The Wall Street Journal
Every second counts for patients receiving angioplasty, a lifesaving treatment for the most serious types of heart attack, in which a catheter with a small balloon at the tip is inserted and inflated to open a blocked artery.
For years widely accepted practice guidelines have recommended getting a heart-attack patient into the cardiac catheterization lab for an angioplasty within 90 minutes of arrival at the hospital. While some hospitals still struggle to meet that standard, it is now considered outdated, as Laura Landro explains on Lunch Break. Photo: University Hospitals Case Medical Center.
There is growing evidence to show that every minute hospitals can shave off “door to balloon” time lowers a patient’s risk of death and serious damage to the heart muscle.
Among the biggest timesavers are sophisticated portable electrocardiograms in ambulances, which record 12 different electrical signals from the heart. More than half of emergency medical systems in an American Heart Association survey reported having the devices in their vehicles, with 35% of those able to wirelessly transmit the results ahead, enabling hospitals to mobilize the cardiac catheterization team before a patient arrives.
Each year, an estimated 400,000 to 500,000 patients have the most serious kind of heart attack, called a “STEMI” (stands for myocardial infarction with St-segment elevation), which is caused by a prolonged decrease in blood supply due to a blocked artery and affects a large area of the heart.
Guidelines developed over the past decade call for hospitals to meet a 90-minute or less time standard for treatment with angioplasty, starting from the moment a patient enters the hospital until the balloon is inflated and blood flow is restored.
Researchers who studied Medicare data from more than 300,000 patients at 900 hospitals found so-called door-to-balloon times fell from a median of 96 minutes in 2005 to 64 minutes in 2010. The best-performing hospitals regularly achieved times under 60 minutes, which “may become the new standard,” the study, published last year in the journal Circulation, concluded.
But hospitals can do even better than that, suggests Harlan Krumholz, the Yale University cardiologist who led the study and whose research has been used to set door-to-balloon time guidelines. “Rather than set a new, lower threshold, we are now saying the time to treatment should be as short as possible, so we treat everyone as quickly and safely as we can.” At Yale, door-to-balloon times have been as low as 14 minutes, he says.
Door-to-balloon times improve when emergency medical services call in or wirelessly transmit ECG results to hospital emergency rooms ahead of arrival, Dr. Krumholz says.
An ECG, which checks for problems with the heart’s electrical activity, is used to distinguish whether a heart attack is the result of a blockage that needs to be opened as soon as possible. With ECG results in hand, the hospital can take additional timesaving measures.
Rather than wait for a cardiologist to review results, which can take a half-hour, ER doctors are making the diagnosis and activating pager systems that scramble cardiology doctors, nurses and technicians with a single call. They are expected to drop what they are doing if in the hospital. During off hours, on-call teams are expected to rush to the hospital, usually within a half-hour, to prepare the cardiac catheterization lab where angioplasty—also known as percutaneous coronary intervention—is done, often followed by placement of stents to keep the artery open.
About 1,100 hospitals are members of the Door-To-Balloon Alliance, launched in 2006 by the American College of Cardiology to provide assistance in meeting the 90 minutes-or-less goal. Patients can check their own hospital’s performance on Medicare’s Hospital Compare website.
University Hospitals Case Medical Center, in Cleveland, began a door-to-balloon improvement project at its Harrington Heart and Vascular Institute after finding it was missing the under-90 minute mark too often.
The medical center’s heart institute donated a wireless transmission system and training worth more than $50,000 to a large EMS systems it works with, to equip more ambulances with portable machines to send ECG results ahead of arrival. The hospital set minute-by-minute goals for individual team members and continues to provide feedback on how well they do for each patient.
The medical center now meets the 90 minute-and-under standard 100% of the time, compared with less than 60% at one point in 2010. Median door-to-balloon time is 47 minutes for patients arriving at the ER on foot or by ambulance, says the institute’s director, Daniel Simon.
Last January, Janice Flint, a 54-year old nursing-home assistant in Cleveland, was feeling what she thought was severe heartburn as she was walking to the bus stop on her way to work. She threw up, and her boyfriend walked her back home.
After she began to feel pain in her jaw, they called 911. Paramedics arrived, loaded her into an ambulance, performed an ECG en route and transmitted the results, indicating a STEMI, to the Case Medical Center emergency department. Within two minutes, doctors there paged the catheterization lab, and staffers were preparing for the procedure.
First, Ms. Flint went to the ER to receive blood-thinner medication, according to Todd Harford, UH Case’s system director of invasive cardiology; then she was sent up to the lab.
A balloon was inflated in her artery within 19 minutes of her arrival, enabling doctors to remove the clot and insert two stents to hold the artery open. Total door-to-balloon time: 35 minutes.
False alarms are a concern. It’s possible a patient rushed to the lab would turn out to have something other than a serious heart attack. At the University of Michigan Health System, a program to improve door-to-balloon performance cut the median time from 67 minutes in 2007 to 55 minutes in 2011. The false-alarm rate increased to 40% of all cases from 15%, according to a study by cardiologist Geoffrey Barnes. Such false alarms can be a drain on staff and a poor use of resources, he says.
The process was modified at the beginning of this year, Dr. Barnes says. Now, if an emergency-room doctor doesn’t have “high suspicion” of a heart attack but still wants another opinion, an on-call cardiologist reviews the case promptly—”without having to activate the entire cardiac catheterization laboratory each time,” he says.
Sahil Parikh, an interventional cardiologist who performs angioplasty at UH Case and is on its 24/7 on-call team, says for every 20 cases he sees one false alarm, including those patients with less-serious heart attacks and those with coronary issues that don’t require an angioplasty. “We always err on the side of caution because we don’t want to risk a heart attack, and most of the time we get it right,” Dr. Parikh says.
Patients often bypass the ER and come directly into the catheterization lab, Dr. Parikh says. If the tables are full they are monitored in the adjacent coronary intensive care unit, where teams start asking questions, administering medications and getting paperwork started.
Patients with other complications, or who need treatment to be stabilized before the angioplasty, don’t count against door- to-balloon time calculations. Delays from staff who hit traffic on their way to the hospital from home do get factored in.
Dr. Harford, the invasive-cardiology director, says while everyone on staff is aware of the importance of saving time, “whether we make it or not, the main thing we are worrying about is saving the patient.”
Write to Laura Landro at email@example.com
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