The Mayo’s “Fast Track” STEMI protocol decreased the median door-to-balloon time at Saint Marys Hospital (Group A) from 90 minutes to 71 minutes (21 percent improvement), with 75 percent of patients receiving it in less than 90 minutes. For patients from the regional hospitals (Group B), median door-to-balloon time was 116 minutes — including an average 57 minutes for transferring the patient from the regional hospital to Saint Marys Hospital. Twelve percent of Group B patients received angioplasty in less than 90 minutes. Door-to-needle time for patients receiving clot-busting therapy at the regional hospital was 25 minutes, with 70 percent of patients receiving treatment in less than 30 minutes. The Saint Marys Hospital STEMI protocol, adopted in May 2004, includes five strategies:
- All patients with suspected heart attack get a 12-lead electrocardiogram, which a physician interprets within 10 minutes of their hospital arrival.
- The emergency department staff activates the cardiac catheterization lab without waiting for review or approval by a cardiologist.
- A single-call system activates the entire cardiac catheterization team.
- The catheterization lab is fully operational within 30 minutes of activation.
- Staff collect data using a computerized, Web-based database with feedback provided to staff within 24–48 hours.
Staff implemented the regional STEMI protocol in December 2004 at 28 hospitals in Minnesota, Wisconsin and Iowa – 12 from the Mayo Health System and 16 independent hospitals. The regional protocol included the five strategies adopted at Saint Marys Hospital, plus an additional five:
- A standardized selection protocol was developed for choosing clot-busting therapy or PCI as primary therapy to restore blood flow to the heart.
- A single phone call system allows receiving cardiologist (at Saint Marys Hospital) and regional physician to discuss case, activate helicopter transfer and activate the catheterization team.
- A central communication center selected the fastest mode of transfer from three helicopters and ground ambulances, with dispatchers looped into the patient care team.
- The air ambulance transport team developed an innovative “hot load” procedure – helicopter engine is left on and time to pick up a patient from landing to take-off is less than 10 minutes – similar to a Mobile Army Surgical Hospital (MASH) unit.
- Saint Marys Hospital emergency department evaluation was bypassed, with patients delivered straight to the catheterization lab, rather than being re-evaluated by on-site staff.
“We did not simply transfer every heart attack patient for angioplasty,” Ting said. “We wanted to organize a system of care that would deliver the best appropriate therapy according to guidelines to get the right patient to the right hospital with the right treatment.”
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Editor’s Note: The American Heart Association in May launched its Mission: Lifeline initiative to more quickly activate the appropriate chain of events critical to improve the quality and speed of care for STEMI patients beginning even before they get to the hospital. The initiative will facilitate communities across the country to develop systems of care that make patients more aware of the importance of calling 9-1-1 at the onset of symptoms, ensure that local emergency medical services are equipped and trained to use 12-lead electrocardiograms for quickly diagnosing a STEMI and enable activation of the catheterization lab while the patient is in-transport. The program will also explore development of a national certification program for components of the STEMI system of care.
Statements and conclusions of study authors that are published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
Integrated system, rapid transfer offers lifeline for heart attack victims
Heart attack patients received lifesaving treatment quickly when hospitals and communities used an integrated, rapid transfer system to get patients to a facility equipped to perform artery-opening procedures, according to a report in Circulation: Journal of the American Heart Association. “Our aim was to develop a standardized system of heart attack care, which included timely access to artery-opening treatment for patents presenting to either the major hospital with a cardiac catheterization lab or to any one of 30 community hospitals without a cath lab,” said Timothy D. Henry, M.D., lead author of the report and a cardiologist at Abbott Northwestern Hospital in Minneapolis, Minn. Abbott Northwestern Hospital is a 619-bed hospital with a cardiac catheterization lab equipped to treat heart attack patients with the artery-opening procedure called percutaneous coronary intervention (PCI), also known as angioplasty. A major heart attack is when a complete blockage occurs in a coronary artery. This is called an ST-elevation myocardial infarction (STEMI). Doctors treat STEMI patients with either emergency angioplasty or by injecting a clot-busting drug. The time between hospital arrival and treatment is called door-to-balloon time with angioplasty or door-to-needle time with drugs. A shorter door-to-treatment time with either angioplasty or a clot-busting drug increases a patient’s chance of survival. American Heart Association guidelines recommend a door-to-balloon time within 90 minutes and door-to-needle time within 30 minutes. “Angioplasty is preferred over clot-busting drugs for STEMI patients when it can be performed in a timely manner by experienced clinicians,” Henry said. “However, angioplasty isn’t universally available – less than 25 percent of U.S. hospitals are capable of offering it.” Henry and his colleagues at the Minneapolis Heart Institute – 46 cardiovascular specialists at Abbott Northwestern Hospital – developed a regional system of care to:
- Standardize STEMI care throughout the system, using hospital-specific protocols and orders;
- Improve timely access to PCI with first door-to-balloon time of less than 120 minutes (whether they sought care directly from Abbott Northwestern or from a community hospital up to 210 miles away);
- Establish a network for collecting data for STEMI patients who present to rural and community hospitals;
- Implement STEMI quality improvement measures at each hospital that include immediate feedback to both emergency and primary care physicians;
- Improve cardiovascular outcomes in STEMI patients throughout the system.
The refined system of care included elements that have been successful in other hospital systems in the Unites States and Europe, such as:
- The emergency department physician diagnoses STEMI patients and activates the system (patient transfer, cardiologist and cath lab staff) with a single call;
- A specific transfer plan is in place, although the plan might be different for each site;
- Transfer patients are taken directly to the coronary catheterization laboratory, without re-evaluation in the emergency department;
- A back-up protocol is in place for anticipated delays, such as inclement weather;
- Education is ongoing, including immediate and quarterly training with emergency department staff, paramedics, angioplasty lab staff, primary care physicians, etc.;
- A comprehensive feedback plan is developed to monitor progress and quality assurance.
A unique part of the program was that doctors treated every patient the same. Even higher risk patients, such as the elderly and those with out-of-hospital cardiac arrest and cardiogenic shock, were transferred to the primary angioplasty center. Other programs have often used selection criteria that would exclude the sickest of patients from data collection.
“Despite the high-risk patient population, in-hospital mortality was 4.2 percent and median length of stay was three days,” Henry said.
From March 2003 to Nov. 2006, 1,345 consecutive STEMI patients were treated at Abbott Northwestern, including 1,048 transferred from non-PCI hospitals. Transferred patients were grouped into zones based on how far they traveled to get to Abbott Northwestern. Zone 1 patients came from within 60 miles of the PCI center, and Zone 2 patients came from 60–210 miles away. The median door-to-balloon time for patients in Zone 1 was 95 minutes and 120 minutes for patients in Zone 2. Median travel time was 22 minutes from a Zone 1 hospital and 34 minutes from Zone 2.
“We’ve shown that an integrated transfer system can expand the benefits of primary PCI to communities that are up to 210 miles away,” Henry said. “Remarkably, despite a 30- and 55-minute longer time to treatment for Zone 1 and Zone 2 patients compared with those who arrived directly at the PCI center, there was no difference in in-hospital, 30-day or 1-year mortality.”
“The success of this regional system was one of the reasons the American Heart Association used it as a model for Mission: Lifeline, our initiative to develop STEMI systems of care across the country,” said Alice Jacobs, M.D., past president of the American Heart Association, professor of medicine at Boston University School of Medicine and director of the cardiac catheterization lab at Boston Medical Center. “Empowering communities to improve their systems of care will get patients with heart attacks to the hospital more quickly. Saving time saves lives and that is our ultimate goal.”
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Editor’s Note: The American Heart Association in May launched its Mission: Lifeline initiative to more quickly activate the appropriate chain of events critical to improve the quality and speed of care for STEMI patients beginning even before they get to the hospital. The initiative will facilitate communities across the country to develop systems of care that make patients more aware of the importance of calling 911 at the onset of symptoms, ensure that local emergency medical services are equipped and trained in the use of 12-lead electrocardiograms for quickly diagnosing a STEMI and enable activation of the catheterization lab while the patient is in-transport. In addition, the program will explore development of a national certification program for components of the STEMI system of care.
Statements and conclusions of study authors that are published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
NR07 – 1171 (Circ/Henry)
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