Rapid response winning heart attack fight
CAMDEN, N.J. — Yvette Samuels was listening to jazz late one night when she felt a stabbing pain down her left shoulder. She suspected a heart attack — she had heard about the symptoms from watching a Rosie O’Donnell stand-up routine on television — and managed to scratch on the door that connected her single room to her neighbor’s. He found her collapsed on the floor.
Paramedics arrived minutes later and slapped electrocardiogram leads on her chest, transmitting the telltale pattern of a heart attack to Our Lady of Lourdes Medical Center here.
As the ambulance raced through the streets, Samuels asked the paramedic, “Can this kill me?” He murmured yes, then told the driver, “Step on it!” She thought to herself, “This will be my last view of the world, the last time I will see the night sky.” Precious minutes
Instead, she survived, her heart undamaged, the beneficiary of the changing face of heart attack care. With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart.
The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association.
Hospitals across the country have adopted common-sense steps that include having paramedics transmit EKG readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once.
Care has improved not just in elite medical centers, but in local hospitals like Our Lady of Lourdes, here in a city littered with abandoned buildings and boarded-up homes that is among the poorest in America, according to the Census Bureau. Disparities that used to exist, with African-Americans, Hispanics and older people facing the slowest treatment times, have disappeared, Dr. Harlan Krumholz, a cardiologist at Yale, and his colleagues said in a paper in Archives of Internal Medicine.
In a heart attack, a blocked artery prevents blood from reaching an area of heart muscle. At first, cells are merely stunned, but as minutes tick by, they start to die.
The way to save the heart is to open the blocked artery by pushing in a catheter, inflating a tiny balloon that shoves the blockage aside and holding the artery open by inserting a stent, a tiny wire cage.
Leading cardiologists had despaired of reaching a national goal set by the American College of Cardiology and the American Heart Association of getting this done for at least half of heart attack patients within 90 minutes of arrival at a hospital.
Often it took more than two hours for blood to flow to a patient’s heart again.
Now, nearly all hospitals treat at least half their patients in 61 minutes or less, according to the most recent data from the American College of Cardiology. At Yale-New Haven Hospital, where half the patients used to have to wait at least 150 minutes before their arteries were opened, the median time is now 57 minutes.
At the Mayo Clinic and at major academic centers like New York-Presbyterian Hospital, it is 50 minutes — a statistic that, amazingly, Lourdes matches.
No city seemed more in need of improved heart care than Camden, where 42 percent of the population lives in poverty and heart disease risk factors abound, according to various studies.
Obesity is rampant, as are high cholesterol levels, high blood pressure and smoking.
Heart care is the hospital’s specialty, and without its revenue, said Dr. Reginald Blaber — who runs the medical center’s cardiovascular disease program — Lourdes would have to close its doors.
In 2007, the first year of a national campaign to speed treatment, half the patients at Lourdes waited at least 93 minutes before their arteries were opened.
By 2011, Lourdes had a median treatment time of 71 minutes. What if ‘it was your mom?’
But at a staff meeting that year, Blaber challenged members of his team to do better. He pointed out that 16 percent of patients had to wait more than 90 minutes. “What if that one time when it took more than 90 minutes, it was your mom?” he asked them.
Staff members set up what they called the D2B task force, standing for door to balloon time — the crucial period from when the patient enters the hospital until the cardiologist can thread a balloon into the blocked artery, inflate it, push the blockage aside and let blood flow again.
They broke down the process, looking for opportunities to shave off a minute or two.
They decided to have paramedics do the EKG, which can show the characteristic electrical pattern of the heart that signals a heart attack, as soon as they reached the patient and transmit it directly to the emergency room.
That meant the staff could spring into action the moment the ambulance pulled in. The hospital designated a beige phone on a counter in the ER for calls from paramedics.
They eliminated the requirement that a cardiologist look at the EKG and decide if an interventional cardiologist, who would open the blocked artery, should see it, too.
Why not just give the emergency room doctor authority to call in the specialist?
It made a huge difference, Blaber said. Before, the ER doctor would fax an EKG to him.
“The fax machine would go eh, eh, eh,” he said. And then he would look at it: “’Oh, God, I can’t read it. Send it again.’ Five minutes go by, seven minutes go by, 10 minutes go by. ‘Yeah, it’s a Stemi,’” he would say, using the acronym for a heart attack. “’Let’s call the interventionalist.’”
In another change, the hospital operator began summoning members of the heart attack team with a single phone call that sounded their beepers simultaneously.
And each member of the staff on call was required to be within 30 minutes of the hospital.