Each year, more than a million Americans have a heart attack — also known as an acute myocardial infarction, or AMI. A third of them don’t survive. Underlying factors, such as coronary heart disease (America’s number one killer), affect survival rates. But the outcome is also highly dependent on what happens in the crucial first minutes of the episode.

For AMI patients, good care means rapid care. “Time is muscle,” say cardiac clinicians, because once there’s an interruption in the flow of blood to the heart (usually caused by a blood clot), muscle cells quickly begin to die off. The faster blood flow is restored, the better the patient’s chance of a full and rapid recovery.

Fast and effective AMI care is one of the key components of IHI’s 100,000 Lives Campaign and has also been identified as an important area for improvement by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS).  

This combined focus on improving AMI care has motivated hospitals throughout the US — including the 2,800 that have joined the Campaign — to review and refine their AMI protocols and procedures. Many are finding unexpected ways to shave precious minutes off the time it takes to restore full blood flow to patients’ hearts. Just as important, hospitals are discovering ways to consistently deliver other elements of effective AMI care in a timely way.

Not Hard, but Challenging

“Good AMI care isn’t hard,” says Interventional Cardiologist Stephen Battista, MD, at 290-bed Fairview Southdale Hospital in Edina, Minnesota, a community facility and one of seven hospitals in Fairview Health Services. “What’s challenging is making sure every patient gets every component every time at the right time.” At the Fairview Southdale Heart and Vascular Center, which treats about 740 AMI patients a year, AMI patients get all the appropriate elements of care 98 percent of the time.

Battista also serves as the quality improvement director for his cardiology group, Minnesota Heart Clinic. He has worked closely with the hospital to put supports in place to meet the challenges of timely and thorough AMI care, working with other staff affectionately dubbed the “Battista Police”; they monitor compliance with AMI guidelines and work with staff to improve.

Optimal AMI care, say the American College of Cardiology (ACC) and the American Heart Association (AHA), includes seven specific components:

• Early administration of aspirin
• Aspirin at discharge
• Early administration of beta-blocker
• Beta-blocker at discharge
• ACE-inhibitor or angiotensin receptor blockers (ARB) at discharge for patients with systolic dysfunction
• Timely initiation of reperfusion (thrombolysis or percutaneous intervention)
• Smoking cessation counseling

“Timely reperfusion” is defined by these organizations as the administration of thrombolytic (clot-busting) drugs within 30 minutes of the patient’s arrival at the hospital, or performing balloon dilation — called primary percutaneous transluminal coronary angioplasty (PTCA) — within 90 minutes. During PTCA, a catheter and balloon are advanced into the artery to clear the blockage, and often a stent is placed to keep the artery open. (Note: CMS, in its 270-hospital pay-for-performance demonstration project that includes AMI care, calls for PTCA within 120 minutes. IHI encourages hospitals to attempt to meet the AHA/ACC goal of 90 minutes, but to reduce the burden on Campaign hospitals that are also reporting to CMS, IHI is also using the 120 minute measure.)

Evidence shows that for a certain subset of heart attack patients — those whose EKGs show an ST-elevated myocardial infarction, or STEMI — PTCA is more effective than thrombolytics, and should be the treatment of choice in hospitals with catheterization capabilities. There are many steps between the patient’s arrival in the emergency department (ED) and his or her successful catheterization, steps that must be carefully and swiftly choreographed in order to comply with the recommended time window.

Challenging though it is, many hospitals are meeting that goal, some with remarkable results. At Fairview Southdale, for example, the average “door-to-balloon” time — from when the patient arrives until the PTCA is performed — is 70 minutes. Advocate Good Samaritan Hospital, a 340-bed facility outside Chicago that is part of the Advocate Health System and also part of the 100,000 Lives Campaign, averages 68 minutes.

To identify ways in which the Fairview Southdale system supported or interfered with speedy care, Dr. Stephen Battista and his team reviewed all the hospital’s AMI cases from a six-month period. “We made a commitment to get rid of every possible barrier,” says Battista. 

At many hospitals, one common barrier to speedy care is a multi-step chain of communication that emergency department (ED) staff initiate when an AMI patient is diagnosed. Typically, the ED physician calls a general cardiologist, who either comes to the ED to examine the patient, or requests a fax of the patient’s EKG. If the cardiologist concurs with the ED physician’s diagnosis, he or she alerts the catheterization (or “cath”)  lab to prepare for an emergency angioplasty.

At Fairview Southdale, as at many hospitals working on AMI care, this process has been shortened. “We empowered the emergency department physician to alert the lab directly,” says Battista. The ED physician makes a diagnosis and notifies the cardiologist that a patient is being sent to the cath lab. The cardiologist meets the patient at the lab and reviews clinical data there, and can veto the procedure if he or she feels an angioplasty isn’t appropriate. This rarely happens, says Battista.

