By Richard Halstead
Marin Independent Journal (California)
Copyright 2006 Marin Independent Journal, a MediaNews Group publication
All Rights Reserved
Janet Barth was at her Ignacio home getting dressed for an early dinner on Sept. 28 - “when all of a sudden, something grabbed me,” she said.
Barth called paramedics who quickly figured out she was suffering a heart attack. Barth told them she was a Kaiser patient and they rushed her to the Kaiser Permanente Medical Center in San Rafael, where she was immediately taken to the hospital’s new catheterization lab. A procedure to reopen an artery in her heart was started within 30 minutes.
“I was surprised because I thought they would take me to the emergency room first,” Barth said.
Marin County hospitals are among the minority of hospitals in the country capable of performing a life-saving procedure on a certain type of heart attack sufferer and completing it with the speed deemed necessary to be effective by medical experts.
Marin patients who need a major artery in their heart reopened to save their life can expect to have the procedure performed within 90 minutes of arrival at either Marin General Hospital in Greenbrae or Kaiser Permanente Medical Center in San Rafael, supervising physicians at the hospitals say.
The lack of a heliport at either hospital, however, makes it difficult to transport heart attack patients quickly enough from remote areas in West Marin, said Dr. William Teufel, medical director of the Marin County’s Emergency Medical Services Program.
“Not having a helipad in Marin County has been a disadvantage to the citizens for the 20 years I’ve been here,” Teufel said.
The American College of Cardiology and the American Heart Association launched a nationwide initiative this week to emphasize the importance of performing angioplasties within 90 minutes of arriving at the hospital. According to the ACC, fewer than a third of the hospitals performing angioplasties meet the 90-minute deadline - even though the risk of dying goes up 42 percent if the procedure takes even an extra 30 minutes.
An angioplasty is the preferred remedy when one of the heart’s major arteries is narrowed or blocked by plaque on its inner walls. A thin tube with a balloon on the end is threaded through a blood vessel in the arm or groin up to the site of the blockage. Then the balloon is inflated to flatten the plaque, and a tiny mesh scaffold, called a stent, is typically inserted to prop open the artery.
A study of 365 hospitals published online by the New England Journal of Medicine last week found that six measures help reduce response times. Those guidelines were:
- Allow emergency room doctors to activate catheterization labs, where angioplasties are done, rather than wait for a cardiologist to make the decision.
- Have a central operator page the angioplasty team.
- Have the emergency room activate the cath lab when paramedics notify them that an electrocardiogram done in the ambulance shows the patient having a heart attack.
- Cath lab team must arrive within 20 minutes.
- Have a cardiologist on site at all times.
- Give prompt feedback to staff on how they did on each case.
“All those things we’ve done for a long time,” said Dr. Joel Sklar, chief of Marin General’s cardiology division.
Marin General opened the county’s first cardiac catheterization lab in 1986 and last week unveiled its third complete modernization of the lab at a cost of $3.2 million. The equipment consists of sophisticated X-ray imaging equipment, which allows doctors to view damaged arteries, and a computerized system for monitoring blood pressure inside the heart.
Marin General does about 350 angioplasties a year, Sklar said. Only 15 to 20 percent of these were performed on people who suffered a heart attack, Sklar said. The rest were done as a preventative measure after the narrowing of an artery was detected, either due to chest pains or some other diagnostic sign, such as shortness of breath.
Marin General was the only hospital in Northern California to receive a five-star rating from HealthGrades for the low mortality rates of its angioplasty patients from 2003 to 2005. HealthGrades, based in Golden, Colo., provides ratings of hospitals used by consumers, employers and health plans. Kaiser was not graded because it has not performed enough angioplasties.
Kaiser opened its San Rafael cath lab in November 2005. The hospital is licensed to perform angioplasties only when a patient is suffering a heart attack, because it lacks the capability to perform open-heart surgery. Kaiser’s San Rafael cath lab performed 30 emergency angioplasties during its first year of operation, said Dr. John Kennedy, the lab’s medical director.
In addition to angioplasties, the cath labs at Marin General and Kaiser are used for doing diagnostic angiograms. Marin General did 432 angiograms in 2005. The Kaiser medical center performed 300 angiograms during its first year.
Before Kaiser opened its cath lab, it treated Marin heart attack patients with clot-dissolving drugs and when necessary transported them to its San Francisco hospital, where an angioplasty could be performed, Kennedy said. At that time, Marin General was the only hospital in the county performing angioplasties.
This spring, officials with the county’s Emergency Medical Services Program met with doctors at Marin General and Kaiser and convinced them to adopt a new response system. Now, heart attack victims are taken to whichever hospital is closest.
Kaiser has given 12 portable electrocardiogram machines to paramedics in Marin. Kaiser and Marin General allow paramedics to activate their cath labs.
Teufel said Marin General was somewhat reluctant to give up its dominance of this specialty. In 2005, Medicare paid Marin General an average of about $18,560 to perform an angioplasty involving the use of a drug-coated stent, said Kathy Graham, a spokeswoman for the hospital.
“It was nice to be the only service in town,” Teufel said. “They would have been happy to continue to be the only one.”
Sklar said Kaiser is the only hospital in California to do angioplasties, even in emergencies, without surgical back-up.
“They’re trying to serve their patients, but it’s an issue,” Sklar said. He also noted that the cardiologists that perform angioplasties at the medical center are based in San Francisco.
Kennedy said the likelihood of requiring emergency bypass surgery in such cases is far less than 1 percent. As for Kaiser’s cardiologists being based in San Francisco, he said, “We have a system that requires all the cardiologists be here within 30 minutes.”
There might be another cath lab in Marin’s future. The Cirrus Group, a Dallas-based real estate development company, is seeking approval to build a specialty hospital that would include a cath lab just outside Mill Valley. The location is next door to a seaplane and heliport complex.
“Any hospital doing cath lab work with a heliport would have an advantage,” Teufel said, “especially in a county where you have rural areas, which we do.”