GUIDELINES ISSUED IN 2008 held that hospitals should offer acute MI patients percutaneous coronary intervention (PCI) in 90 minutes or transfer them to another hospital. That led many experts to wonder how many hospitals would be able to improve their door-in-door-out times.
That’s particularly a problem because fewer than one-third of U.S. hospitals can perform PCI. To no one’s surprise, less than 20% of the 3,800 or so U.S. hospitals that don’t provide PCI in-house ever hit that 90-minute transfer target.
But three years after the guidelines were issued, hospitals in North Carolina have found a way to beat those bad odds by joining a statewide network focused on STEMI patients. More than 120 of the state’s hospitals belong to the RACE network (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) and use protocols to speed up transfers for these patients from non-PCI hospitals to PCI-capable facilities.
As a result, North Carolina hospitals have slashed their door-in-door-out times to an impressive 45 minutes, says Seth Glickman, MD, MBA, assistant professor of emergency medicine at the University of North Carolina, Chapel Hill. That’s down from a pre-intervention median of 97 minutes.
One number to call
Participants in the network have each created a hospital-wide reperfusion protocol for all STEMI patients, which typically includes fibrynolitic therapy, transfer to a PCI-capable hospital or a combination of the two. The program urges its member hospitals to use a series of care processes, eight of which are designed to speed cardiac transfers and were evaluated in a study published this summer in the July 28 issue of Circulation: Cardiovascular Quality and Outcomes.
According to Dr. Glickman, one of the most important processes is having a central phone line that EMS, ED and hospital personnel can call when providers decide that a patient is having a heart attack. Once the central phone operator learns that a PCI patient needs to be transferred, a protocol kicks in to notify the receiving hospital, start up that cath lab or other treatment services, and prepare for the patient’s arrival.
“Before they would have to pick up the phone, identify a cardiologist, work through the transfer process,” Dr. Glickman explains. “The cardiac cath lab might not have been notified immediately.”
Various members of the network play different roles. Rural hospitals without PCI capability, for example, focus on identifying STEMI patients and preparing them for transfer. Urban and university medical centers, on the other hand, focus more on facilitating communication from rural hospitals, preparing to receive patients and getting treatment started faster.
Staying on the stretcher
Once patients arrive in the emergency room of a non-PCI hospital, several arms of the protocol help shave valuable minutes off transfer times. One of the most critical is also the simplest: Patients remain on the EMS stretcher they arrived on.
It may seem obvious, but transferring the patient to a hospital bed, attaching leads to new monitors and adjusting tubing for IVs can all take precious minutes. That’s especially true, Dr. Glickman notes, when all of that needs to be reversed to put the patient back into an ambulance for transfer.
Another crucial step in the ED is getting an ECG of the patient within 10 minutes. That ensures that the patient’s status has been properly identified and provides data to send immediately to the receiving hospital.
But the linchpin of the RACE protocols, Dr. Glickman points out, is training EMS teams to identify STEMI patients faster. The parts of the protocol that target EMS teams reduced median transfer times by about 30 minutes, according to the Circulation study.
EMS companies participating in the network during the study installed 12-lead ECG machines in their ambulances to be used on patients with chest pain. They also trained EMS paramedics to recognize ST-elevations on ECG readouts so they can identify true STEMI events.
“It provides early notification to the hospital that a patient is coming in with a heart attack,” Dr. Glickman says. That in turn triggers the other RACE protocols.
If the data from the ECG are clear, EMS teams can transport patients directly to the nearest PCI-capable health center instead of a local hospital. “They used to communicate with local hospitals to alert them to an incoming patient who might need a transfer,” says Dr. Glickman. “Now, EMS teams are bypassing some rural hospitals and going straight to the PCI-capable facility.”
EMS workers also are trained to recognize less obvious heart attack symptoms, such as nausea or dizziness.
No network? No problem
Even if hospitals can’t participate in the type of formal network created in North Carolina, Dr. Glickman says that there are steps facilities can take to speed up the transfer process. A big first step is identifying hospitals within 50 miles of your own that can perform PCI. Setting up a channel of communication exclusively for transfers “a central number or a single point of contact, for example “is another key factor.
But another important step is establishing solid relationships with EMS services in your area and working with them to create protocols to identify and transfer STEMI patients. Dr. Glickman says that those protocols should arrange for local EMS to keep patients on their stretchers. Protocols should also direct EMS to transport patients to the nearest PCI-capable facility if patients meet certain clinical parameters.
One unexpected outcome of the RACE protocols and other national efforts has been a focus on a new benchmark for STEMI transfers: “first medical contact to balloon time.” The clock starts ticking when patients first encounter a clinician or paramedic in the field and stops when patients undergo angioplasty, Dr. Glickman explains.
While transferring STEMI patients within 90 minutes may sound ambitious, he insists it’s achievable. That’s particularly true as EMS teams get better at identifying early signs of a STEMI event and are given the green light to take STEMI patients directly to where they need to go.
Sara Jackson is a freelance health care writer based near Richmond, Va.
Published in the December 2011 issue of Today’s Hospitalist