American hospitals are making major strides in reducing the time it takes to administer potentially life-saving balloon angioplasty to heart attack patients, and Nashville’s four major downtown hospitals all boast aggressive initiatives to shave precious minutes off their times. Their strategies are working.

 

“The bottom line with these patients is they have some type of blockage, so you want that balloon to open up that blockage so that you regain the blood flow throughout the heart. The longer the blockage is in place, the more damaging it can be to the heart muscle,” said Kevin Orndorff, administrator of the TriStar Heart Network and Centennial Heart Center. This ‘time-is-muscle’ awareness is the impetus behind parallel efforts at Centennial, Vanderbilt University Medical Center, Baptist Hospital and Saint Thomas Hospital to improve response when patients present with a ST-segment elevation myocardial infarction, or STEMI.

 

All four hospitals are members of the D2B Alliance, a community of more than 1,100 hospitals globally that are committed to reliably reducing their door-to-balloon times to less than 90 minutes, which is the recommendation of the American College of Cardiology and the American Heart Association. When setting the ambitious objective in 2004 the ACC and AHA acknowledged the organizational challenge required to meet or beat the goal. Before, hospital units were more self-contained, with the emergency medical services, the emergency department, the cardiac catheterization laboratory and other units working almost independently – more of a silo model than a horizontal one. Breaking down those barriers has been the key to dropping D2B times, which begin when the patient crosses through the Emergency Department door.

 

“It’s worked about as remarkably as I’ve seen anything work cross-culturally in a hospital setting. Our cath-lab staff really bought into this strategy,” said Kevin Rankin, MD, interventional cardiologist with Saint Thomas Heart at Baptist Hospital. Baptist began its efforts to reduce D2B times in earnest in 2006, when its median time was 85 minutes. The hospital’s median time in 2009 (through October) was 58 minutes.

 

Baptist’s system partner, Saint Thomas Hospital, had a median time of 72 minutes in 2006, and its time through the first 10 months of 2009 was 60 minutes. “Looking at the top 50 hospitals in this country, Saint Thomas Hospital ranks within the top three of that group for door-to-balloon times,” said Howard Walpole, MD, the hospital’s chief of cardiac sciences. “Door-to-balloon time is directly related to mortality of heart attacks. Because of this, we meet once a month to evaluate each case to see how we can improve our times.” In fact, a D2B time of one hour versus two hours means a mortality rate drop from 7 to 8 percent down to 1 to 2 percent.

 

At VUMC, there’s a similar evaluation process. “We have an interdisciplinary team that meets every month, and we review all of our cases,” said Brittany Cunningham, quality consultant, Vanderbilt Heart Institute. “Yet, we take that one step further, and every time a patient comes in, I collect all the data and review that case, and I break it up into six different intervals.”

 

Those steps include, for example, the time from the door to the EKG, the time to read the EKG and the time to activate the cath lab. All that information is sent to physicians, nurses, technicians, managers and administrators, who respond with feedback within 24 hours. “If anything happened with that patient, we know immediately,” Cunningham said.

 

Vanderbilt’s median time dropped from 65.5 minutes in 2008 to 55 minutes in 2009. That number includes the D2B time of patients who simply walk into the emergency department with symptoms, as well as the time of patients who enter the hospital via EMS.

 

Bringing EMS personnel into the fold and making them part of the team is a priority with Nashville’s largest hospitals, as well. All coordinate training opportunities for EMS to help them understand their critical role in speeding up heart attack patients’ treatment. Hospitals have even invited EMS personnel into the cath lab to witness a balloon procedure “to see what’s on the other end of this. When they see it visually, they understand,” Rankin said.

 

Within the TriStar network, hospital administrators have participated in EMS ride-alongs to witness the challenges outside the hospital walls. “A real key is involvement of EMS,” Orndorff said. “They are a critical partner and deserve a lot of credit in the success of the reduction in these times. A lot of this is about pitching and catching, and they’re the ones bringing the patient in. So if the patient can be appropriately prepped, we’re ready to receive and move the patient on through the process.” He said “the next frontier” is working with outlying hospitals to decrease times from those facilities to the downtown cath lab. Some transfers from as far away as Heritage Medical Center in Shelbyville to Centennial have been clocked at under 100 minutes, and a recent D2B time from StoneCrest Medical Center’s door in Smyrna to Centennial was 67 minutes.

 

The D2B median time for patients presenting to Centennial was 41.5 minutes in 2008 and 32 minutes in 2009. Centennial’s median time prior to 2007 was greater than an hour.

 

The D2B Alliance recommends a list of strategies to its participating hospitals, and Nashville’s largest four have met the main objectives: