Excellence in Heart Attack Receiving Centers

Streamlined processes and STEMI networks are among the efforts being used to improve care for heart attack patients.

This article first appeared in the July/August 2014 issue of HealthLeaders magazine.

Not too long ago, if an ambulance was called to help someone experiencing an ST-elevation myocardial infarction, the EMS workers would routinely take that person to the nearest hospital. If that facility wasn't equipped to treat such a severe heart attack, physicians had two choices: Administer the patient thrombolytic clot medicine and hope for the best, or find another hospital that could accept a STEMI patient and arrange for transport, wasting valuable time.

But now, at a growing number of organizations around the country, heart attack receiving centers are developing a number of ways to streamline that process, including creating STEMI networks within their region and educating EMS workers so that they can perform EKGs and activate the heart attack receiving center's cath lab while still on the road.

In 2012, the American Heart Association and the Society of Cardiovascular Patient Care began accrediting hospitals that participate in and meet certain standards for these coordinated systems of care for STEMI. To be accredited, hospitals must guarantee percutaneous coronary intervention readiness 24/7, coordinate with EMS and referral centers, facilitate STEMI patient transport, collect data, and measure performance, among other measures. Once the patient arrives at the receiving center, the door-to-balloon time should be within 90 minutes.

Summa Akron (Ohio) City Hospital received the American Heart Association's Mission: Lifeline accreditation in 2012. The 550-bed facility began using PCI to treat STEMI patients in 2004 and immediately began to address referral issues, standardizing treatment protocols for all STEMI patients. The organization then adopted the tenets of the American College of Cardiology's door-to-balloon initiative and began to affiliate with more local hospitals and expand its STEMI network.

"We really embraced the whole concept because it was very consistent with what we were doing, and getting the receiving center [certification] was validation of a lot of the work that we had done," says Kenneth Berkovitz, MD, chairman of the cardiovascular disease department at Summa Akron City and St. Thomas Hospitals, and medical director of Summa Cardiovascular Institute, which comprises more than 50 cardiologists and cardiothoracic and vascular surgeons, four hospitals, and 15 physician offices. "As providers this has been very easy for us to embrace, and it has been a really great team-building strategy and a great alignment strategy for us."

Success key No. 1: Building external partnerships

Danville, Pennsylvania–based Geisinger Health System has two hospitals with AHA-accredited heart attack receiving centers—Geisinger Medical Center, a 422-licensed bed facility that performs about 220 PCI procedures for STEMI patients each year, and Wyoming Valley, a 242-licensed-bed facility that performs about 100 procedures for STEMI patients a year. Geisinger credits much of its success to its neighboring hospitals and referring centers.

"To be an excellent STEMI receiving center you have to have a great relationship with the referring hospital because if they don't do a good job, we can't do a good job," says Peter Berger, MD, chairman of cardiology for Geisinger Health System. "You also have to have a great relationship with the EMS ambulance and Life Flight. If all of those pieces aren't in place, we can't be as good as we need to be. Often the receiving centers get all the credit, but that's a mistake because those other referring hospital providers have to be on board for rapid and effective treatment to be administered."Over the past few years, Geisinger has worked to help all ambulance systems in its region educate EMS workers on performing and reading an EKG in the ambulance. If workers perform an EKG and determine the patient is experiencing a STEMI, the ambulance can divert the patient to a heart attack receiving center, bypassing the nearest hospital that cannot offer PCI.

"We have shown that when the nearest facility is bypassed that it's not only safe to transport the patient the longer distance, but it also allows much more rapid treatment and termination of the heart attack—and the patient does better as a result," Berger says. "If the local hospitals were not willing to transfer the patient or to be bypassed altogether, we would not be able to achieve the excellence that we have. It shows how these hospitals that participate in these STEMI networks have to put the patient's needs first above their potential financial well-being, because they miss billing opportunities when they refer patients immediately to a receiving center that can perform immediate PCIs."

