Should Heart Attack Care be More Like Trauma Care?

[Ridryder 911]

Should Heart Attack Care be More Like Trauma Care?

Courtesy the EMS House of DeFrance http://www.defrance.org

In a heart attack, every minute counts. But should patients spend a few more of those minutes getting to a hospital that can provide the most advanced treatment, rather than just the closest hospital?

That question is at the heart of a current debate among heart specialists: whether to make heart attack care more like trauma care, with ambulance crews taking certain patients to specialized hospitals that can perform emergency heart procedures, rather than stopping at the closest hospital.

A new study looks at a crucial issue in that debate: how close Americans live to hospitals that can perform angioplasty, which is considered the best treatment for the form of heart attack called STEMI, if it’s done quickly. Only a fraction of American hospitals perform angioplasties, which re-open blocked blood vessels in the heart and can be done electively to prevent a heart attack or urgently to treat one.

The new research shows that nearly 80 percent of Americans live within an hour’s ambulance trip of an angioplasty-performing hospital. The University of Michigan and Yale University research team made the finding by combining and analyzing census data, hospital locations, driving distances and estimated driving times.

The researchers also found that the closest hospital to about 58 percent of Americans doesn’t do angioplasty. But the extra drive time to an angioplasty hospital would be less than 30 minutes for most of them, though many patients in rural areas would have farther to go.

The research will be published March 8 in the journal Circulation, and will also be presented March 13 at the annual meeting of the American College of Cardiology.

“There are many more issues involved in regionalizing heart attack care, with proximity to specialized hospitals being necessary, but not sufficient, for making such a system feasible,” says lead author Brahmajee Nallamothu, M.D., MPH. an assistant professor of internal medicine at the U-M Medical School, researcher at the VA Ann Arbor Healthcare System and member of the U-M Cardiovascular Center.

“This study puts in perspective what it would mean for patients to be diverted from the closest hospital to one that performs angioplasty.” Says Harlan Krumholz, M.D., senior author and professor at the Yale School of Medicine. “For some patients the difference in time is trivial, for others it may add a potentially dangerous delay to their treatment. It suggests that a national policy needs to take into account local geography.”

Adds co-author Eric Bates, M.D., a U-M professor of cardiovascular medicine who has studied emergency heart attack care for years, “This analysis is a first step. It shows that the majority of patients don’t have geographic limitations that would obstruct the concept of regionalization, but it doesn’t address implementation and economic issues.”

One of the major issues in the regionalization debate is the ability of ambulance crews to distinguish STEMI heart attacks from other problems using portable electrocardiogram equipment, since only STEMI patients have been shown to derive more benefit from emergency angioplasty than from fibrinolytic (clot-busting) drugs that can be given at most hospitals.

Research by the new paper’s authors and others also continues to show that emergency angioplasty holds the most benefit for patients when it’s performed by experienced doctors at hospitals where it is the “default” STEMI treatment and when it can be performed in a timely way.

For these reasons and more, Nallamothu notes that the regionalization of heart attack care will probably have to happen on a local and state basis, rather than nationally. Already, he says, several cities such as Boston and states such as Maryland have started to implement new protocols for ambulances and hospitals that allow quick diagnosis of STEMI and immediate transport of STEMI patients to hospitals that can perform emergency angioplasty.

The new study is based on data from the 2000 U.S. Census broken down by individual tracts, the American Hospital Association’s database of hospitals’ locations and the services they provide, Medicare data on angioplasty billing by hospitals, and driving times, distances and road routes derived from commercial geographical mapping software. The researchers added in time for the dispatching of an ambulance and the assessment and loading of a patient at the scene by the emergency medical personnel.

In all, 1,176 hospitals provided angioplasty, about 25 percent of all acute-care hospitals at the time. The number and percentage have almost certainly grown since 2001, as more states allow hospitals to perform angioplasty even if they don’t have open-heart surgery capability in case of a complication.

The median driving time to an angioplasty hospital was calculated to be 11.3 minutes, or a distance of 7.9 miles. Driving times and distances were calculated using road routes, not “as the crow flies.”

The researchers also calculated the “bypass delay” – the additional minutes an ambulance would have to drive to get to an angioplasty hospital if it wasn’t the closest hospital. The median was 10.6 minutes, and 9.7 miles. A total of 73.8 percent of adults whose ambulances would have to bypass another hospital to get to an angioplasty hospital would be able to get there within 30 minutes, and 90 percent would get there within 60 minutes of additional driving time.

