Improving Door-to-Balloon Times in STEMI: A Review of Quality Improvement Initiatives Across Healthcare Systems

ST-segment-elevation myocardial infarction (STEMI) remains a time-sensitive cardiovascular emergency in which treatment delays substantially worsen outcomes. Door-to-balloon (D2B) time has become a central quality metric, reflecting the efficiency and coordination of systems of care. This review synthesizes evidence from registries, guideline statements, and multicenter quality improvement (QI) initiatives aimed at reducing D2B times. Prehospital strategies, such as field electrocardiogram acquisition, direct catheterization laboratory activation, and emergency medical services bypass protocols, consistently shorten reperfusion delays and improve survival. Within emergency departments, structured STEMI alert pathways, fast-track triage, standing orders, and parallel workflows accelerate diagnosis and activation. In-hospital models emphasizing standardized pathways, cath lab readiness protocols, interdepartmental collaboration, and simulation-based training improve both mean D2B performance and variability across sites. Digital interventions, including electronic health record alerts, real-time dashboards, artificial intelligence-assisted electrocardiogram interpretation, and mobile communication platforms, further streamline workflows and reduce delays. Persistent barriers remain, including staffing shortages, lack of interoperability, and variable adherence to standardized protocols. Future directions include adaptive QI tailored to institutional capacity, integration of predictive analytics and wearable technologies, and a shift toward patient-centered outcomes such as tissue-level perfusion and long-term survival. Collectively, these strategies highlight the importance of system-wide coordination, innovation, and continuous QI in achieving durable improvements in STEMI care.