Emergency Physician Cath Team Activation Slashes Door-To-Balloon Times, But Only a Quarter of Hospitals Adopt Practice
2007; Elsevier BV; Volume: 50; Issue: 6 Linguagem: Inglês
10.1016/j.annemergmed.2007.10.005
ISSN1097-6760
Autores Tópico(s)Emergency and Acute Care Studies
ResumoIn the movie Ghostbusters, the character played by Bill Murray fends off the seductive advances by a demon-possessed Sigourney Weaver, saying, “I make it a rule—never get involved with possessed people.”When she kisses him passionately, he breaks free and gasps, “Actually, it’s more of a guideline than a rule.”For years, a 90-minute door-to-balloon time has been the guideline—but seldom the rule—for myocardial infarction patients. That may be about to change. At least 3 recent studies have begun building an evidence-based case for empowering the emergency physician to activate the cath lab team without calling in a cardiologist to make the decision, one of the most important factors in slashing door-to-balloon times.At the Troy Beaumont Hospital, in Troy, MI, researchers found that in the 6 months before the protocol was revised to allow emergency physicians to activate the team, the average door-to-balloon time was 147 minutes. Afterward, the average was 106 minutes.At St. Francis Hospital in Indiana, the average time during regular hours was 113 minutes before the change versus 75 minutes afterward, and 123 minutes versus 77 during off-hours.A wide-ranging study of 365 hospitals surveyed the difference in door-to-balloon times for 6 different strategies, one of them allowing the emergency physician to activate the cath team. The difference between those who did and those who didn’t was 8.2 minutes.Building a Critical Mass“There’s a huge critical mass building on the issue, and I don’t think anyone thinks that it’s a bad idea,” said Elizabeth H. Bradley, professor at the Yale School of Public Health and lead author of the latter study, which was published in November 2006 in the New England Journal of Medicine.If “time is muscle,” and this is such a good idea, why isn’t everyone doing it? The study by Bradley et al found that only 22 percent of the hospitals surveyed allowed emergency physicians to activate the cath team in regular hours, and just 27 percent in off-hours. (She says it’s probably significantly more now.)“Just because it makes sense doesn’t mean that you can just flip a switch and easily do it,” said Dr. Joon Sup Lee, associate chief of cardiology at the University of Pittsburgh Medical College, citing “institutional barriers” as the principal obstacle.“This is breaking the mold of how most specialized medical decisionmaking is occurring,” said Lee, whose college made the change about 2 ½ years ago.“We cut door-to-balloon times almost in half in a year,” said Lee’s colleague at Pittsburgh, Donald M. Yealy, MD, vice chairman of emergency medicine, adding that it required considerable groundwork. “The cardiologist has to be willing to give up control; it’s a big step.”Proponents note that the cardiologist is not losing any control over the final decision—whether to do the procedure. After all, he is the one that has to perform it. In fact, if the cath team is called in at the same time as he is, they will be ready to go when he does make the decision.Challenging Tradition“Medicine tends to be a field of convention and tradition, and a lot of things that we do is because that’s the way it’s been done, and questioning it has always been a big thing,” said Dr. Umesh Khot, lead researcher on the St. Francis study. “ Right now, with our own institution, this is very accepted, but when we started this a couple of years back this caused an enormous amount of political and almost negative feedback.”He continued, “Especially at night or after-hours on the weekend, you’re talking about mobilizing, in our case, about 6 or 7 cath members, 4 or 5 of them from home. . . If you had a large amount of false activations—that would rapidly burn out your staff.”But false activations have not been found to be a problem by any of the published studies or at any of the adopting institutions. “In our case, it was like one out of 100, and in that case it was really more of a misdiagnosis than it was a miscommunication. We have really no issue as far as accuracy of diagnosis.”Others echoed that opinion. Jeptha Curtis, an interventional cardiologist and instructor at Yale’s School of Medicine, said, “There is a certain amount of suspicion on the side of cardiologists that they’re the only ones that can interpret an EKG correctly and there will be too many false activations if they are not allowed to see the EKG and interview the patient before activating the lab.”But, he added, “In our study, the number of false activations was quite low, on the order of about one per month.”Yealy said the requisite diagnosis before making the activation decision is a limited one and the symptoms are quite recognizable: “The people who benefit the most are the ones who have the specific type of heart attack where the ST segment is elevated. That’s not that hard to pick up. It’s within the skill set of the vast majority of emergency physicians.”