and occupational identities serve as a source of
pride, as well as a source of invidious comparison [44]. People working on reperfusion process for
achieving door to balloon times have different status and occupational identities. For example, an
interventional cardiologist has a very different status and occupational identity from an EMS technician or
CCL assistant. However, every ones work is important for implementing these strategies. For example, in
order to achieve a rapid door to balloon time, the contribution of an EMS nurse for obtaining ECG during
the implementation of pre hospital triage is as important as an interventional cardiologists contribution
during catheterization. The existence of distinct occupational identities creates a potential for divisive
relationships, and can hamper the coordination process if disrespect takes place over mutual respect.
Communication is also an important element of teamwork. In order to implement strategies to reduce
door to balloon time, professionals teams require timely and frequent communication for single call
activation, prehospital activation, having the CCL ready in 20 min, and real-time data feedback.
3.3. Clinical leadership
Clinical leadership has been ranked as third most important factor, and is slightly lower than teamwork.
Unlike industrial organizations, the concept of leadership in healthcare organizations is not limited to the
leadership from governing body, and the chief executive officer and other senior managers [45]. Due to the
presence of an organized body of clinical professionals, healthcare organizations have a diffuse leadership
structure [46]. This diffuse structure manifests that the leadership in healthcare organizations may come
from different sources [46,47]. In most healthcare organizations we can find a group of leaders recognized
as clinical or physician leaders [45]. The presence of this group is because the physicians possess a unique
body of knowledge that confers a certain measure of autonomy in clinical decision making [46]. Thus, the
clinical leaders play a critical role in the process of implementation and resource allocation.
Clinical leaders are well positioned to take initiatives for implementation and remove barriers among
individuals and departments [47]. Among the common principles necessary for successful implementation
of TQM/CQI in hospitals, commitment from physician leadership has been considered as a distinct
principle along with the top management commitment [47]. Senior management and physician leaders,
although work together toward a common goal, both groups of leaders use different professional
philosophies during a work process. The common professional philosophy used by senior management
can be explained as the support for quality improvement and the availability of human and technical
resources [48], while the professional philosophy of clinical leaders follows the concepts of presence,
engagement, facilitation, and leading the change implementation [48].
An important distinction between senior management and the physician leaders is that clinical leaders
have the standing to provide clinical supervision and oversight of its members clinical care and
performance [45]. While performing supervisory role, they are well positioned to lead change. This
supervisory role involves them in direct interactions with the clinical staff during the implementation
process. Implementation of evidence based practice takes place majorly through the medical staff who
works under the supervision of clinical leaders. So, clinical leaders are an important organizational factor
for the implementation of strategies to reduce door to balloon time.
3.4. Multidisciplinary liaison
Among the most important organizational factors, multidisciplinary liaison has been ranked number four.
According to Longman dictionary of contemporary English liaison is defined as the regular exchange of
information between groups of people, especially at work, so that each group knows what the other is
doing. In STEMI care with PCI many organizations and departments, such as emergency medical
services, primary care units, emergency department, coronary unit, catheterizations unit etc. are involved.
So, a multidisciplinary liaison is necessary for implementing strategies to reduce door to balloon time.
In the process of STEMI care with PCI there are a number of factors that are beyond the control of
interventional cardiology. For example, activation of cath lab depends much on cooperative behavior of
emergency medical services. Depending on time from symptoms onset to first medical contact (FMC),
EMS has a greater responsibility in identifying STEMI, selecting reperfusion strategy, notifying for CCL
activation, and speedy transfer to receiving hospital. On the hospital end, a rapid response to EMS
notification by activating cath lab and preparing cath lab team puts high responsibility on all involved
from the person who receives the notification to cath lab staff. If the patient comes to emergency
department (ED) by personal means, it is the responsibility of ED team to recognize STEMI as soon as
possible, notify for the activation of cath lab and cath lab team, and rapidly transfer the patient to CCL.
These activities require regular exchange of information, timely and accurate communication [49] with
cardiology unit and interventional cardiology, rapid patient transfer, and trusting behaviors among all
involved in reperfusion process. All this is possible through a good multidisciplinary liaison.
3.5. Senior managements support
Senior managements support has been ranked as fifth most important organizational factor. Senior
managements support refers to the extent to which top management takes interest in implementing these
strategies, and is willing to provide necessary resources and remove barriers. Incentives and support in
staffing issues are especially important when the hospitals seek to implement the strategies such as an
attending cardiologist is always on site and staff arrival in cath lab within 20 minutes of being paged.
Moreover, managing recourses and establishing suitable mechanisms for real time data feedback also
depend on senior managements support. Without a support from senior management, hospitals may face
the shortage of equipment and other resources, and consequently the implementation of these strategies
may become very difficult.
In sum, the results indicate that successful implementation of strategies to reduce door to balloon time will
encompass positive behaviors of professionals involved in STEMI care, teamwork, committed clinical
leaders, multidisciplinary liaison, and senior managements support. These factors are imperative for the
implementation of these strategies. To a great extent, the factors identified in this research are consistent
with earlier conceptualization of the approaches for reducing door to balloon time [28]. However, an
organizational focus specific to the strategies to reduce door balloon time was lacking in literature. We
believe that an appropriate level of organizational factors identified in this research will promote
amenable use of these strategies.
4. Conclusion
Recognizing the fact that most STEMI patients exceed their door-to-balloon times, hospitals are struggling
to reduce treatment delays. Evidence from existing research suggests that the strategies to reduce door to
balloon time have greater ability to reduce treatment time. However, these strategies are underutilized,
and the reason behind this underutilization may be found in the absence of specific organizational factors.
Taking into account the underutilization of these strategies, we conducted this research with the purpose
of exploring organizational factors that can facilitate the routine use of these strategies. The results of this
research suggest that evidence based strategies, although important, may not by sufficient for reducing
door to balloon time. This research contributes to improve understanding of professionals and researchers
about the organizational factors that are important for the implementation of these strategies.
As with any research, this study also has some limitations. This research explored a group of
organizational factors, but a causal relationship between these factors and the implementation of the
strategies to reduce door to balloon time remains to be determined. Future research can use these factors
for examining such relationship. This research was not aimed at testing theory, but to explore
organizational factors specific to the implementation of strategies to reduce door to balloon time. Future
research can use theoretical underpinnings to develop hypothetical relationship between these specific
organizational factors and the implementation of the strategies to reduce door to balloon time. Future
research can also investigate into how these factors can be established in STEMI care organizations.

Acknowledgement
The authors are thankful to Dr. Carlos Macaya, ex-president of Spanish Cardiology Society, and Dr. Javier
Goicolea, the head of interventional cardiology of Hospital Puerta de Hierro for their continuous support
during this research. The authors are also thankful to all the participants of this research.
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EXPERIMENTAL & CLINICAL CARDIOLOGY

Volume 20, Issue 10, 2014

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