One-third of EDs may fail to meet 90-minute target for heart attack patients
ACC offers help to meet guidelines for door-to-balloon times
Noting that only about one-third of hospitals provide emergency care to heart attack patients quickly enough to meet scientific guidelines for saving lives, the American College of Cardiology (ACC) has debuted a campaign called "D2B: An Alliance for Quality," aimed at helping EDs and their hospitals cut an average of 30 minutes off their door-to-balloon (D2B) times by adopting six core strategies:
- Electrocardiogram (ECG) diagnosis of heart attacks in the ambulance.
- A simultaneous page summoning a cardiologist, a surgeon, and other hospital staff.
- Having a cardiologist at the hospital at all times.
- Having ED physicians activate the catheterization surgery room instead of waiting for an on-call cardiologist.
- Expecting staff to be at the cath lab within 20 minutes of being paged.
- Tracking step-by-step performance on each heart-attack case, and reviewing those cases regularly.
The launch was timed to coincide with the on-line publication of a study in the Nov. 13, 2006, edition of the New England Journal of Medicine that looked at D2B times in 365 hospitals nationwide and found a range of between 55 and 120 minutes.1 Some of the six strategies above were practiced by the hospitals with the best times; however, not a single one of the 365 hospitals used all of the strategies.
Meeting the 90-minute guideline represents "an enormous organizational challenge — a relay race with multiple handoffs," asserts John Brush, MD, FACC, a Norfolk, VA, heart specialist who helped the ACC design the new project. "It starts with EMS or with the triage nurse, depending upon how the patient gets there." From that point, he continues, there is the handoff between the triage nurse and the nurse in the back or the ED doctor; then, the ED physician has to hand off to the cardiologist. The cath lab represents still another handoff.
"All of these handoffs need to be simplified and organized," Brush asserts. This simplification is much more a function of effort than of budget, he says. "It does not cost anyone a dime to put in place," he claims. "It will require effort, and somebody's time to make sure it works." It also will require a multidisciplined team to review progress, he says, "but it will not require any new equipment, new drugs, or new facilities."
Many of the six core strategies involve the ED, beginning with communication with EMS, and initial reading of the ECG, Brush says. "It is also the ED physician who activates the cath lab; that's his or her call," he notes. "Then, there is the notification of the interventional cardiologist on call."
What success looks like
Despite the fact that there is clearly room for improvement, there are some facilities that are achieving great success in shortening D2B times. For example, Christiana Care Health System in Wilmington, DE, has achieved an average time of 68 minutes for patients who come in via EMS, according to Robert E. O'Connor, MD, MPH, director of education and research in the Department of Emergency Medicine.
They started addressing the issue in 1999. "We first kept an MI registry, looking for ways to reduce door-to-drug time, but as we ramped up angioplasty procedures, it shifted to door-to-balloon time," he says.
When the Christiana system is working ideally, says O'Connor, events unfold as follows: The patient dials 911 and reports chest pain; the paramedics arrive, conduct a quick assessment, and if it seems they ought to be doing an ECG, they will communicate with the ED over the radio. The ED then initiates the system's Heart Alert program, which notifies the cath lab staff — who may be at home or who may be in the facility. Once the cardiologist is alerted, they have the option of "upgrading" the case for intervention.
O'Connor notes that D2B times are about 15-20 minutes longer if the patient arrives by private car, "because you can't do the ECG in advance." Accordingly, the Christiana care is trying to get the public to call 911. "We are doing it through a public education campaign," he says. This campaign involves Christiana's cardiologists working with family physicians to make sure their high-risk patients are aware of the importance of calling 911. "In addition, any chance we get we will talk to the media about how important it is to use the 911 system," O'Connor adds.
O'Connor says Christiana follows all six of the ACC's recommended core strategies. "We didn't used to have a cardiologist at all times, but now we have cardiology fellowships," he says.
There is also an active quality assurance program in place to monitor compliance with guidelines. For example, it examines the time intervals for the following:
- from symptom onset to "call 911;"
- from "call 911" to when the ECG is done;
- from ECG to arrival at the hospital;
- from ECG to activation of the heart alert program;
- the time it takes to call the cath lab;
- the time it takes to decide whether the patient needs reperfusion therapy;
- when the patient arrives and when they leave the cath lab.
