When a person has a heart attack, time is of the essence. Every minute that the heart muscle is deprived of oxygen increases the risk of permanent damage and death, so the faster a hospital team can find the source of the problem and restore blood flow, the better.
But not everyone with chest pain is suffering a myocardial infarction. And even those who are require different treatments depending on the type of heart attack. Some do best with drugs; for others, an emergency angioplasty is the best response.
For those patients, the Joint Commission, which accredits hospitals, set a goal in 2006: The angioplasty should start within 90 minutes of arrival – a standard known as “door to balloon time,” a reference to the balloon inserted with the catheter to find and unblock the artery.
Nationally, when the goal was set, fewer than half of patients who needed emergency angioplasty were getting it within the target time. Now Rhode Island Hospital, which just four years ago fell far short of the standard, is being used as a national model for how to attain it.
Aiming to help its members to improve care, VHA Inc., an alliance of nonprofit hospitals and other organizations, began in January to issue “blueprints” of exemplary work done at specific institutions that can be replicated at other facilities.
One such blueprint, issued in February, shows how Rhode Island Hospital dropped its door-to-balloon times from more than 120 minutes for almost two-thirds of patients in 2004, to under 90 minutes for 94.3 percent of patients by mid-2007.
That put the hospital in the top 10 percent of hospitals nationwide on this measure, and Dr. David O. Williams, chief of interventional cardiology, said it’s dropped more with a catheterization lab inside the new emergency department, to an average of about 60 minutes.
Williams spoke recently about the hospital’s efforts at the American College of Cardiology annual meeting in Chicago. And in January, Williams and his colleagues hosted a two-day visit from VHA Inc. leaders, including chief medical officer Dr. Trent Haywood, to gather data for the “blueprint,” which they followed up with a presentation by the Rhode Island Hospital team at VHA’s annual meeting in Orlando.
In an interview, Haywood said the hospital’s work in this area stood out among VHA’s 1,400 member hospitals, “and we’re always excited to explore and learn from top performers and share that throughout our network” to help others achieve similar results.
So how did Rhode Island Hospital do it?
For starters, it made angioplasty – or percutaneous coronary intervention, as doctors call it – the standard treatment for patients with the type of heart attacks for which it’s advised: ST-segment elevation myocardial infarctions. (The alternative is drug treatment, which is still recommended when there’s been a substantial delay between the heart attack and treatment.)
By setting that standard, said Nancy Towers, nursing director of the emergency department, the hospital “focused everyone’s attention.” The question became how to identify patients who’d need angioplasty as quickly as possible, and minimize the time to treat them.
The next step was to figure out where the delays occurred, and that brought together two teams that barely used to cross paths: the emergency-room doctors and nurses, and the cath lab doctors and nurses. They soon realized that differences in how they worked were delaying treatment, Towers said: For example, ER nurses usually insert IVs inside the bend of the elbow, but in the cath lab, the arm is folded behind the head, so the nurses were having to move the IVs. They also used a different kind of tubing for IVs.
Now, for heart-attack patients, everything is done exactly as it will work for the cath lab, Towers said. The details are printed on hot-pink paper in every treatment area.
The system for activating the cath lab team also changed. Every chest-pain patient gets an electrocardiogram upon arrival in the ER, and ST-segment elevation shows up in the EKG, but a cardiologist used to have to validate the diagnosis before the cath lab team was called in.
Now the ER doctors are trained to make that judgment themselves, Williams said. And there’s a one-page call system that activates the entire angioplasty team, which in turn has committed to arrive within 30 minutes of being paged. The three measures combined cut door-to-balloon times by more than 40 minutes.
The next step is to cut times even more by identifying angioplasty patients even before they arrive at the hospital. Many chest-pain patients get EKGs on the way to the hospital, but those test results are generally not shared with the ER team, Williams said. Now, following the lead of an American Heart Association initiative called Mission: Lifeline, the hospital is working to get EKG data from rescue units, starting with the Warwick Fire Department.
“That is a system that has been used successfully elsewhere,” Williams said. “That’s the way it’s done in Boston … and we’re trying to get that initiated here.” •
