Patient Flow E-Newsletter
Volume 4, Issue 1
February/March
Special Focus Issue-Improving Cardiac Care
When the Centers for Medicare & Medicaid Services' (CMS) door-to-balloon performance measure for heart attack patients with ST-elevation myocardial infarction (STEMI) changed from 120 minutes to within 90 minutes in 2006, hospitals across the country took notice. Emergency department (ED) and cardiology teams were already struggling to meet the previous guideline of 120 minutes.
Like many hospitals, Duke University Medical Center receives STEMI patients that have been transferred from hospitals that cannot perform percutaneous coronary intervention (PCI). While time spent at a non-PCI hospital is not included in the publicly reported measure, Duke recognized that excessive time delays existed before the patient received appropriate reperfusion treatment.
In 2003, Duke conducted a survey of surrounding non-PCI hospitals to determine the total first door-to-balloon time for these STEMI patients first door-to-balloon time. The results were alarming - the median door-to-balloon time was approximately 180 minutes and at least half of that time patients spent waiting to be transferred in the ED at a non-PCI hospital. No system was in place to coordinate rapid transfers to Duke's catheterization lab. This delay not only affected the patient needing PCI, but also diverted resources and provider attention from other patients needing care in the ED of the non-PCI hospital, slowing throughput overall.
"There are amazing systems in cities and regions to manage the transfer of trauma patients efficiently to the most appropriate hospital for the level of care needed," said Mayme Lou Roettig, R.N., M.S.N., executive director of Reperfusion of Acute MI in Carolina Emergency departments (RACE). "Yet we do not have a comparable system in place to triage and transfer STEMI patients, who make up about 40 percent of all heart attack patients."
(See RACE Description)
"The pre-RACE system at Duke for handling transfer STEMI patients was cumbersome and inefficient. Sometimes the non-PCI hospital ED physician would call Duke's CCU, the ED, a cardiology attending they knew personally, bed control or Life Flight. Whoever they accessed at Duke would then page the cardiology fellow on-call. Once the on-call cardiologist returned the call to the non-PCI hospital, the two hospitals would determine the best way to coordinate the patient's care and transfer," said Roettig. "Only after all of this happened would Duke call in the cardiac catheterization team to receive the patient. STEMI patients were basically caught in a butterfly net; they were trapped or stuck in the non-interventional ED, awaiting transfer, while their heart muscle was potentially dying."
In a one year period (2003-2004), Duke was able to reduce its median door-to-balloon time for STEMI transfer patients from 180 minutes to less than 120 minutes. Achieving this 33 percent reduction in door-to-balloon time meant working with their surrounding non-PCI hospitals and EMS as well as making changes within Duke itself.
New protocols included:
- Supporting reperfusion decisions from ED physicians at non-PCI hospitals to improve transfer times;
- Creating a toll-free single activation telephone number, "the hotline" for ED physicians at non-PCI hospitals to directly access Duke Cardiology, activate the cath lab, & coordinate transfers between non-PCI hospitals and Duke;
- Having the catheterization lab available 24 hours a day so the lab is ready to perform PCI within 30 minutes after receiving the Code STEMI alert;
- Designating a direct transfer route and elevator from the Duke ED reception area to the cath lab;
- Standardizing the protocol/STEMI order set and most efficient method of transfer options at non-PCI hospitals.
Building on Duke's success, a consortium of the state's health care providers established the RACE program in the Spring of 2005 under a two-year grant from Blue Cross and Blue Shield of North Carolina. Leadership within the consortium took the lessons learned from the Duke experience and developed a manual of recommended changes to care for STEMI patients that involves multiple stakeholders including EMS, critical care transport teams, non-PCI hospitals, and PCI hospitals. (See the RACE Point of Care Operations Manual)
Novel time-saving processes include:
- Utilizing local EMS whenever available to transfer within 50 miles of the PCI hospital;
- Keeping EMS-delivered patients suspected of STEMI on the EMS stretcher and monitoring leads at the non-PCI hospital so that they are ready to be placed back in the original EMS ambulance for transfer when the ambulance is available;
- Standardizing Code STEMI kits (including medications, IV quick start materials, orders, etc.);
- Avoiding IV continuous medication- thus eliminating pumps and tubing changes.