When a patient presents at Geisinger, the average time to treat a heart attack victim is 38 minutes, beating the national average of 59 minutes despite its rural location, Berger says. Patients who are transferred to Geisinger from a local hospital have a median first door-to-balloon time of 81 minutes, versus the national average of 101 minutes, he says. Additionally, performing prehospital EKGs appears to have reduced Geisinger heart attack patients' mortality by 50%.

While referring hospitals may be passing on potential revenue, joining a STEMI network allows them to become part of a larger community and the perks that come with it. Baptist Health Louisville, a 519-licensed-bed AHA-accredited receiving center, identified referring hospitals as a source of slow-down in treating STEMI patients and developed protocols for them to follow, with a goal of getting the patient out of the referring emergency department and to Baptist within 30 minutes of arrival.

"We've seen hospitals that were extremely slow before [implementing our protocols] and are now very fast," says William Dillon, MD, interventional cardiologist and director of STEMI care at Baptist, which treats an average 200 STEMI patients each year. "The beautiful thing is that in some of these smaller hospitals the turnover of these ER docs is high, but the [nursing and administrative staff] turnover is not and they all know what do."

Within STEMI networks, receiving centers extend training and support to EMS providers as well. University of Kansas Hospital, a 694-staffed-bed AHA-accredited receiving center that has been treating PCI for 15 years, has found it helpful to have an open dialogue with ambulance companies to discuss and improve their STEMI process challenges. The hospital offers EMS workers EKG education and interpretation skills and has empowered them to activate the cath lab from the field without having to send the hospital the EKG results.

"We trust the EMS providers to get an EKG and identify changes consistent with a heart attack," says Matthew Earnest, MD, cardiologist at University of Kansas Hospital's Center for Advanced Heart Care. "They call our hospital and activate the cath team so we're waiting for them when the patient arrives at the hospital. It cuts down on that waiting time."

The hospital saw an approximate 20% reduction in door-to-balloon time once EMS began activating the cath lab from the road.

"When I took over, we were at about 65–68 minutes, and we are now consistently below 50," Earnest says. "The cost of this is false activations, but we have been actively participating in EMS education, which has helped."

Success key No. 2: Streamlining multi-disciplinary teamwork

Another proven time-saver with treating STEMI patients—and a key element to building a successful heart attack receiving center—comes from streamlining care in-house.

In 2000, when Dillon came on board at Baptist Health, doctors would treat STEMI patients in a number of ways depending on how the patient entered the system, the time of day he or she arrived, and several other factors; that variation ultimately wasted time and resulted in a 15% heart attack mortality rate. To improve patient outcomes, the cardiology department got in line with AHA and ACC guidelines and began treating all STEMI patients via PCI.

"That decision was not super-popular with some physicians. Some people thought it was the wrong thing, but in order to [standardize care for heart attacks] you have to make a big commitment from the hospital standpoint," Dillon says. "You need to have cath lab [staff] dedicated and willing to come in any time, because at least two-thirds of the time when someone has a heart attack, it's off-hours."

By the time a STEMI patient leaves the hospital, several departments in addition to cardiology have had a hand in his or her care, including the ICU, pharmacy, cath lab, radiology, and the nursing team. Interdepartmental finesse is a key to a thriving heart attack receiving center, especially because the emergency department has to agree to be bypassed when a STEMI patient arrives from a referring hospital or ambulance, thereby missing out on potential educational and billing opportunities.

And because the ED is often not involved, a dedicated cath lab team with members willing to respond to STEMI patients at all hours is a critical component of a heart attack receiving center.

"If we're in-house or out-of-house it doesn't matter—the arrival of a STEMI patient will go to all cath lab team member pagers," Earnest says. "If we're at home when we get the page, we immediately get in the car and we're in the hospital within 30 minutes, ready to treat the patient in the cath lab."

In the past seven years at Geisinger, there have been 11 instances when two STEMI patients have arrived at the same time. Although they don't have a formal second call team system, in
each instance they asked cath lab team members who were not on call to come in to treat the patient, and without exception everyone asked reported to the hospital immediately.

"Although that's an infrequent situation, that also gives me pride about how the care providers at Geisinger put their patients first," Berger says.

