It’s been an exciting year for emergency cardiac care. The American Heart Association came out with the new policy statement on out-of-hospital cardiac arrest in January [1] and the 2010 AHA ECC Guidelines were published in October. [2]
Whether we’re talking about STEMI, cardiac arrest, or stroke, a common theme that I see emerging is an emphasis on regional systems of care.
This should seem obvious to prehospital professionals. After all, the ‘S’ in EMS stands for “System.” But the unfortunate reality is that health care in the United States is extremely fractured and “EMS” is often delivered within a non-system.
However, there is cause for hope!
The American College of Cardiology launched a national Door-to-Balloon (D2B) Initiative in 2006 with the express purpose of “taking the extraordinary performance of a few hospitals and making it the ordinary performance of every hospital.” [3]
In 2005 less than half of hospitals were delivering life-saving care within the guidelines-recommended time frame. [4] By December 2009, more than 80 percent of participating hospitals showed at least 75 percent of their patients were receiving this life-saving procedure within 90 minutes of arriving at the hospital. [5]
D2B times of less than 90 minutes are now commonplace and some top STEMI Receiving Centers (like MUSC in Charleston, SC) routinely demonstrate D2B times of less than 60 minutes. [6]
So what changed?
These hospitals made it their explicit goal to reduce door-to-balloon times and they implemented the core strategies of the D2B Alliance. [7]
- ED physician activates the cath lab
- Single-call activation system activates the cath lab
- Cath lab team is available within 20-30 minutes
- Prompt data feedback
- Senior management commitment
- Team-based approach
- Prehospital 12-lead ECG activates the cath lab (optional)
Having witnessed the growing pains within my own STEMI system and now participating on EMS Advisory Committee of the SC Chapter of AHA Mission: Lifeline, I can tell you that “getting the team together” was (and is) the most difficult part.
Once all the stakeholders in the process sit around the same table together, look at the evidence, examine the data, and ask themselves what they would want to see happen for members of their own family, all of the inter-departmental barriers melt away and there is no limit to what can be accomplished.
The next logical step now that hospitals have their houses in order is to “move the clock back” to first medical contact, which means EMS. We’ve been talking about ‘EMS-to-Balloon’ (E2B) for a while now, [8] but the timing has never been more critical.
As more states like South Carolina follow the lead of regional STEMI systems like the ones in Southern California, Minnesota, the RACE program in North Carolina, and others [9] we see that EMS has a critical role both in triaging patients to the most appropriate facility (which is often not the closest) and early notification so that hospitals can call in the appropriate assets while the patient is still in the field.
EMS also has an important role to play when patients self-report to hospitals that are not best equipped to handle their emergency.
That, in a nutshell, is a regional system of care.
An increasing number of communities (and states) are showing that it’s possible. The success of these initiatives cannot be ignored.
As more cardiac arrest patients experience return of spontaneous circulation (ROSC) and more attention is paid to post-resuscitation care, it only makes sense that regionalization continue so that cardiac arrest patients can receive the benefits of PCI and therapeutic hypothermia.
Likewise, it is not acceptable for victims of acute stroke to languish at hospitals that are unwilling or unable to deliver timely evidence-based therapy.
It’s not too early and it’s not too late. The decisions we make right now will affect the quality of life for thousands of patients for the rest of our careers and long after we are gone.
How often is a generation given the opportunity to be the system builders? To create order from chaos? To turn dreams into reality? To direct the relationship between means and ends so that real lives are saved and loved ones are returned to their families?
I don’t know about you, but that’s why I got into this business.
There is no higher calling.
References
1. Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association. Circulation. 2010 Feb 9;121(5):709-29. Epub 2010 Jan 14
2. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation. Volume 122, Issue 18_suppl_3; November 2, 2010
3. John Brush, MD, The D2B Alliance for Quality. STEMI Systems. Issue Two. May 2007
4. Bradley EH, Curry LA, Webster TR, et al. (2006). “Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems”. Circulation 113 (8): 1079–85
5. Krumholz HM, Bradley EH, Nallamothu BK, et al. A Campaign to Improve the Timeliness of Primary Percutaneous Coronary Intervention. J Am Coll Cardiol Intv, 2008; 1:97-104
6. Eric Powers, MD. Planning is Key to Reducing Door-to-Balloon Time. Diagnostic and Interventional Cardiology, March/April 2009
7. Bradley EH, Nallamathu BK, Curtis JP, et al. Summary of evidence regarding hospital strategies to reduce door-to-balloon times for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Crit Pathw Cardiol. 2007 Sep;6(3)91-7
8. Rokos IC and Bouthillet TL. The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance. STEMI Systems. Issue Two. May 2007
9. Rokos IC, French WF, Koenig WJ, et al. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: Impact on door-to-balloon times across 10 independent regions. J Am Coll Cardiol Cardiovasc Intervent 2009; 2:339-346