At Advocate Good Samaritan Hospital, things that used to happen sequentially now happen simultaneously. “We used to average 20 minutes to the first EKG, 25 minutes until the ED physician saw the patient, and 45 minutes until the cath lab team was notified,” says Colleen Kordish, RN, Good Samaritan’s Cardiovascular Outcomes Coordinator. Today, under a new program called Cardiac Alert, when the paramedics call in a possible or known AMI (many ambulances are now equipped to perform an EKG en route to the hospital and with digital technology can instantly send the results ahead of the patient), the ED physician, one or two ED nurses, the EKG technician, and often a cardiologist are waiting, says Kordish.

The Cardiac Alert program at Advocate Good Samaritan has enabled clinicians to reduce the door-to-balloon time to an average of 68 minutes (see the graph below). 

Most hospitals also say they rely on effective use of communication technology to save time. At Good Samaritan, for example, when an AMI patient is en route by ambulance, the ED staff instructs the hospital operator to send out an overhead page throughout the hospital that alerts the cath lab staff, the EKG technicians, the ICU charge nurse, and even registration.

At Fairview Southdale, some individual pagers can be linked together. “We are on a group page,” explains Cheri Hammer, manager of the cath lab. “The ED calls one number, and all the cath lab staff’s pagers go off.” This is particularly important outside of regular hours. “When that page goes out,” says Dr. Battista, “we get in our cars and start heading in.”

Some hospitals have rearranged staff responsibilities to save time. At Good Samaritan, if the AMI call goes out after normal hours, it is the job of hospital-based transport paramedics to open the cath lab and turn the machines on. “There is an eight-minute warm-up time for the machines,” explains Kordish, who worked in the cath lab prior to assuming responsibility for coordinating cardiovascular care improvement. “This way the lab is ready when the cath staff arrive.”

At Memorial Hermann Hospital in Houston, Texas, where compliance with AMI guidelines has increased from about 60 percent in 2003 to more than 90 percent today, ED staff assist the cath lab in preparing patients for the catheterization procedure. “We shave the patient’s groin and insert a Foley catheter and two IV lines. This saves time, because the patient is getting prepped while the cath staff is preparing the lab,” explains James McCarthy, MD, Medical Director of the ED. Memorial Hermann, one of nine acute-care hospitals in the Memorial Hermann Healthcare System, is a700-bed academic medical center that serves as the primary teaching hospital for the University of Texas Medical School.

Additionally, at Memorial Hermann the ED nurse now facilitates transport of the patient to the cath lab, rather than waiting for a cath staff member to come get the patient. “No ED nurse wants an AMI patient to stay any longer than necessary in the ED, so they are particularly motivated to get the patient to the cath lab quickly,” says Katharine Luther, RN, MPM, Memorial Hermann’s Director of Performance Improvement.

“When you really start examining your processes,” says McCarthy, “you find minutes everywhere you can save. It cements the concept that if you are slow by a few minutes here and a few minutes there, you will miss the goal.”  Sometimes shaving minutes off is simply a matter of practical thinking. “When they’re called in at night, our cath staff can park in the ED valet parking,” says McCarthy. “That saves them about 10 minutes.”

Some changes, such as where on-call staff can park, are relatively simple to implement. Others, such as which physician activates the cath lab, are trickier because they involve entrenched lines of authority that can be hard to challenge.

“Teamwork is key,” says Eric Nelson, Fairview Southdale’s Clinical Quality Manager. Nelson says that physician leadership is essential to developing a sense of teamwork. “Dr. Battista has been a very strong and visible champion in our effort. That’s made a huge difference, and we’ve had excellent engagement among all the stakeholders in examining the status quo and working to improve it.”

As physician champion at Fairview, Battista took on the job of broadly communicating the goals of better AMI care, and the potential impact on outcomes. “I gave a series of presentations to nurse coordinators, the hospitalists, the ED physicians, and key internal medicine groups, in order to get everyone on board,” he says.

Data is a particularly powerful motivator, says Memorial Hermann’s ED Director McCarthy, where similar changes have been made. “Show your cardiologists data that other hospitals are reducing mortality because they treat their AMI patients faster, and they’ll get very motivated to improve,” he says.

At Memorial Hermann, cath and ED staff continually work together to understand each other’s needs and concerns. “I meet with the cath lab staff regularly,” says McCarthy, “to hear about their concerns and issues, and to review cases where we had problems.”

Hospitals report that one common worry—that in the interest of speed, ED staff will make the wrong call and activate the cath lab needlessly, costing both time and money—has not been a significant problem, and is understood to be part of the learning process. Colleen Kordish at Advocate Good Samaritan, where a cardiologist does come to the ED to assess the patient, says that about a third of patients who are referred to the cath lab don’t end up getting a PTCA. “We consider that an acceptable percentage,” she says. “And when that happens, the physicians are very supportive. They use it to educate the ED staff and paramedics.” Sometimes, she adds, these diagnoses are very tricky. “If the cardiologist couldn’t be sure, how could the paramedic?”