Mortality rates, cardiac enzyme readings and markers also are monitored.
The data is reviewed by the cardiology research department and cardiology fellows, as well as by the emergency medicine department. "The information is then given back to pre-hospital care providers, the ED, and the cardiology performance improvement department," O'Connor says.
Looking to improve
Just because an ED is not yet using all six of the core strategies does not mean it isn't using some successful approaches. For example, the ED at Exempla St. Joseph Hospital in Denver, CO, is meeting the 90-minute goal about 60% to 70% of the time, according to Adam Hill, MD, an ED physician.
Exempla St. Joseph has had the ability to perform ECGs in the field for a long time, notes Hill, who says the program works very well. It is based on a clear set of criteria:
- The patient is between 40 and 75 years of age.
- The patient has typical anginal history for MRI.
- There are at least 2 ml of ST segment elevation and two contiguous leads with reciprocal changes. (The ST segment represents the period from the end of ventricular depolarization — represented by the QRS complex — to the beginning of ventricular repolarization — represented by the T wave.)
- There is no widened QRS. (The Q, R, and S waves on the ECG represent the ventricular activity of the heart.)
- The second paramedic agrees with the first paramedic that the patient meets all the criteria.
When the criteria are met, a call is placed to the "control tech" designated by the ED manager. The patient flow manager assigns the patient a bed. "As long as the cath lab staff is in, the patient rolls through the front door and straight up to the lab with no stopping in the ED," says Hill. "If the cath lab is unavailable or the patient needs resuscitation, they will stop in the ED."
Exempla St. Joseph is looking to meet the rest of the criteria — such as having a cardiologist available 24/7 — and has joined the ACC program to help get up to speed. "We've been working at it for a couple of months and have almost everything in place; we're just in the process of working the bugs out," Hill reports.
Virginia Commonwealth University (VCU) Medical Center in Richmond also has recently updated a successful system. "We have had [field] ECGs in the city since the 1990s," notes Joseph P. Ornato, MD, chairman of the Department of Emergency Medicine, so it's not new to have an alert come in from paramedics.
"What is new at the hospital is that in the last year and a half we have actually put in a formal alert system with a 'gang page,'" says Ornato. This page, he explains, is activated by the physician in the ED. "The cath team and the CCU team are both notified at the same time and start descending on us," he says. VCU has a cardiologist who is at least at the fellow level available 24/7, Ornato adds.
Reference
- Bradley E, Krumolz H, et al. N Engl J Med Nov. 13, 2006; Early On-line Edition. Web: content.nejm.org.
Sources/Resource
For more information on reducing door-to-balloon times, contact:
- John Brush, MD, FACC, Norfolk, VA. Phone: (757) 889-6783.
- Adam Hill, MD, Exempla St. Joseph Hospital, 1835 Franklin St., Denver, CO 80218. Phone: (303) 837-7111.
- Robert E. O'Connor, MD, MPH, Director of Education and Research, Department of Emergency Medicine, Christiana Care Health System, Wilmington, DE. Phone: (302) 733-1000.
- Joseph P. Ornato, MD, Chairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center-AD Williams, Second Floor, Central Wing, Suite 233, Room F235, 1201 E. Marshall St., Richmond, VA 23298-0401. Phone: (804) 828-5250.
- The American College of Cardiology's program, "D2B: An Alliance for Quality," offers participating facilities the ability to share experiences and to collect tools such as standard order sets, critical pathways, and data collection forms, as well as a list of resources. For information on how to participate, go to www.D2Balliance.org.
For more information on how to eliminate waiting times for patients, contact:
Noting that only about one-third of hospitals provide emergency care to heart attack patients quickly enough to meet scientific guidelines for saving lives, the American College of Cardiology (ACC) has debuted a campaign called "D2B: An Alliance for Quality," aimed at helping EDs and their hospitals cut an average of 30 minutes off their door-to-balloon (D2B) times by adopting six core strategies:You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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