When Every Minute Counts
While sobering, it was the kind of feedback that Nathaniel Niles, MD, and his colleagues knew they needed to hear. About two years ago Dr. Niles, an interventional cardiologist at Dartmouth- Hitchcock Medical Center (DHMC), had begun presenting the idea of setting up a rapid transfer process that would allow STEMI (ST Elevation Myocardial Infarction) patients to bypass the local emergency departments (EDs) and be transported directly to DHMC's Catheterization Laboratory.
"STEMIs represent the classic form of heart attack where a coronary artery has completely clotted off. A STEMI patient is best treated with an intervention such as angioplasty to open up the vessel as soon as possible," explains Niles. "In the past, STEMI patients would typically receive thrombolytics (clot busters) as their primary treatment, but these drugs can fail and they carry some significant risks. Most rescue squads now have 12-lead EKG capacity which allows them to make the STEMI diagnosis in the field, notify us, and administer prehospital care. If the transport can be made rapidly enough, we can achieve a better outcome by avoiding thrombolytics and bringing the patient directly to the Cath Lab to open the artery."
But when Niles talked with Rick Marasa, MD, who runs the ED at Springfield Hospital and provides medical control for the rescue squads in his area, Niles initially felt some resistance. "Dr. Marasa said that he'd be happy to consider doing it, but wasn't sure that we could provide a fast enough ‘door-to-balloon' (D2B) at our end—which measures the time between when the patient arrives at DHMC's door and when we actually open the artery," says Niles. "The ‘gold' standard is 90 minutes or less. At the time, we weren't consistently achieving that. I told him we'd work on it and get back to him."
Niles had created a patient registry in 2001 for collecting detailed data on STEMI cases coming into DHMC. This now became an essential tool for process improvement in attaining two main objectives: to reduce door-to-balloon times to less than 90 minutes in 75 percent of STEMI cases, and to design a pre-hospital triage system for providing timely angioplasty to STEMI patients in DHMC's referring area. To help them achieve these goals, Niles and his colleagues obtained support from DHMC senior management and formed a multidisciplinary group—with representatives from Cardiology, Emergency Medicine, EMS, Communications, CCU, Cardiac Cath Lab, DHMC administration and Quality Management—that was expanded to include local rescue squads and referring hospital ED representatives.
"We brought together the right people to make pretty substantial changes in our process of care, and they've done a fantastic job," says Niles. "We want to acknowledge the organizational support of Evelyn Schlosser, RN, from the New England Alliance of Hospitals and Tammy Anderson, RN, from the Cath Lab."
"One of the most important things we did was to join the American Heart Association's D2B Alliance and adopt a number of their proven strategies for reducing D2B time," says Sheila Conley, RN, a Quality Improvement Associate in the Department of Cardiology, who serves as project coordinator. "These included streamlining the activations to the Cath Lab, mobilizing the Cath Lab team in 30 minutes, providing prompt data feedback, and allowing Emergency Medical Services (EMS) squads to activate the Cath Lab directly. Essentially, better teamwork."
"One huge benefit out of the STEMI project is the immediate feedback that we receive on each case that tells us how well we did against a set of criteria that we use to measure our performance," says Mike Hinsley, a paramedic who leads the EMS squad in Hanover. "This helps us with our quality assurance and improvement, our training, and it also reiterates the fact that the pre-hospital care provider is very much a part of the team with Dartmouth-Hitchcock."
Framework for Success
These collective efforts have led to some impressive results. "Over the past year, we've been able to reduce our door-to-balloon time to 90 minutes or less in 77 percent of our cases," says Niles. "Our median doorto- balloon time has dropped from 126 minutes to about 65 minutes—the national average D2B time is 118 minutes. Moreover, our transfer protocols have enabled us to offer this approach to significantly more patients who would have been taken to local EDs and received thrombolytics in the past. Our mortality rate with this approach has consistently been about 40 percent lower than predicted with standard thrombolytic treatment. We hope it will be lower still with shorter D2B times."
"I've been a medical director now for over 20 years, and I know how hard it is to implement these kinds of changes," says Dr. Marasa. "The job that Nat Niles and everyone at Dartmouth have done is remarkable—they've made real believers out of us. We've already had several patients from our hospital that have met the criteria for getting to the Cath Lab immediately and it's worked out extremely well. I should also add that, even for the patients that don't meet this criteria, the support we get from Cardiology at Dartmouth is fabulous."
"What I'm most enthusiastic about is that, together, we've been able to create a regional network— comprising 20 hospitals and 40 EMS agencies— that provides a very high level of care for this condition," says Niles. "And we've built a framework for continued improvement in the future."