By Kim Kiser
How Minnesota doctors and hospitals have led in reducing door-to-balloon time for heart attack patients.
James Mona, D.O., knew he was in for a long night when he began his evening shift in the emergency department at Hutchinson Medical Center at 7 p.m. on April 11, 2007. The area was being hit with what turned out to be the last snowstorm of the season, and the waiting room was full of patients.
Around 7:30 p.m., Mona felt a burning sensation in his chest. Convinced it was heartburn, he took an antacid and kept working.
“One of the nurses said, ‘You look like heck, what’s going on?’” he recalls. “I told her I was having some indigestion, a little burning.”
Mona assured the nurse it wasn’t chest pain. “But that’s what patients often tell us when the come to the ER. It’s not really pain; it’s discomfort, tightness, and sometimes other sensations,” he says. As the only physician in the ER that night, Mona moved on to his next patient.
The mild burning sensation turned into a feeling of tightness. Mona started getting light-headed and sat down at the workstation. At 8:58 p.m., the two nurses on duty insisted the 53-year-old physician have an ECG. When Mona looked at the tracings, he was shocked to learn that he was having an anterolateral ST-segment elevation MI (STEMI).
Mona then did for himself what he’s done for so many of the heart attack patients he’s treated—activated the hospital’s Level 1 MI protocol, the goal of which is to get patients from the ER in Hutchinson to the cath lab at Abbott Northwestern Hospital 60 miles away in Minneapolis in 90 minutes or less.
Mona began giving orders. He directed one of the paramedics to call Abbott to let them know there was a Level 1 MI on the way from Hutchinson and to prepare the cath lab, while the nurses ran through a standard list of questions: Had Mona experienced recent bleeding? Did he have a bleeding disorder? Did he smoke? Had he ever had a stroke? A heart attack? What medications had he taken?
The nurses started an IV and began administering medications from a toolbox specially labeled for Level 1 MIs: four baby aspirin to help preserve blood flow to the heart, nitroglycerin, morphine for pain and to preserve coronary blood flow, oxygen, a half-dose of TNkase to break up the clot, 600 mg of clopidogrel, and three doses of IV metroprolo. They drew blood to test for markers of damage to the heart muscle—troponins, myoglobin, CPK, and creatine kinase myocardial band. A technician took a chest X-ray.
Because of the poor visibility that night, the LifeLink helicopter stationed in Hutchinson was unable to fly, so Mona was transported by ambulance. Despite the snow and icy roads, Mona was in the cath lab at Abbott ready to have a blockage in his left circumflex artery opened 64 minutes after leaving the emergency department in Hutchinson.
The very system that had saved the lives of so many of his patients had just saved his own.
Although James Mona’s story is dramatic, his diagnosis wasn’t unusual. According to American Heart Association (AHA) figures, Mona is one of more than 400,000 people in the United States each year who experience an ST-elevation heart attack, the type caused by sudden total blockage of a coronary artery. Mona was more fortunate than many in that he was treated according to AHA and American College of Cardiology (ACC) guidelines that recommend giving clot-busting drugs within 30 minutes of arrival at a hospital or angioplasty within 90 minutes in order to minimize damage to the heart muscle and improve the odds of survival.
However, despite proven benefits of such treatments, 30 percent of heart attack patients in the United States still don’t receive them, and of those who do, less than half are treated in as timely a manner as Mona. A survey of 365 hospitals by Yale University researchers, the results of which were published in the November 2006 New England Journal of Medicine, showed the average door-to-balloon time—or the amount of time between the patient’s arrival at a hospital with percutaneous coronary intervention (PCI) capability and treatment—was 100 minutes and that few hospitals were implementing time-saving strategies. A study published in Circulation the previous year showed that for patients transferred, it was even worse. The average time was 180 minutes, with less than 4 percent being treated within 90 minutes.
Such findings have made reducing door-to-balloon time a priority for the AHA and the ACC. Last year, the ACC created the national D2B Alliance, the goal of which is to help hospitals with PCI capabilities achieve the recommended time in 75 percent of cases. So far, 900 hospitals have committed to that goal. “It’s the best example of a quality-improvement effort on a national level we’ve undertaken as cardiologists,” says Henry Ting, M.D., vice chair for clinical practice in Mayo Clinic’s division of cardiovascular disease and a member of the alliance’s steering committee. “Although it may not be as eye-catching or glamorous as a new drug, a new stent, a faster CT machine, or a new heart center, this quality-improvement effort can have substantially more impact on a heart attack patient’s chances of surviving.”
