Science - January 2009
Tex Med . 2009;105(1):45-47.
By Ken Ortolon
John Galindo walked by the poster hanging outside a colleague's office every day but never stopped to ask what it meant. "It said STEMI in big ol' letters on there," said Mr. Galindo.
One Saturday afternoon last March, he found out the hard way what STEMI means. While mowing his lawn, he suffered a heart attack. The paramedics who rushed him to the hospital had a 12-lead electrocardiogram (EKG) onboard their ambulance and quickly determined he was having a STEMI, an ST-elevation myocardial infarction, the most severe type of heart attack. Within an hour of Mr. Galindo's arrival at the hospital, a cardiologist was inserting coronary stents in two blocked arteries to restore blood flow to his heart.
Mr. Galindo, who ironically works as a customer service manager for the South Central Affiliate of the American Heart Association (AHA), was lucky. According to AHA, more than 100,000 STEMI patients annually fail to receive the best available treatment to restore blood flow to the heart. In summer 2007, AHA launched an initiative called Mission Lifeline to change that.
Texas is one of a handful of states in which Mission Lifeline is being piloted. Loni Denne, RN, BSN, senior director of Mission Lifeline for the AHA South Central Affiliate, says AHA chose Texas because of the amount of STEMI initiatives already under way in Austin, Houston, Corpus Christi, San Antonio, Temple, and other Texas cities.
The American College of Cardiology (ACC) also is on the attack against STEMI. In 2006, ACC launched D2B: An Alliance for Quality to help hospitals cut their "door-to-balloon" times for STEMI patients. Door-to-balloon time is the amount of time it takes from the moment a patient arrives at the hospital until blood flow through a blocked artery is restored through balloon angioplasty or percutaneous coronary intervention.
Throwing a Lifeline
ST-elevation myocardial infarction gets its name from a waveform that shows up clearly on an EKG. For patients suffering a STEMI, time is of the essence.
"From the moment that it's identified as a STEMI, we want things to move very quickly because the rate of mortality goes up drastically the longer we delay getting the patient definitive treatment," said Ms. Denne. "The American Heart Association has recognized that we have a lot of work to do to raise awareness about STEMI and to ensure that every single system involved in the care of the STEMI patient has a process in place so that expedient care happens."
Gregory Dehmer, MD, chief of the Cardiology Division at Scott & White Hospital in Temple, says that by 2003 an abundance of research data clearly showed that angioplasty was superior to fibrinolytic therapy for treating acute myocardial infarction.
"It clearly moved to the forefront then," Dr. Dehmer said. "But even as that was beginning there were key data from different sources in the United States that showed we were not doing it fast enough. This is really a situation in which time does equal muscle."
The goal of AHA's Mission Lifeline is to build a network of STEMI care systems across the country capable of providing a coordinated approach to STEMI care that will speed door-to-balloon times and improve patient outcomes. That also is the goal of ACC's D2B initiative. Both organizations recommend that hospitals create systems allowing them to perform balloon angioplasty and restore blood flow to the heart in under 90 minutes after a patient gets to the hospital. D2B's goal is to meet that timeline in 75 percent of cases nationally.
Austin interventional cardiologist Robert Wozniak, MD, says that requires a systems approach involving emergency medical services (EMS), hospital emergency department physicians and nurses, catheterization laboratory teams, and the cardiologists.
"We're looking at this as a system approach and not as silos," said Dr. Wozniak, who has been involved in Mission Lifeline and serves as the ACC consultant to the Texas Medical Association Council on Scientific Affairs. "We're all working together, and that's been to me the most exciting thing I've had to deal with in medicine."
The Council on Scientific Affairs is considering recommending that TMA support STEMI initiatives.
But AHA says there are a number of challenges to creating STEMI systems of care. One of the biggest is inadequate recognition by patients and bystanders of acute MI symptoms and the urgency of calling 911. Also, most EMS vehicles nationwide are not equipped with 12-lead EKGs, and current processes of evaluating and treating suspected STEMI patients in emergency departments include a number of potentially avoidable delays.
Finally, AHA says primary care and specialist physicians tend to work separately rather than in integrated networks in caring for STEMI patients.
Ms. Denne says Mission Lifeline seeks to address all of those challenges. As part of Mission Lifeline, AHA collaborates with local EMS organizations to analyze the effectiveness of EMS as part of the STEMI system of care. AHA also has begun state and local initiatives to identify ways to implement national recommendations for STEMI systems.
ACC's D2B initiative has similar goals for giving hospitals evidence-based strategies for cutting their door-to-balloon times. They include having the emergency department physician activate the catheterization laboratory team, setting up a pager system where one call summons the entire team to the hospital, and having the team ready to perform percutaneous coronary intervention within 20 to 30 minutes of notification.
ACC also recommends prompt data feedback on how well the system performs, a commitment to the program from senior hospital management, and a team-based approach.
Scott & White is following those strategies as well as building relationships with EMS systems and community hospitals in nearby counties to speed transfer of STEMI patients, Dr. Dehmer says. Once a Scott & White emergency physician determines a patient is having a STEMI, he or she can summon the entire STEMI team with one pager number.
"That means the interventional cardiology doctors, nurses, and other support people in the cath lab, the ICU team all get one page," Dr. Dehmer said. "Nobody calls, nobody asks 'Why are you paging me?' You just come to the hospital."
Scott & White also has a STEMI coordinator who works with community hospitals in surrounding counties. Those hospitals receive standardized protocols and standard order sets to simplify and speed up the transfer of patients to Temple.
And, Dr. Dehmer says Scott & White never turns down a STEMI transfer for any reason. Their goal, he says, is to achieve the "30-30-30" rule -- no more than 30 minutes at the outside hospital awaiting transfer, no more than 30 minutes in transfer, and no more than 30 minutes "from the time they hit our door till that artery is open and the heart attack has been aborted."
Timothy Mixon, MD, interventional cardiologist at Scott & White, says that for patients initially arriving at Scott & White, the door-to-balloon time is less than 60 minutes. For patients transferred from outlying hospitals, the times average between 110 and 120 minutes, he says.
Those times have allowed Scott & White to achieve a total mortality of just 2 percent, compared with a national average of 5.7 percent, he says.
Getting a Head Start
The AHA South Central Affiliate began its pilot in Texas by engaging STEMI advocates through a Central Texas task force. That task force later was expanded to a statewide conference in 2007 that attracted more than 250 attendees from more than 60 cities, including more than 100 hospital and EMS representatives.
Dr. Wozniak says these efforts have helped Austin-area hospitals "raise their game."
"In Austin, it would be hard to find somebody who hasn't improved their door-to-balloon times," he said. "It would just be unheard of now because if you don't have that you're not competitive in the marketplace."
TMA's Council on Scientific Affairs heard a report on Mission Lifeline from Dr. Wozniak in September. He says the council plans to submit a report to the TMA House of Delegates this year recommending that TMA support STEMI initiatives.
That report also likely will recommend that TMA adopt a policy similar to one the American Medical Association adopted in June. It calls for AMA to work with relevant societies to conduct a thorough analysis of the geographic, economic, and political barriers to optimal care of STEMI patients, such as the cost of ambulance EKG hardware, reimbursing one county for care given to a patient from another county, and the cost of shifting patients to centers that can perform preferred treatment. That policy, presented to the AMA House of Delegates by ACC, also calls for AMA to develop model legislation to break down those barriers.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
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