“The false positive, or the cry-wolf scenario,” said Dr. Lee, “has occurred very, very rarely. Our experience has been that once empowered and once you set the communication between the emergency department and cardiology that the decision-making is pretty robust, and the emergency physicians are very good at making the right call.”And Bradley agrees. “If the emergency physician overcalls that would be a problem. But even if it is a false activation, there are things that a cardiologist might want to do other than a percutaneous coronary intervention.“The other problem is an under-call. I don’t think either of those is corroborated heavily in the research literature that they happen often enough to stop people.”Creating ConsensusIf the research supports the idea, and practical experience has verified it, the next problem is getting everyone to accept it. All those hospitals that adopted the procedure say there are several things that must happen for it to be implemented successfully.First, everyone involved—medical staff, management and the emergency nurses and technicians—must buy into it beforehand. And leadership from the top is imperative.“I can’t overemphasize the importance of the institutional commitment to make this happen,” said Lee, “because without that you can’t get that interdepartmental cooperation.”After that comes cardiology-emergency medicine agreement on exactly where the borderline is between making the call and not making it. Simple enough if there is one emergency medicine provider and one cardiology provider, seldom the case.“In many facilities,” said Dr. Lee, “the hospitals are dealing with several different cardiology groups who are rotating call, so to get an agreement from all the cardiology groups on the same phone call may not be that easy.”Asked if the staff enthusiastically accepted the new procedure, once adopted, Dr. Khot laughed and said, “No, I wouldn’t say that. They did it, but I think until the numbers started coming back there was still a lot of skepticism that it would work.”That highlights another important aspect of reducing door-to-balloon times: feedback. Khot said real-time access to the data on times and results are crucial and a common aspect of the most successful programs.“We’ve sort of made it a contest,” said Dr. Pat Crocker, medical director at Brackenridge Hospital in Austin, Texas. “How short can you make the ED stay, how fast can you get the patient into the lab, how fast can you get him prepped and ready. We report those numbers monthly and everybody looks at them and we send ‘attaboy’ notes back to the physician, nurses and the technicians who were involved in the shortest times.”The same approach has been very successful at Lee’s center in Pittsburgh.“We’ve instituted a system that within 24 hours everyone who’s touched that patient knows exactly what the timeline was,” he said.Besides the benefits of reducing times to below 90 minutes—shown by the National Registry of Myocardial Infarction to have a mortality rate of about 3%, compared to 7.4% for 150 minutes or more—the new procedure might also reduce patient stays and hospital costs.In the St. Francis study, Khot said, the average costs dropped from $28,826 per admission to $18,280. He said they are now studying the impact on hospital revenues, and hope to publish the results in six to eight months.Before the DoorOnce most hospitals have reduced the time from the door to the balloon, several doctors said, the next step is cutting the time lost before the patient even gets to the door. Some institutions have already begun tackling that problem.“We can get the team ready before they even show up,” said Pittsburgh’s Dr. Yealy. “With today’s technology, an EKG is essentially just an electrical signal that can be sent by a cell phone from virtually anywhere. It’s not that difficult.”At St. Francis, said Khot, “We have had EKGs in the ambulance for about a year and are still working on integrating that into our system.”Dr. Crocker said they are implementing out-of-hospital EKGs at Brackenridge in Austin but want to push the decision point even further than that—into the home or other place where the patient first presents to a paramedic.“If you look across the country, the average time between call for assistance to 911 and arrival at the hospital is almost pushing an hour. And so our approach was ‘Let’s change the thinking of the paramedic at the scene’ … We have re-educated (them) to think ‘OK, a chest pain patient? They’re awake and talking? The next question is, ‘Do they have ST segment elevation?’ So, we get the EKG on ‘em, and if there is demonstrable ST segment elevation, the paramedic calls the hospital right then.”The American College of Cardiology has set up a growing network—the D2B Alliance—of institutions that are aggressively tackling the issue of reducing times. It currently numbers some 900 hospitals, more than half of those nationwide that do percutaneous coronary interventions.And between 250 and 350 institutions have participated in D2B’s ongoing series of “Webinars” offering advice and support on implementing the various strategies of cutting door-to-balloon times.The process is accelerating and, according to Dr. Crocker, it must: “Hospitals that can’t get beyond serial processing of the acute MI patient will never meet the AHA guideline, never in a million years. They’ll never get there.” In the movie Ghostbusters, the character played by Bill Murray fends off the seductive advances by a demon-possessed Sigourney Weaver, saying, “I make it a rule—never get involved with possessed people.” When she kisses him passionately, he breaks free and gasps, “Actually, it’s more of a guideline than a rule.” For years, a 90-minute door-to-balloon time has been the guideline—but seldom the rule—for myocardial infarction patients. That may be about to change. At least 3 recent studies have begun building an evidence-based case for empowering the emergency physician to activate the cath lab team without calling in a cardiologist to make the decision, one of the most important factors in slashing door-to-balloon times. At the Troy Beaumont Hospital, in Troy, MI, researchers found that in the 6 months before the protocol was revised to allow emergency physicians to activate the team, the average door-to-balloon time was 147 minutes. Afterward, the average was 106 minutes. At St. Francis Hospital in Indiana, the average time during regular hours was 113 minutes before the change versus 75 minutes afterward, and 123 minutes versus 77 during off-hours. A wide-ranging study of 365 hospitals surveyed the difference in door-to-balloon times for 6 different strategies, one of them allowing the emergency physician to activate the cath team. The difference between those who did and those who didn’t was 8.2 minutes. Building a Critical Mass“There’s a huge critical mass building on the issue, and I don’t think anyone thinks that it’s a bad idea,” said Elizabeth H. Bradley, professor at the Yale School of Public Health and lead author of the latter study, which was published in November 2006 in the New England Journal of Medicine.If “time is muscle,” and this is such a good idea, why isn’t everyone doing it? The study by Bradley et al found that only 22 percent of the hospitals surveyed allowed emergency physicians to activate the cath team in regular hours, and just 27 percent in off-hours. (She says it’s probably significantly more now.)“Just because it makes sense doesn’t mean that you can just flip a switch and easily do it,” said Dr. Joon Sup Lee, associate chief of cardiology at the University of Pittsburgh Medical College, citing “institutional barriers” as the principal obstacle.“This is breaking the mold of how most specialized medical decisionmaking is occurring,” said Lee, whose college made the change about 2 ½ years ago.“We cut door-to-balloon times almost in half in a year,” said Lee’s colleague at Pittsburgh, Donald M. Yealy, MD, vice chairman of emergency medicine, adding that it required considerable groundwork. “The cardiologist has to be willing to give up control; it’s a big step.”Proponents note that the cardiologist is not losing any control over the final decision—whether to do the procedure. After all, he is the one that has to perform it. In fact, if the cath team is called in at the same time as he is, they will be ready to go when he does make the decision. “There’s a huge critical mass building on the issue, and I don’t think anyone thinks that it’s a bad idea,” said Elizabeth H. Bradley, professor at the Yale School of Public Health and lead author of the latter study, which was published in November 2006 in the New England Journal of Medicine. If “time is muscle,” and this is such a good idea, why isn’t everyone doing it? The study by Bradley et al found that only 22 percent of the hospitals surveyed allowed emergency physicians to activate the cath team in regular hours, and just 27 percent in off-hours. (She says it’s probably significantly more now.) “Just because it makes sense doesn’t mean that you can just flip a switch and easily do it,” said Dr. Joon Sup Lee, associate chief of cardiology at the University of Pittsburgh Medical College, citing “institutional barriers” as the principal obstacle. “This is breaking the mold of how most specialized medical decisionmaking is occurring,” said Lee, whose college made the change about 2 ½ years ago. “We cut door-to-balloon times almost in half in a year,” said Lee’s colleague at Pittsburgh, Donald M. Yealy, MD, vice chairman of emergency medicine, adding that it required considerable groundwork. “The cardiologist has to be willing to give up control; it’s a big