Specific strategic plans ensure timely emergency care for heart attack patients

Hospitals that provide the most rapid emergency angioplasty have specific strategies to expedite the care of patients with heart attacks, researchers at Yale School of Medicine report in the November 13 New England Journal of Medicine.

The timeliness of heart attack care in hospitals varies widely across the country, according to the authors. In this study, 365 hospitals nationwide were surveyed about how they treat heart attack patients. The researchers identified strategies that were correlated with "door-to-balloon" time--the time from when a patient enters hospital doors to the time blood flow is restored to the heart by opening a blockage with angioplasty. The faster patients are treated, the better their likelihood of survival.

The study found that among the hospitals sampled, the range of door-to-balloon times was between 55 and 120 minutes. The national guideline for door-to-balloon time is 90 minutes or less. Many hospitals do not achieve these national guidelines for even most of their patients. However, some hospitals do better than others and six strategies were associated with significantly faster door-to-balloon times.

These strategies included having emergency medicine physicians activate the catheterization laboratory, having a single call to a central page operator activate the laboratory, having the emergency department activate the catheterization laboratory while the patient is en route to the hospital, expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged, having an attending cardiologist always on site and having staff in the emergency department and the catheterization laboratory use real-time data feedback for staff about their performance.

"Despite the effectiveness of these strategies, a minority of the hospitals surveyed were using them, even though many of the strategies were feasible and could be immediately implemented," said lead author Elizabeth Bradley, professor of public health in the Department of Epidemiology and Public Health at Yale.

"We know that reducing door-to-balloon time is important, but now we also have more evidence about how to achieve faster door-to-balloon times," Bradley said. "Having a good interventional cardiologist is not enough. How the hospital processes are organized and managed, and how teams work together within the hospital really matters to patient outcomes, especially in heart attack care, which requires coordination among many different staff members."

The study coincides with the launch of the new "D2B" campaign by the American College of Cardiology, the American Heart Association and other partners, to improve door-to-balloon times by providing hospitals with practical tools to achieve this goal. The campaign, which will help educate hospitals on how to implement these six strategies, derives in large part from a four-year National Institutes of Health grant that helped to produce this study.

"With this and previous studies, we have generated the knowledge that can help all hospitals provide timely care to their patients," said study co-author Harlan Krumolz, M.D., the Harold H. Hines, Jr. Professor of Medicine at Yale School of Medicine at Yale. "With the D2B campaign to translate the science into action, we want to see what is currently considered outstanding care become standard and routine care. These strategies provide the roadmap for that to happen."

Krumholz said most of the D2B recommendations are reasonably straightforward but in some cases require a change in culture, including increased collaboration between emergency department physicians and interventional cardiologists.

"The project is designed for all hospitals--to help the best get even better and those who are lagging in door-to-balloon times to catch up," said Krumholz. "We are seeking to sign up every hospital in the country that offers emergency angioplasty for patients with heart attacks.

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In addition to Bradley and Krumholz, the multidisciplinary team of authors on the NEJM article included Jeph Herrin, Yongfei Wang, Barbara Barton, Tashonna Webster, Jennifer Mattera, Sarah Roumanis, Jeptha Curtis, M.D., Brahmajee Nallamothu, M.D., David Magid, M.D., Robert McNamara, M.D., Janet Parkosewich and Jerod Loeb.

The study was funded by the National Heart, Lung and Blood Institute and the Patrick and Catherine Weldon Donaghue Medical Research Foundation.

Citation: N Engl J Med, Early Online Edition; 355 (November 13, 2006)


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