How Hospitals Can Beat the Clock
From the annual American Heart Association meeting in Chicago: Part three in a series of web-exclusive articles
The clock is ticking when someone having a heart attack is brought to the door of the emergency department. "We know if we can get the artery open in 90 minutes, we have a very good chance of survival with much less damage," says Cleveland Clinic cardiologist Steven Nissen, president of the American College of Cardiology. So caregivers move into high gear. The patient is rushed from the emergency department to the catheterization laboratory and an angioplasty balloon is inflated to reopen the artery blocked by the heart attack. Urgency fills the air.
That's how it's supposed to happen. In 2004, 90 minutes was set as the "door to balloon" goal in new guidelines from the ACC and the American Heart Association. But many hospitals flunk the standard. Nationally, only about 35 percent of heart-attack patients go from door to balloon in 90 minutes. Now, however, armed with findings and suggestions from a study presented this week at the American Heart Association's annual science meeting, hospitals have a checklist of six proven ways, endorsed by the ACC and the AHA, to speed up the process.
The list includes, for example, giving emergency physicians authority to alert the cath lab to get ready for a patient instead of waiting for a cardiologist's approval, the usual rule. According to the study, published online Monday in the New England Journal of Medicine, that step alone saves about eight minutes. Or, as an alternative, emergency personnel outside the hospital could alert the cath lab if an electrocardiogram indicated a possible heart attack, yielding a reduction of 15 minutes. Another change would require the cath lab staff to arrive within 20 minutes of being paged, lopping off another 19 minutes.
"You have to have support from the top–these are behavioral changes," says American Heart Association president Raymond Gibbons, a cardiologist at the Mayo Clinic in Rochester, Minn., which instituted changes several years ago that largely track key elements of the new program. Door-to-balloon time, which already was around 90 minutes, dropped to just over an hour. But Gibbons notes that not all hospitals can adopt all of the measures. An example: Because of spotty cell reception in the Rochester area, he says, requiring an on-call cardiologist to report for duty within 20 minutes is impractical.
Beating the clock can produce impressive results. Tallahassee Memorial Hospital has cut a full day from the average heart-attack patient's stay after shrinking its door-to-balloon time from about 110 minutes a few years ago to 70 to 80 minutes in the most recent numbers. And the death rate of these patients has plummeted by 36 percent. The federal government's "Hospital Compare" website offers information on how hospitals perform in door-to-balloon time–though most hospitals are missing from the site and the reports are currently based on the percentage of patients who meet a 120-minute standard, not 90.
Home-to-hospital time also is critical. Physicians urge anyone who might be having a heart attack to get to the closest hospital quickly by calling 911. Symptoms include tightness across the chest or pain down the left side of the jaw, shoulder, or arm. Don't drive yourself, cautions study coauthor Harlan Krumholz, a cardiologist at Yale-New Haven Hospital. And don't delay, as many do out of denial and fear. "Nobody wants to think they're having a heart attack," says Nissen. "It's got to be something else. Indigestion, a pulled muscle."
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