Hundreds of hospitals around the country are joining the most ambitious project ever undertaken to give faster emergency room care to people suffering major heart attacks.
Fewer than one-third of such patients now get their blocked arteries reopened within 90 minutes of arrival, as guidelines recommend. The risk of dying goes up 42 percent if care is delayed even half an hour longer.
“There’s a very, very large opportunity here to improve patient care,” said Dr. John Brush, a Norfolk, Va., heart specialist who helped the American College of Cardiology design the new project, which is to be launched Monday at an American Heart Association conference in Chicago.
Jim Kern, 47, of Norfolk, experienced both extremes. When he had his first heart attack on Aug. 22, he endured excruciating pain while filling out mundane paperwork and waiting as triage nurses changed shifts. It took nearly four hours to get proper care.
When he had a second attack on Oct. 30 — after the hospital adopted new rapid-care measures — doctors “were there within 15 minutes of the time I hit the door and were already starting to do the prep,” Kern said. “The attention and everything I was given was a difference of day and night.”
Major medical groups and government agencies have endorsed the project, including the National Heart, Lung and Blood Institute, whose director, Dr. Elizabeth Nabel, called it the biggest heart care initiative since paramedics were trained to do CPR in the early 1990s.
It targets heart attacks caused by a total or near-total blockage of a major artery that prevents enough oxygen from reaching the heart tissue. About a third of the 865,000 heart attacks in the United States each year and 10 million worldwide are of this type.
The preferred remedy is angioplasty, in which doctors snake a tube through a blood vessel in the groin to the blockage. A tiny balloon is inflated to flatten the crud, and a mesh scaffold called a stent usually is placed to prop the artery open.
Door to balloon in 90 minutes
Guidelines have long called for a “door-to-balloon” time of 90 minutes, “but we just haven’t engineered our emergency rooms to cut out some of these steps that aren’t needed” and cause delays, Nabel said.
With funding from her agency, Yale University researchers Elizabeth Bradley and Dr. Harlan Krumholz surveyed 365 hospitals and found six measures that consistently helped, and the average time they saved:
- Letting ER doctors activate the catheterization lab and prepare it for angioplasty instead of waiting for a cardiologist to review a case and decide what to do (8.2 minutes).
- Establishing a one-call system so a central operator pages an angioplasty team instead of having ER staff hunt down phone numbers and individual doctors on call (13.8 minutes).
- Having the ER activate the cath lab when paramedics alert them that an electrocardiogram done in the ambulance shows the patient is suffering a heart attack (15.4 minutes).
- Expecting staff to be at the cath lab within 20 minutes of being paged (19.3 minutes).
- Having a cardiologist on site at all times (14.6 minutes).
- Giving immediate feedback to the staff on how they did on each case (8.6 minutes).
Hospitals participating in the campaign pledge to get fast care to patients and to generally follow such steps. Most involve internal procedural changes and little cost, say doctors connected with the campaign.
“If each one cuts out 5 minutes here and 10 minutes there, it starts to add up,” Brush said.
The early action to call in staff and activate the cath lab resulted in very few false alarms — one or two every six months, researchers found.
Also, steps like having paramedics do EKGs on the way to the hospital turned out to matter less than what hospitals did with the information.
Hospitals now are wasting too much time summoning too many people to consult on a case before starting treatment, Bradley said.
Too many cooks in the kitchen
“You can imagine all those calls and all those people involved,” she said. “Our recommendation is to allow the emergency room physician to decide” and assemble a team, “and they should be able to do it with one single call.”
Study results were published online by the New England Journal of Medicine and will appear in its Nov. 30 print edition.
About 1,250 of the 5,000 hospitals in the United States do emergency angioplasties and are being invited to join the campaign. Dozens of hospitals in Europe and North and South America also have expressed interest.
“We want to take the level of performance that is now only exhibited by a minority of hospitals and make it what is found everywhere,” Krumholz said.