step.” Proponents note that the cardiologist is not losing any control over the final decision—whether to do the procedure. After all, he is the one that has to perform it. In fact, if the cath team is called in at the same time as he is, they will be ready to go when he does make the decision. Challenging Tradition“Medicine tends to be a field of convention and tradition, and a lot of things that we do is because that’s the way it’s been done, and questioning it has always been a big thing,” said Dr. Umesh Khot, lead researcher on the St. Francis study. “ Right now, with our own institution, this is very accepted, but when we started this a couple of years back this caused an enormous amount of political and almost negative feedback.”He continued, “Especially at night or after-hours on the weekend, you’re talking about mobilizing, in our case, about 6 or 7 cath members, 4 or 5 of them from home. . . If you had a large amount of false activations—that would rapidly burn out your staff.”But false activations have not been found to be a problem by any of the published studies or at any of the adopting institutions. “In our case, it was like one out of 100, and in that case it was really more of a misdiagnosis than it was a miscommunication. We have really no issue as far as accuracy of diagnosis.”Others echoed that opinion. Jeptha Curtis, an interventional cardiologist and instructor at Yale’s School of Medicine, said, “There is a certain amount of suspicion on the side of cardiologists that they’re the only ones that can interpret an EKG correctly and there will be too many false activations if they are not allowed to see the EKG and interview the patient before activating the lab.”But, he added, “In our study, the number of false activations was quite low, on the order of about one per month.”Yealy said the requisite diagnosis before making the activation decision is a limited one and the symptoms are quite recognizable: “The people who benefit the most are the ones who have the specific type of heart attack where the ST segment is elevated. That’s not that hard to pick up. It’s within the skill set of the vast majority of emergency physicians.”“The false positive, or the cry-wolf scenario,” said Dr. Lee, “has occurred very, very rarely. Our experience has been that once empowered and once you set the communication between the emergency department and cardiology that the decision-making is pretty robust, and the emergency physicians are very good at making the right call.”And Bradley agrees. “If the emergency physician overcalls that would be a problem. But even if it is a false activation, there are things that a cardiologist might want to do other than a percutaneous coronary intervention.“The other problem is an under-call. I don’t think either of those is corroborated heavily in the research literature that they happen often enough to stop people.” “Medicine tends to be a field of convention and tradition, and a lot of things that we do is because that’s the way it’s been done, and questioning it has always been a big thing,” said Dr. Umesh Khot, lead researcher on the St. Francis study. “ Right now, with our own institution, this is very accepted, but when we started this a couple of years back this caused an enormous amount of political and almost negative feedback.” He continued, “Especially at night or after-hours on the weekend, you’re talking about mobilizing, in our case, about 6 or 7 cath members, 4 or 5 of them from home. . . If you had a large amount of false activations—that would rapidly burn out your staff.” But false activations have not been found to be a problem by any of the published studies or at any of the adopting institutions. “In our case, it was like one out of 100, and in that case it was really more of a misdiagnosis than it was a miscommunication. We have really no issue as far as accuracy of diagnosis.” Others echoed that opinion. Jeptha Curtis, an interventional cardiologist and instructor at Yale’s School of Medicine, said, “There is a certain amount of suspicion on the side of cardiologists that they’re the only ones that can interpret an EKG correctly and there will be too many false activations if they are not allowed to see the EKG and interview the patient before activating the lab.” But, he added, “In our study, the number of false activations was quite low, on the order of about one per month.” Yealy said the requisite diagnosis before making the activation decision is a limited one and the symptoms are quite recognizable: “The people who benefit the most are the ones who have the specific type of heart attack where the ST segment is elevated. That’s not that hard to pick up. It’s within the skill set of the vast majority of emergency physicians.” “The false positive, or the cry-wolf scenario,” said Dr. Lee, “has occurred very, very rarely. Our experience has been that once empowered and once you set the communication between the emergency department