Success key No. 3: Sharing data and generating buy-in

Collecting and analyzing data from each STEMI patient and distributing that information to all parties involved helps heart attack receiving centers to identify and address variants and weak points.

Many, including Geisinger, have a dedicated STEMI nurse coordinator who provides feedback on every single patient to the referring hospital, EMS, and everyone else who was involved in that patient's care. The data—including the amount of time it took to complete each step of the process, from the field EKG to transport to cath lab—is then analyzed for opportunities for improvement.

"It's an incredibly important part of the process because once you have developed a system that meets the needs of patient, a different set of interventions is required to maintain excellence," Berger says. "Every single one of the nearly dozen time intervals we record are analyzed to see if there are any opportunities for improvement. When those other care providers do well, we send them periodic recognition of their excellence in contributing to [the] care of heart attack patients in the STEMI network, and many display that with pride in their emergency departments."

Summa Akron City Hospital feeds its STEMI patient data into a software program that breaks down each component of the patient's presentation and generates reports filled with colorful graphs and charts. "Because of this software, we really have a very quantitative analysis of each STEMI patient," Berkovitz says. "We immediately send feedback to all constituents, from the interventional cardiologist to the ER team to the paramedics."

The data is sent to stakeholders within 24 hours of the patient's entry into the system. When possible, pictures of the patient's artery are included along with the synopsis and graphic breakdown. As a result of analyzing this data, Berkovitz was able to determine that the EMS evaluation-to-balloon time (versus door-to-balloon time) was an opportunity for improvement. After working with EMS team members, the E-to-B times began to improve.

"[The EMS workers in the field] are the ones getting faster and the ones leading the charge," he says. "As a receiving center it's absolutely critical to have them engaged and have them understand how important they are, as well as give them that feedback and data so they can see how they're doing. That way they can have actionable data points so they can improve their processes, and it's very rewarding. And what that does is set the table for the next time these people take care of a STEMI patient—they know they are really an important part of the team."

When Akron City Hospital began tracking EMS times in 2009, the E-to-B time was 81 minutes, below the national benchmarks of 90 minutes for direct presentation and 120 minutes for transfers from another medical facility. As of Q4 2013, the hospital's E-to-B time was down 76 minutes.

To drive home the sense of ownership and buy-in among team members, Summa Akron City tries to infuse some fun into the process, by giving out T-shirts to high-performing EMS workers and rewarding the fastest cath lab team with a free coffee cart for a month.

Baptist Health also shares patient data with everyone involved in the patient's care and internally holds a quarterly meeting with all stakeholders to review each STEMI case.

"All of that is really critical because then it generates buy-in and everyone feels like they're doing something," says Dillon. "The cardiologist gets all the praise, but to be honest we can't do it without our team. And when you get that buy-in from people it creates tremendous pride, and the staff at our hospital are extremely proud of our program."

Success key No. 4: Financial considerations

Though patients are returned to the referring hospital for follow-up care, the hospital sending STEMI patients to a receiving center does take a financial hit.

"The referring hospital not only loses the money from the patient they just referred, but because of that, the acuity level of the overall hospital is slightly lower and, as a result of their immediate transfer of heart attack patients, they are reimbursed slightly less for patients with other medical or surgical illnesses," Berger says. "If a referring hospital sends all heart attack patients to a receiving hospital, their next gallbladder removal is reimbursed slightly less, so there's a financial incentive for institutions to do the wrong thing."

As for heart attack receiving centers, the actual financial benefit is unclear.

"Getting designated as an accredited heart attack STEMI receiving center is hard to do and not everyone can do it," Dillon says.

The actual number of extra patients Summa Akron City receives isn't that high, Berkovitz says, but being designated as a heart attack receiving center is important validation of its excellent cardiac care program and likely has a halo effect on other service lines.

"That's where we begin to receive business benefits," he says. "Being a heart attack receiving center is part of the portfolio of a full-service, leading cardiovascular program. It commits to a standard of care and it requires your organization to have an infrastructure and a commitment to excellence, and I think that is a good business strategy."

Reprint HLR0814-8