But a bigger challenge is getting patients from remote communities to a facility that has PCI capabilities. “We know that PCI is the best therapy for a person who is having a STEMI,” says Tim Henry, M.D., an interventional cardiologist with Abbott Northwestern Hospital’s Minneapolis Heart Institute. “But less than 25 percent of hospitals in the U.S. have PCI availability.”
In order to better serve patients in outlying areas, the AHA launched Mission: Lifeline, one of the objectives of which is to reduce the time it takes to get patients to PCI centers. Mission: Lifeline is promoting the Level 1 MI Program, which was designed by Henry and colleagues and is used at Hutchinson Medical Center and 32 other hospitals in greater Minnesota. Level 1 is a coordinated approach to treatment and transport of STEMI patients in a given area.
Dressed in jeans and looking weary after a long night on call, Henry explains that much of his inspiration for the Level 1 program came from the patients in the far regions of Minnesota he treats through the Minneapolis Heart Institute’s outreach program and from having grown up in Westhope, North Dakota, a town of about 500 near the Canadian border. “My parents are 70 miles away from the closest medical center in Minot,” he explains.
A review of 1,335 patients with a suspected ST-elevation myocardial infarction (STEMI) who were brought to Abbott Northwestern Hospital’s cath lab from community and rural hospitals and underwent coronary angioplasty found that 14 percent had no culprit coronary artery and 11.2 percent had negative cardiac enzyme tests.
Of those patients who did not have a blocked coronary artery, many were women who may have experienced stress cardiomyopathy (see p. 10), patients with new or presumably new left bundle-branch block, and patients who had had a previous myocardial infarction or coronary bypass.
The study’s authors suggested that false alarms may be another quality measure for evaluating STEMI programs.
The findings were published in the December 19, 2007, Journal of the American Medical Association.
Henry had read about coordinated systems that were being used in Denmark and the Czech Republic but was told they could never be replicated in the United States. In those countries, the average distance to a PCI center is about 30 miles, the hospitals own the ambulances, and physicians often go out on emergency calls. Here, helicopters and ambulances are staffed by emergency medical technicians and are independent of hospitals, and patients can be more than 200 miles from the nearest cath lab.
Although patients had long been transferred from other hospitals to Abbott for PCI, Henry found it was usually done on an ad hoc basis, with the average time from arrival at the first hospital to balloon angioplasty at Abbott being three hours. In 2002, he and David Larson, M.D., an emergency physician at Ridgeview Medical Center in Waconia, surveyed all hospitals in the state that didn’t have cath labs and found that one-third of them had no standing protocol for treating patients with STEMI. Of those that did, most didn’t use them. “We felt we needed to develop a standardized approach to treatment of STEMI just like we have for trauma,” Henry explains.
Henry and Larson convened a committee of cardiologists, invasive cardiologists, emergency physicians, nurses, and answering service, pastoral care, cardiac rehab, and security personnel to take a critical look at how they handled STEMI patients. They examined every aspect—from the information they gathered about patients, to the drugs they administered, to the way transportation methods were decided, to the way staff at Abbott were summoned to the hospital when a PCI patient was on the way. They then designed a protocol they believed would get patients from an outlying hospital to Abbott more efficiently while delivering the most effective care possible along the way.
One of the first challenges to making the protocol, which became the blueprint for the Level 1 program, work was to change the decision-making process. Previously, emergency physicians in the community hospitals transmitted ECG results to a cardiologist at Abbott. The cardiologist determined whether the patient was having a STEMI, then ordered the transfer. That chain of events could take 20 minutes to an hour.
Henry had to convince the cardiologists to let the emergency physicians evaluate the ECG and tell Abbott a STEMI patient was on the way. Once notified, cardiologists at Abbott could, with a single page, alert about 20 people including the cath lab team, cardiac rehab team, the charge nurse in the cardiac care unit, pastoral care, and security that a Level 1 MI was on the way.
At the community hospitals, physicians began using a standardized form on which they circle answers to questions about the patient’s history. Nurses administer drugs from a specially labeled toolbox filled with all the medications a STEMI patient needs. The toolbox has saved up to 20 minutes on average, as the nurses don’t have to wait for the doctor to order the drugs or retrieve them from the hospital’s pharmacy. The availability of the toolboxes has also increased use of the right medications. “We went from 50 percent of drugs being given to nearly 100 percent all because of one box or bucket,” says Barb Unger, R.N., director of cardiovascular emergency programs for the Minneapolis Heart Institute, who has been training staff at the regional hospitals.
Before the patient leaves for Abbott, nurses or technicians draw blood. They run tests while the patient is en route, then fax the results to Abbott along with the patient’s history, ECG reading, and information about which drugs were given in the emergency department. When patients are transported by air, they are “hot loaded” (the engine keeps running and the rotors continue to spin) into the helicopter. Hot loading can save up to 14 minutes.
