Heart Attack Care: Your life may depend on which hospital you choose

Big news was released today in the treatment of heart attack.

Please allow me a (slightly) wordy intro.

——

I’m not normally an alarmist. I often vouch for the heart’s durability.

The exception to this rule is heart attack.

Heart attacks are…well…very serious. In this case, alarm is clearly a good thing. So is teamwork.

It’s been said so many times: Practicing medicine is a team sport. For without nifty tools and the help of trained staff, doctors would be useless. And few therapies show off the merits of teamwork more than rescuing patients from a heart attack (or MI-myocardial infarction.) It’s like a symphony—from paramedics doing ECGs in the field, to the wireless transmission of the ECG recording, a rapid transfer to an intervention-ready hospital, with a waiting and able cath lab staff and of course, the skilled interventional cardiologist who passes the wire, squishes the stent and takes the credit. All this triumph saves lives—of mothers and fathers and brothers and teachers and cycling buds, and on and on.

Yes, for sure, saving the life of another human is the highest reward. But I have to admit there’s also something else really enjoyable about the care of an acute MI. That is…the fact that it is a true emergency. So urgent is the need for timely intervention, medical people actually bypass nonsense—like box checking and stupid intake questions. Care comes first; documentation and chart reconciliation is an after-thought! (I don’t wish heart problems on anyone, but let it be said that watching my hospital’s team care for an MI is inspiring. It’s the fury of Medicine at its finest. Nonsense rides in the back seat. Teamwork and cooperation in the front.)

Okay, sorry about the wordy intro.

Let’s get to the news. As published in the journal, Circulation, (and nicely recapped by Reed Miller on theHeart.org) a group of researchers from North Carolina were able to show leadership and organization improved heart attack care across an entire state. This is amazing stuff.

The Study:

The outcome of a heart attack turns on the speed with which a closed artery is opened. (A medical term is necessary here—we call this emergency PCI or percutaneous coronary intervention, usually done with a stent.) The challenge is getting heart attack patients diagnosed and treated quickly. It’s easy when patients present to PCI-ready hospitals. In these best cases, the well-drilled teams spring into action and the patient gets whooshed to the cath lab for heart-saving PCI.

But this isn’t always how it happens in the real world. Many patients with heart attack are seen first in the field by EMS, or, they may present to hospitals not equipped for PCI. There they are; chest pain ongoing, heart muscle dying and life hangs in the balance. Seriously, we only have one heart.

The decision of where to treat a heart attack makes a huge difference. Time is muscle. Remember…it’s a true emergency.

This is where the efforts in North Carolina shine. Researchers were actually able to organize a statewide system—called RACE-Regional Approach to Cardiovascular Emergencies—that expanded rapid heart attack care to all hospitals in the state. Their methods were simple yet remarkable: (It all hinged on a pit-crew analogy–“where everyone knows what to do instead of trying to figure out who will do what.”)

  • First, a leadership team was organized.
  • Next, a registry that collected important data was initiated.
  • Then came an agreement of 21 PCI hospitals in which all agreed to cooperate towards the single purpose of rapidly treating heart attack patients. Time is muscle—and heart muscle is life. They cooperated!
  • The 98 non-PCI centers got on board to move quickly—either to transfer patients efficiently or to deliver clot-busting drugs. Again, they cooperated!
  • The final step was communication between hospitals and EMS regarding all aspects of the process. This important step cannot be underestimated. It’s extraordinary to get competing medical systems to talk to each other. Cooperation!

Is it any wonder that a methodology that centered upon leadership, organization and a shared vision of the greater good for the patient resulted in favorable outcomes? Of course it did. This important study showed:

  • More patients had attempts at opening the occluded artery.
  • Treatment times for hospital transfer patients improved substantially.
  • Patients presenting to non-PCI hospitals had shorter times to transfer and to intervention.
  • Patients presenting to PCI hospitals received faster PCI.
  • Most importantly, heart attack patients treated within time guideline goals had a mortality of only 2.2% versus 5.7% for those treated outside of guidelines.

The conclusions were easily supported by the data:

By extending regional coordination to an entire state, rapid diagnosis and treatment of [heart attack] has become an established standard of care independent of health care setting or geographic location.