Advanced Modalities:
- Providing EMS the capability to bypass non-PCI hospitals when a PCI center is within time-to-treatment goals;
- Allowing paramedics to utilize prehospital ECG to activate Code STEMI and call in the cath lab team.
The Phase 2 experience has grown from Duke's referral system to establish five regions across the state, representing nearly three-fourths, of North Carolina's acute care facilities. This includes 10 PCI hospitals and 58 non-PCI hospitals across the state. Each region consists of networks of EMS, non-PCI hospitals and PCI hospitals. In Phase 3 of the project, starting later this year, cardiac care for STEMI patients will be regionalized throughout the state of North Carolina.
Ms. Roettig said that it has been a remarkably smooth process considering that RACE requires competing hospitals that share referrals from the same hospitals to work together. "We found that non-PCI hospitals are eager to have protocols and a workable system in place. They know that they cannot provide the level of care that all STEMI patients need (particularly those who are fibrinolytic ineligible and those in cardiac shock), so they want these patients to get to a location quickly where they can receive the appropriate care," she said. "By transferring STEMI patients more efficiently, non-PCI hospitals are better able to respond to their other patients' needs as well." If referrals are shared, each PCI center's hotline number is listed on the non-PCI hospital RACE poster. (See the RACE poster)
RACE staff created a form for the RACE Regional Coordinators to collect data on the timeliness of care provided during pre-RACE implementation at the non-PCI hospitals and one year after the project. This form allows hospitals to measure their success throughout the RACE intervention. The pre-RACE data from 55 non-PCI hospitals across North Carolina yielded similar delays as the Duke experience. The median time the STEMI patients remained in the non-PCI ED from first door in to first door out was a median time of 89 minutes.
(See the Referring Hospitals Collection Form)
RACE consortium leadership recognized that the availability of PCI hospitals varies across North Carolina and that one model would not work for the whole state. The consortium developed two models of care. There is the urban model, which focuses on transfer. In this model, EMS can bypass non-PCI hospitals or the non-PCI EDs can quickly triage and move patients to the PCI center. The rural model allows non-PCI hospitals to give patients fibrinolytics if the patient is eligible. If the patient is reperfused with fibrinolytics, the non-PCI hospital may either urgently transfer the patient to the PCI center's CCU ('drip & ship') , or let the patient rest overnight and then transfer them the next morning to a PCI hospital. There are several non-PCI centers that perform 'elective' PCI. If the patient rapidly reperfuses with fibrinolysis, they may be admitted and intervened on in an elective fashion the next day. Predominantly in North Carolina, the drip and ship method if used at the rural non-PCI centers.
If the patient is not eligible for fibrinolytics or fibrinolysis fails, the patient is transferred to a PCI hospital immediately.
"Our ultimate goal in meeting the 90-minute guideline is what we call the '30-30-30 approach.' That would mean we have 30 minutes from door in at a non-PCI hospital to door out, 30 minutes to transfer the STEMI patient to a PCI hospital and 30 minutes to get them into a cath lab and have a balloon up," said Roettig.
With a program that is now nearly statewide, North Carolina's RACE Program is sharing lessons learned along with a handful of other metropolitan regions that have adopted similar code STEMI programs. Atlanta, Boston and Los Angeles have each established city-wide programs and Texas is in the early stages of establishing a state, RACE-like approach. Minneapolis has established a regional transfer program as well. Efforts like the RACE program are working to improve the survival rates of patients rushed to the hospital with a heart attack and establishing innovative triage and transfer methods to better address patient flow.
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Mayme Lou Roettig, R.N., M.S.N.
Executive Director of RACE
Reperfusion in AMI in Carolina Emergency Departments
Duke University Medical Center/Duke Clinical Research Institute
Durham, North Carolina
