Swift system for heart attack care improves treatment

Heart attack patients received lifesaving care up to an hour sooner after an Indiana hospital implemented a novel protocol to rapidly activate the cardiac catheterization lab, researchers reported in Circulation: Journal of the American Heart Association.

Compared to the traditional protocol, patients arrived at the cardiac catheterization lab (cath lab) sooner for artery-opening procedures, had less heart damage and shorter hospital stays. The new protocol also reduced the cost of care.

Patients in the study had a type of heart attack called ST-segment elevation myocardial infarction, or STEMI, which is caused by a completely blocked artery. The quicker a patient with this heart attack has the artery opened, the better the chances are for survival and less permanent damage to the heart.

Currently, the preferred treatment for this type of heart attack is emergency angioplasty, which is also called percutaneous coronary intervention (PCI). In this procedure, which is performed in a cath lab, a thin wire with a tiny balloon on the end is threaded through an artery to the blockage. When the balloon is inflated, it clears the blockage and restores blood flow to the heart. Many times a wire mesh tube, called a stent, also is placed to help prop the artery open and prevent re-blockage.

"The benefit of emergency PCI depends on how quickly a patient receives treatment. However, only about a third of patients in the United States receive treatment within the recommended 90 minutes," said Umesh N. Khot, M.D., lead study author and a cardiologist at Indiana Heart Physicians/St. Francis Heart Center in Indianapolis, Ind.

The time between a patient's arrival at the hospital to the time he or she receives PCI is called the door-to-balloon time. Current American Heart Association/American College of Cardiology guidelines recommend a door-to-balloon time of 90 minutes or less for STEMI patients.

In this study, researchers made two fundamental changes to their STEMI treatment procedures. First, the emergency department physician who first sees the patient activated the cath lab.

"Traditionally, most hospitals require the emergency department physician to contact a cardiologist who comes to see the patient. Only after the cardiologist sees the patient is the cath lab activated," Khot said. "Waiting for the cardiologist before activating the cath lab delays care without any clear benefit."

The second part of the new protocol involved an in-house Emergency Heart Attack Response Team (EHART), consisting of an emergency department nurse, a critical care unit nurse and a chest pain unit nurse. Upon activation of the cath lab by the emergency department physician, this team arrived in the emergency department and immediately moved the patient to the cath lab and prepared the patient for emergency PCI.

"Patients have to wait in the emergency department for the catheterization team members to prepare the cath lab or arrive from home during nights and weekends. We had nurses who were already in the hospitals 24/7 immediately move the patient to the cath lab and start setting up for the emergency procedure," Khot said.

To analyze the protocol, researchers collected door-to-balloon time for 60 STEMI patients undergoing emergency PCI before the new system was implemented and compared them to 86 consecutive STEMI patients treated after the protocol was established.

Median door-to-balloon time decreased by a third overall from 113.5 minutes to 75.5 minutes. It dropped from 83.5 minutes to 64.5 minutes during regular hours and from 123.5 minutes to 77.5 minutes during off-hours. Treatment within 90 minutes increased from 28 percent to 71 percent.

"The strides in transfers between hospitals made by the new protocol are also notable," Khot said. "Nationally, only 4.2 percent of patients transferred between hospitals achieve restored blood flow within 90 minutes. With our new protocol, 62 percent of these patients were treated within 90 minutes, and the median door-to-balloon time decreased by a full hour, from 147 minutes to 85 minutes."

"This study reinforces the importance of the American Heart Association's Mission: Lifeline, a new initiative to improve the quality and speed of care for STEMI patients," 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. "Mission: Lifeline will empower communities to improve their systems of care to bring patients with heart attack to the hospital more quickly. Then it is crucial that the hospital team be prepared for their role in that system once the patient is at their door. Saving time saves lives and that is our ultimate goal."

In addition to improved door-to-balloon time, the study revealed that the size of the heart attack suffered by patients decreased by 40 percent. Faster treatment also resulted in the average hospital stay being two days shorter (falling from five days to three days), and the average hospital costs per admission declined by nearly $10,000, from $26,826 to $18,280.

"Our findings indicate widespread implementation of this simple strategy can substantially improve the quality of care of heart attack patients nationwide while reducing health care costs," Khot said.