My take home:

First, the researchers deserve a hearty shout out. This is incredible work. It’s hard to put into words how hard it is to overcome the bureaucracy of entrenched healthcare systems. I am stunned.

Second, this study reinforces an important public service message: Patients having chest pain and symptoms of heart attack should seek medical attention quickly.

Third, despite what billboards say about fast emergency care close to home, in the event of a heart attack, you are best served by going to a PCI-capable hospital. My hospital boasts some of the fastest PCI times in the state, but not infrequently, unsuspecting heart patients often go to two non-PCI hospitals across the street, where they experience delays in care. If a choice is feasible, always get to the PCI-ready hospital.

Finally, let’s end with a message of hope. Here is to hoping hospitals in the community can get past competitive forces to direct heart patients to the closest PCI-ready hospital. For if one thing is a certain in America; there’s plenty of heart disease treatment to go around.

Please folks. Be informed. In the event of chest pain and heart attack, you want care at a PCI-capable hospital. You want speed, teamwork and cooperation.

JMM

8 comments

  1. As an EMS provider in NC I’ve seen first hand the benefits of such a system. We have statewide EMS protocols to ensure that our 12-Leads can be used for activation. In many areas of the state, EMS activates the STEMI system in the field based on paramedic interpretation. Non-PCI hospitals also utilize similar STEMI protocols based on their distance from PCI hospitals. Whether you arrive as a Walk-Up or take a ride with EMS, we’re all working towards a shared goal.

    It’s through this collaboration that allows our area to consider it the norm to have 911 Call to Balloon times of under 60 minutes!

  2. Wonderfully worded summary by Dr. John that conveys KEY messages to the lay public for what to do when chest pain strikes. In between the lines I “feel” the longing for extension of “the symphony” of care to other health-related domains. Development of this smooth-working collaborative effort for acute coronary syndromes proves that it CAN be done in at least one area – and presumably in many other health-related arenas …

  3. John,
    This is a major health failure in our state. Currently Kentucky is 50 out of 51states (DC included) in the country in AMI mortality. North Carolina is a roll model program and there are others in Minnesota and Michigan. We are in the process of improving this and we are going to develop a state wide system here also. Most EMS systems in counties with a PCI center will divert STEMI patients to a PCI center already. At least 50% of patients foolishly drive themselves to the hospital and that may be to a non-PCI center. Recently, we had a case of a young woman who went to an ER with a $100,000 glass sculpture that was 5 minutes from our PCI hospital. She arrived 90 minutes later. Unfortunately for John Q. Public, it is hard to tell from watching the ads and TV where to go. Unlike atrial fibrillation, this is a decision that needs to be made quickly and there is no time for research. We are making major in roads into improvement in care here and it will be better.
    To your one reader the PCI centers in Jefferson County, KY are Baptist East, Audubon, Nortons, Jewish and University Hospital.

  4. I’ve always enjoyed the way in which John writes. Too, I am reminded that the marvelous W.S. Maugham wrote his opening novel ‘Liza of Lambeth’ while practicing medicine early in his career in London. I’ll be interested to see if John uses his gift for written sentence modulation and his tool kit of literary devices to build the heart of even another career. Rick Cheatham, Atlanta, GA.

  5. Question: How does one FIND the PCI or STEMMI hospitals? My daughter in Salisbury NC has been trying to locate her closest and has not been able to find the search criterion to meet her wish. I’m getting ready to look for them here in the Houston, TX, area, but think I know ‘who’ they will be.

    1. As a paramedic in NC I can tell you the easiest way to get to the right hospital is to call 911. EMS will take you to the most appropriate facility, especially if you’re having a heart attack. Paramedics in NC often times activate the STEMI system from the field (we do it from your house or the scene in Southeastern NC).

      From Salisbury you have a lot of options. In the Charlotte area you have CMC-Northeast in Concord, CMC-Mercy, CMC, Presbyterian, and Gaston. Towards Winston-Salem you have Wake-Forest Baptist, Moses Cone, and Forsyth.

      EMS will know which one will be the quickest to reach and by acquiring a 12-Lead ECG (an electrical picture of your heart) can speed the entire process up by calling ahead to get the cath lab ready (especially on nights and weekends).

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