While 79 percent of American adults lived within a 60 minute ambulance trip of an angioplasty hospital, there was tremendous variation across the nation. In the mid-Atlantic states, New England, and West Coast states, more than 82 percent of adults were within an hour of such a hospital, while in the plains states and desert Southwest, the percentage was in the 60s. No matter what state they lived in, only 47 percent of rural adults were within an hour’s drive of an angioplasty hospital. And rural adults also faced longer “bypass delays” than adults in suburban and urban areas.

In addition to Nallamothu, Krumholz and Bates, the study’s authors are Yongfei Wang, M.S. and Elizabeth Bradley, Ph.D. of Yale.

[Nate]

The problem thus lies how do we determine what is a true heart attack and what is just gastric reflex, that way we aren't over loading the few true cardiac hospitals. Our other option would be to make every hospital a cardiac style hospital (isn't as expensive as everyone thinks). Take for instance, Bay Shore is the local hospital that we transport too. It does have everything needed to treat AMI, and pretty extensive cardaic service ability; however there is a hospital out where I live that doesn't even have a cath lab.

I guess we are lucky here in Houston, almost every hospital with the exception of maybe two or three can handle an AMI with no problem.

[flight-lp]

Yeah Nate, we are fortunate in Houston. On the north side we have 9 cath lab hospitals, 6 of which have open heart capability (of course why any hospital would cath patients without open heart capability is beyond me, so called diagnostic caths are dangerous as hell should they go south). I always transport any cardiac patient to one of these facilities. STEMI's go to the closest hospital with CV surgical capabilities and a cath lab. If one is not immediately available, put your patient on a helicopter and fly them to one. Going to the local ER not only delays definitive care, it also opens the patient up to numerous complications, especially if the ER doc administers thrombo's. I have seen more than one patient thrown into an uncotrollable bleed, even as far as a patient going into DNC. Just like trauma's, go to the closest MOST APPROPRIATE facility.....

[Doczilla]

The problem thus lies how do we determine what is a true heart attack and what is just gastric reflex, that way we aren't over loading the few true cardiac hospitals.

ST elevation on 12 lead. There hasn't been a real benefit established for rapid catheterization of NSTEMI or unstable angina. Most cardiologists will go to the cath lab for positive enzymes, just not within an hour. So really the debate is only over STEMI since the others can wait long enough for stabilization and transfer or for the cath lab to open in the morning.

'zilla

[Nate]

We still are using the LP10 at the city.

[Asysin2leads]

Quite frankly, if someone is in the care of good ALS, I'd rather them take the ride to a place with a cath lab. IV, Morphine, Oxygen, Nitro, Aspirin, 3 leads, 12 leads, bloods ready to go, tell me why exactly we need to stop at East Bumblecrap General if the hospital with the cath lab isn't to far down the road?

[als_medic_uk]

Angioplasty should not be delayed, more so for the patients who have presented prior to the 3 hours of pain onset. When a delay for angioplasty is going to be longer than the recommended 60 minutes, then post delivery of fibrinolytic drugs/fibrinolysis is generally used.

Regards.

[nsmedic393]

Anybody out there using thrombolytics in the pre-hospital environment?

[AZCEP]

Seems to me that we are over-specializing our "emergency" care.

Trauma to a trauma center

Cardiac to a cardiac center

Stroke to a stroke center

COPD to a respiratory center?

Diabetics to an endocrinology center?

Sickle cell patients to a hematology center?

I can accept the fact that the facilities that specialize, or deal with a specific problem are going to be better at it, but to what end? Pretty soon we will end up needing multiple "centers" for the complaints that we see every day.

I can see it now:

The stubbed toe center, or how about the "lonely elderly patient" center. The list goes on and on.

Wow, that went cynical fast, didn't it?

[paramedicmike]

That's alright, AZCEP. I was thinking the same thing you were. We can take anything and turn it into a specialty center.

I like Nate's idea that we work on expanding the capabilities of existing facilities. However, while expense might not be a limiting factor, the problem I see lies with in hospital providers who might not otherwise do these procedures. Would there be enough exposure for them to remain proficient in these skills?

I debate this issue with some of my coworkers regularly. They seem to think that any hospital with an ER is capable of handling any type of (specifically cardiac) patient(s). My position is if we know them to be having an active STEMI, they'd be better off if we drove the extra couple miles to a facility with an active cath lab.

While I don't think they're necessarily wrong (sure, the local ER can hang NTG, push thrombolytics and ship them out to a tertiary care center which, coincidentally, is the same facility that we would have driven to had we bypassed the local ER), I don't think that's the best thing for the patient as it results in a delayed arrival to cath time.

But who knows. Interesting concept, though.

-be safe.