Since 2002, Abbott Northwestern has seen its door-to-balloon time from outlying hospitals drop from about 180 minutes in places such as Waconia. Today, half the patients coming from facilities within 60 miles have a door-to-balloon time of 95 minutes or less; half coming from communities between 61 and 210 miles away arrive in 122 minutes or less. Of those taken directly to Abbott, the median door-to-balloon time is approximately 50 minutes.
Survival rates have improved as well. Data from the Minnesota Heart Survey showed that in 2001 and 2002, six-month mortality for STEMI patients ranged from 12 percent at hospitals with PCI capability to 20 percent at those that did not. A study of 1,692 patients treated at Abbott between March of 2003 and August of 2007, including more than 1,300 who came from hospitals as far as 210 miles away, showed an overall one-year mortality of 7.2 percent.
In addition to saving time and lives, the Level 1 program has also saved money. Hospital stays for STEMI patients brought to Abbott have dropped from an average of five to seven days, to three days. Less than 3 percent of patients need implantable defibrillators, and of those patients age 80 and older, 94 percent return home. “In the old days, if you were over 80, you’d go to the hospital and they’d treat you, but 30 percent of those patients died, and many of those who didn’t ended up in a nursing home,” Henry recalls.
Unger says she and Henry have shared the protocol with 50 other PCI centers around the country and continue to fine-tune it as they learn from those facilities and others about what works and what doesn’t. They are now developing similar protocols for patients with sudden cardiac arrest, abdominal aortic aneurysm, critical limb ischemia, and other conditions that require fast treatment.
In 2004, Mayo Clinic started a second regional program, called the Mayo FAST TRACK for STEMI. Mayo is currently working with 28 hospitals in Minnesota, Iowa, and Wisconsin, all of which are within 150 miles of Saint Marys Hospital in Rochester, which has a cath lab with PCI capability. Ting says that before they started, door-to-balloon time for patients presenting directly to Saint Marys was 98 minutes; it’s now down to 62 on average. And door-to-balloon time for patients coming from area hospitals has dropped from 220 minutes to 107. “Patients are alive because of this,” he says.
Mayo, Abbott, and other area hospitals are also working with first responders to cut door-to-balloon time even further by emphasizing “preactivation.” During preactivation, paramedics, rather than emergency department physicians, can determine whether a patient is having a STEMI based on the patient’s history and ECG reading. They then make the necessary calls to activate the cath lab. Henry and Larson did a pilot with paramedics in Waconia in 2002 and were impressed with the results. “There’s no question that people who are preactivated get here significantly faster than those who are not,” says Henry.
In the last two years, the metro area has seen a push to implement preactivation. Fairview Southdale Hospital, for example, has been working with EMTs from the Edina Fire Department and seen door-to-balloon time decrease by 15 to 20 minutes when they preactivate the cath lab, says Stephen Battista, M.D., an interventional cardiologist with Fairview Southdale. In addition, the hospital has had a 100 percent survival rate for those patients who have come in on calls that used preactivation. “If you have the right ECG in the field, it’s like getting a head start in a race,” Battista explains.
Unger says that in the last year, 98 percent of cases involving preactivation that came to Abbott resulted in patients getting to the cath lab in less than 90 minutes. Mayo began working with ambulance services in Olmsted County in October of 2007. In cases where preactivation was used, Ting says door-to-balloon time dropped from 60 minutes to 30. Furthermore, Ting states, preactivation has changed the rules of the race—the measure of interest is no longer door to balloon, it is first medical contact to balloon, the goal being 90 minutes or less.
The next challenge in the effort to save STEMI patients, Ting believes, is to reduce the time from when a person starts experiencing symptoms to the time he or she has blood flow restored to the heart muscle.
Ting and colleagues have two papers in press that show the average delay from onset of symptoms to arrival at the hospital is two hours in the United States—a number that has not changed in the last decade. “We’ve done many things to shorten door-to-balloon time after a patient arrives at a hospital. Now we need to focus efforts on decreasing symptom onset–to-balloon time,” he says. “We have a tremendous opportunity to improve outcomes and survival by identifying the reasons why patients delay before coming to the hospital.”
James Mona, who did not recognize that his own symptoms were heart pain, agrees that the public needs to be taught that there are a variety of symptoms that may or may not be classic and to call 911 when they experience any of them.
He admits that had he been at home and not at work, his story may not have ended the way it did. “If I, as a physician, wasn’t sure this was cardiac chest pain, and as much as it seemed that it wasn’t, my experience drove home the point that if you get something you think might be angina, even if it might not be, come in.” MM
Kim Kiser is the associate editor of Minnesota Medicine.