News:Door-to-Ballon Time less than 90 Minutes is Achievable and Sustainable: the Geisinger experience. August 12, 2007
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August 12, 2007 By Grendel Burrell [1]
For the all patients presenting initially to the Geisinger Medical Center, Danville, PA (www.geisinger.org) emergency department with STEMI during the first 4 months of 2007, 100% of patients achieved door-to-balloon times (D2B) of < 90 minutes. Many of the D2B times were <30 minutes; most patients treated that rapidly had ECGs transmitted from the ambulance. Additionally, for the >50 STEMI patients transferred from community hospitals for primary PCI, the median time from presentation at the community hospital to the first balloon inflation at Geisinger was only 101 minutes. How did they accomplish this when many institutions struggle with the ACC/AHA goals (1) for time to treatment?
WikiDoc asked Dr. Jim Blankenship, Director of Geisinger’s Cardiac Cath Lab, what changes were made to accomplish this laudable D2B time. “We developed a system so that ECGs are performed within 5 minutes of arrival for patients presenting to out ED with a complaint of chest pain. ECGs obtained at referring hospitals are faxed to our emergency physicians. The emergency physician reviews the ECG and activates the cath lab with a single page that goes out to the entire cath lab team and others involved in the early treatment of STEMI patients.” These steps reduced the time to diagnosis, and improved the speed with which the cath lab was activated and patients were treated.
Efforts to improve time to treatment included visits to all local hospitals and assistance with the development of a standard treatment protocol at all referring hospitals. At the same time, a “One Call is All” program was implemented by which a referring hospital can transfer a patient to the Geisinger ED with just “one call”. This program is applicable to more than just STEMI patients, but clearly improves communication and develops a culture of rapid transfer in which everyone--EMTs, physicians, nurses, ECG techs, administrative personnel, administrators, and volunteers--knows that he/she has a part to play in the care of STEMI patients.
Overcoming issues and obstacles at Geisinger wasn’t any easier than it is anywhere else. In some cases there was reluctance to abandon the “old ways” and to use the new program. Geisinger has “protocolized” that the emergency department contact the interventionalist directly- not to go through the time laden, historical system of contacting the cardiology fellow who contacts the staff cardiologist who finally calls the interventionalist. It’s not always easy to identify patients whose symptoms are not cardiac, but heightened awareness of the critical importance of time to treatment has improved time to diagnosis and intervention of patients with ongoing ischemia and any ECG finding.
Pre hospital ECGs are available on some ambulance units and there is a local effort to equip all ambulances with this equipment. But the cost is significant at $20,000 per ambulance. “Clearly, the transmission of a prehospital ECG can save valuable minutes,” said Blankenship. “In some cases we have EMTs call in or transmit a STEMI ECG and then have the helicopter meet the EMT unit at a remote helipad, completely bypassing the local hospital, and thus saving more time,” he added. “Furthermore, patients in whom the ECG is transmitted from the ambulance now bypass our ED and go directly to the cath lab, even if they haven’t been evaluated by another ED. That really allows us to reduce the time to treatment.”
Implementing a STEMI protocol in referring hospitals and having a plan for transfers helps. Eastern PA can experience weather that may prevent the helicopter from flying, and having a back up plan for reliable ground transport is critical. When the helicopter is flying, the Geisinger team introduced simplifications to care at the community hospitals that have positively impacted the job of the helicopter transfer crew and ground (“scoop”) time. Heparin and nitroglycerin drips are not initiated at the community hospital, and scoop time has decreased from 30 to approximately 10 minutes. But weather isn’t the only influencer of regional care. Some emergency departments were required to notify the family physician before transfer. And some EDs referred to multiple centers and time can be lost in the decision making process of which center, which physician.
At Geisinger, time to treatment is a commitment of all staff involved in diagnosis and treatment of AMI. All, literally all, interventional cardiologists live within 20 minutes of the hospital and most live within a 7 minute drive. On-call techs are required to be able to arrive at the hospital within 30 minutes. The emergency department is located “about 30 steps from the cath lab” making quick consults between ED and interventional cardiology easy. There’s a collaborative approach between emergency medicine and interventional cardiology to the management of acute coronary syndromes.
What’s the basis of this incredible commitment to change systems, to buck tradition, to do the right thing? Blankenship concluded, “We have a tradition of excellence. We are very much like an academic medical center, but here, we clearly set excellent patient care as the top priority. Teaching and research are important, but patient care is absolutely our number 1 priority.”
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