and cardiology that the decision-making is pretty robust, and the emergency physicians are very good at making the right call.” And Bradley agrees. “If the emergency physician overcalls that would be a problem. But even if it is a false activation, there are things that a cardiologist might want to do other than a percutaneous coronary intervention. “The other problem is an under-call. I don’t think either of those is corroborated heavily in the research literature that they happen often enough to stop people.” Creating ConsensusIf the research supports the idea, and practical experience has verified it, the next problem is getting everyone to accept it. All those hospitals that adopted the procedure say there are several things that must happen for it to be implemented successfully.First, everyone involved—medical staff, management and the emergency nurses and technicians—must buy into it beforehand. And leadership from the top is imperative.“I can’t overemphasize the importance of the institutional commitment to make this happen,” said Lee, “because without that you can’t get that interdepartmental cooperation.”After that comes cardiology-emergency medicine agreement on exactly where the borderline is between making the call and not making it. Simple enough if there is one emergency medicine provider and one cardiology provider, seldom the case.“In many facilities,” said Dr. Lee, “the hospitals are dealing with several different cardiology groups who are rotating call, so to get an agreement from all the cardiology groups on the same phone call may not be that easy.”Asked if the staff enthusiastically accepted the new procedure, once adopted, Dr. Khot laughed and said, “No, I wouldn’t say that. They did it, but I think until the numbers started coming back there was still a lot of skepticism that it would work.”That highlights another important aspect of reducing door-to-balloon times: feedback. Khot said real-time access to the data on times and results are crucial and a common aspect of the most successful programs.“We’ve sort of made it a contest,” said Dr. Pat Crocker, medical director at Brackenridge Hospital in Austin, Texas. “How short can you make the ED stay, how fast can you get the patient into the lab, how fast can you get him prepped and ready. We report those numbers monthly and everybody looks at them and we send ‘attaboy’ notes back to the physician, nurses and the technicians who were involved in the shortest times.”The same approach has been very successful at Lee’s center in Pittsburgh.“We’ve instituted a system that within 24 hours everyone who’s touched that patient knows exactly what the timeline was,” he said.Besides the benefits of reducing times to below 90 minutes—shown by the National Registry of Myocardial Infarction to have a mortality rate of about 3%, compared to 7.4% for 150 minutes or more—the new procedure might also reduce patient stays and hospital costs.In the St. Francis study, Khot said, the average costs dropped from $28,826 per admission to $18,280. He said they are now studying the impact on hospital revenues, and hope to publish the results in six to eight months. If the research supports the idea, and practical experience has verified it, the next problem is getting everyone to accept it. All those hospitals that adopted the procedure say there are several things that must happen for it to be implemented successfully. First, everyone involved—medical staff, management and the emergency nurses and technicians—must buy into it beforehand. And leadership from the top is imperative. “I can’t overemphasize the importance of the institutional commitment to make this happen,” said Lee, “because without that you can’t get that interdepartmental cooperation.” After that comes cardiology-emergency medicine agreement on exactly where the borderline is between making the call and not making it. Simple enough if there is one emergency medicine provider and one cardiology provider, seldom the case. “In many facilities,” said Dr. Lee, “the hospitals are dealing with several different cardiology groups who are rotating call, so to get an agreement from all the cardiology groups on the same phone call may not be that easy.” Asked if the staff enthusiastically accepted the new procedure, once adopted, Dr. Khot laughed and said, “No, I wouldn’t say that. They did it, but I think until the numbers started coming back there was still a lot of skepticism that it would work.” That highlights another important aspect of reducing door-to-balloon times: feedback. Khot said real-time access to the data on times and results are crucial and a common aspect of the most successful programs. “We’ve sort of made it a contest,” said Dr. Pat Crocker, medical director at Brackenridge Hospital in Austin, Texas. “How short can you make the ED stay, how fast can you get the patient into the lab, how fast can you get him prepped and ready. We report those numbers monthly