Delivering the Whole Package

But there is more to good AMI care than rapid emergency treatment. “The stent changes one inch of the patient’s artery,” says Fairview Southdale’s Battista, “but the patient still has yards of diseased arteries.” That’s why the other elements of AMI care are important.

To ensure that patients get everything the guidelines call for, many hospitals working to improve AMI care use reminder sheets, standard order sets for chest pain patients, cardiac discharge order sets so patients go home on the proper medications, as well as hospital-wide smoking cessation programs.

David Calkins, MD, Senior Fellow at IHI responsible for developing and helping with implementation of the 100,000 Lives Campaign’s six clinical interventions, says this approach is key to supporting consistently good AMI care. “Tools such as standard order sets are very effective,” he says. “Aspirin and beta blockers are appropriate for virtually every AMI patient. For the occasional patient with a contraindication to one or the other, the physician can override the orders. But the standing order should be the default.”

Equally important is education about the value of those tools. “Physicians often resist using standing order sets,” says Terrie Johansen, Clinical Quality Coordinator at Nebraska Medical Center, a 689-bed acute care hospital and academic medical center in Omaha, Nebraska. Johansen says a combination of factors have helped the physicians she works with overcome that resistance.

“We use Six Sigma tools and processes in all our quality improvement efforts,” she says, so change is an accepted part of the organization’s culture. Since early 2003, Nebraska Medical Center has launched a series of AMI-related improvement projects, focusing specifically on areas such as reducing the time it takes for on-call cath lab staff to be ready for a patient; the development of a comprehensive smoking cessation program; and the development and use of standardized order sets, along with comprehensive staff education.

Being a teaching hospital also helps embed the use of standing orders, says Johansen. “The residents like the order sets; they serve as good reminder tools. And most doctors find that once they start using them, it’s a lot easier than writing out a bunch of orders by hand.” Knowing the power of data to drive change, Johansen says she and her staff also make sure the physicians get a serving of data with lunch. In addition to providing data through more formal reporting mechanisms, says Johansen, “We put table cards on the physicians’ lunch tables showing how we are doing on each of our AMI measures.”

Nebraska Medical Center has significantly improved its compliance with appropriate AMI medication use, providing, for example, aspirin at discharge to 98.5 percent of patients (up from 85.7 percent in 2003), and beta-blockers at arrival to 98 percent (up from 91.5 percent in 2003).

A surprisingly challenging part of making sure all AMI patients get all elements of care appropriately is, simply, identifying who those patients are. “Sometimes patients are admitted with syncope [fainting spells], heart palpitations, even pneumonia, and maybe they had had chest pains a few days earlier,” says Colleen Kordish at Advocate Good Samaritan. “They don’t necessarily show up in the system as MI patients.”

“They’re just not on the radar screen,” agrees Stephen Battista at Fairview Southdale. Both hospitals made staff changes to deal with this problem. At Fairview, a nurse on every unit has been designated as a cardiac care coordinator (there are two on the cardiac unit). The care coordinators are responsible for reviewing patients’ lab results every morning looking for elevated troponins or heart muscle proteins, an indication of a possible AMI, and arranging for appropriate follow-up care. At Good Samaritan, a cardiac rehab nurse gets a daily “troponin report” for the same reason. “The lab report is a better tool than the listings of admitting diagnosis,” says Kordish. “We used to find only about 60 percent of our MI patients. Now we find 100 percent.”

Another hidden pitfall in achieving full compliance with AMI guidelines is simply proving that you have done so. “Documentation is so important,” says Dr. Battista at Fairview Southdale. Sometimes patients will be given aspirin or beta-blockers when they are en route to the hospital by ambulance, and this must be documented in the patient’s chart. Other nuances of the guidelines need to be well understood. “If a patient has quit smoking within the past year, you still need to provide smoking cessation counseling under the guidelines,” says Battista. “Or if you counsel an AMI patient to quit smoking, and that same patient comes back in two weeks for a bypass, you need to counsel them again.” And, he adds, it must be documented in the chart in order to “count.”

Consistently providing the specified components of AMI care to all appropriate patients improves patient outcomes. At Fairview Southdale Hospital the heart attack survival rate is 95 percent, compared with a national average of 93 percent. At Memorial Hermann, increasing compliance with guidelines tracks with decreasing mortality, as shown in the graphs below.

At Advocate Good Samaritan, reports Colleen Kordish, the AMI survival rate is 96 percent. Good Samaritan is known locally as the hospital of choice for cardiac care, which is why other local hospitals have asked the staff at Good Samaritan to show them how they achieve such excellence. “We've worked with two other hospitals to assist them with their AMI care process,” says Kordish.

IHI Senior Fellow David Calkins, MD, says that good AMI care is challenging in part because it involves so many different providers. “The patient typically starts in the ED, where many of the early elements of AMI intervention need to happen,” he says. “Later on others take over responsibility for things such as ACE inhibitors, and smoking cessation counseling often happens at the end of the hospital stay. Getting all this right requires good communication among providers every step along the way.”

10/28/2005