and everybody looks at them and we send ‘attaboy’ notes back to the physician, nurses and the technicians who were involved in the shortest times.” The same approach has been very successful at Lee’s center in Pittsburgh. “We’ve instituted a system that within 24 hours everyone who’s touched that patient knows exactly what the timeline was,” he said. Besides the benefits of reducing times to below 90 minutes—shown by the National Registry of Myocardial Infarction to have a mortality rate of about 3%, compared to 7.4% for 150 minutes or more—the new procedure might also reduce patient stays and hospital costs. In the St. Francis study, Khot said, the average costs dropped from $28,826 per admission to $18,280. He said they are now studying the impact on hospital revenues, and hope to publish the results in six to eight months. Before the DoorOnce most hospitals have reduced the time from the door to the balloon, several doctors said, the next step is cutting the time lost before the patient even gets to the door. Some institutions have already begun tackling that problem.“We can get the team ready before they even show up,” said Pittsburgh’s Dr. Yealy. “With today’s technology, an EKG is essentially just an electrical signal that can be sent by a cell phone from virtually anywhere. It’s not that difficult.”At St. Francis, said Khot, “We have had EKGs in the ambulance for about a year and are still working on integrating that into our system.”Dr. Crocker said they are implementing out-of-hospital EKGs at Brackenridge in Austin but want to push the decision point even further than that—into the home or other place where the patient first presents to a paramedic.“If you look across the country, the average time between call for assistance to 911 and arrival at the hospital is almost pushing an hour. And so our approach was ‘Let’s change the thinking of the paramedic at the scene’ … We have re-educated (them) to think ‘OK, a chest pain patient? They’re awake and talking? The next question is, ‘Do they have ST segment elevation?’ So, we get the EKG on ‘em, and if there is demonstrable ST segment elevation, the paramedic calls the hospital right then.”The American College of Cardiology has set up a growing network—the D2B Alliance—of institutions that are aggressively tackling the issue of reducing times. It currently numbers some 900 hospitals, more than half of those nationwide that do percutaneous coronary interventions.And between 250 and 350 institutions have participated in D2B’s ongoing series of “Webinars” offering advice and support on implementing the various strategies of cutting door-to-balloon times.The process is accelerating and, according to Dr. Crocker, it must: “Hospitals that can’t get beyond serial processing of the acute MI patient will never meet the AHA guideline, never in a million years. They’ll never get there.” Once most hospitals have reduced the time from the door to the balloon, several doctors said, the next step is cutting the time lost before the patient even gets to the door. Some institutions have already begun tackling that problem. “We can get the team ready before they even show up,” said Pittsburgh’s Dr. Yealy. “With today’s technology, an EKG is essentially just an electrical signal that can be sent by a cell phone from virtually anywhere. It’s not that difficult.” At St. Francis, said Khot, “We have had EKGs in the ambulance for about a year and are still working on integrating that into our system.” Dr. Crocker said they are implementing out-of-hospital EKGs at Brackenridge in Austin but want to push the decision point even further than that—into the home or other place where the patient first presents to a paramedic. “If you look across the country, the average time between call for assistance to 911 and arrival at the hospital is almost pushing an hour. And so our approach was ‘Let’s change the thinking of the paramedic at the scene’ … We have re-educated (them) to think ‘OK, a chest pain patient? They’re awake and talking? The next question is, ‘Do they have ST segment elevation?’ So, we get the EKG on ‘em, and if there is demonstrable ST segment elevation, the paramedic calls the hospital right then.” The American College of Cardiology has set up a growing network—the D2B Alliance—of institutions that are aggressively tackling the issue of reducing times. It currently numbers some 900 hospitals, more than half of those nationwide that do percutaneous coronary interventions. And between 250 and 350 institutions have participated in D2B’s ongoing series of “Webinars” offering advice and support on implementing the various strategies of cutting door-to-balloon times. The process is accelerating and, according to Dr. Crocker, it must: “Hospitals that can’t get beyond serial processing of the acute MI patient will never meet the AHA guideline, never in a million years. They’ll never get there.”
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