Integrated city-wide emergency protocol cuts heart attack deaths by half
Research and trials led by Dr. Michel Le May, Director of UOHI's CoronaryCare Unit, have proven that taking a fresh approach to cardiac treatment leadsto a significant reduction in mortality. Specifically, the Heart Institutemodel trains advanced care paramedics to diagnose ST-Elevation MyocardialInfarction (STEMI), a major form of heart attack, and route patients directlyto the Heart Institute, bypassing local emergency departments (ED). At UOHI,an emergency STEMI team, available 24/7, administers the type of care provento be optimal for the survivability of STEMI patients.
"The whole point to this approach is to eliminate time, either time spentin an ED or from the moment an ambulance crew responds to a 911 call to themoment effective treatment is administered," said Dr. Le May. "The longer ittakes to receive appropriate care, the greater the risk of damage to the heartand, by extension, the higher the rate of mortality."
Dr. Le May's results in the New England Journal of Medicine (2008;353:231-40) show that, using the new protocol, in-hospital heart attack deathsbetween May 2005 and May 2006 dropped to less than 5% for Heart Institutepatients, down from 10% for patients who were treated using conventionalapproaches.
Traditionally, patients experiencing chest pains who arrived at theemergency department were examined by the ED doctor and, in consultation witha cardiologist, the STEMI condition was diagnosed. In the majority of cases,clot-busting drugs (thrombolytics) were administered and the patient'scondition subsequently monitored. With this approach, patients requiring"urgent" additional treatment were often transferred to the Heart Instituteonly after a 2-3 hour delay.
With the new protocol, the ED doctor who detects a STEMI case immediatelyarranges for an ambulance to route the patient to the Heart Institute. Nothrombolytics are employed and no local cardiologist is required.Alternatively, paramedics who respond to a 911 call can also diagnose a STEMIcondition and proceed directly to the Heart Institute, bypassing the ED.
In both cases, a "Code STEMI" is triggered and a specialized HeartInstitute team is waiting to perform a Percutaneous Coronary Intervention(PCI) or angioplasty. This method involves using a balloon to clear blockedarteries.
In its first full year of using the Heart Institute's new protocol, atotal of 344 STEMI patients were transported to the Heart Institute. Of these,209 were delivered by ambulance from local hospital EDs and 135 weretransported directly from the field as a result of 911 calls. The mediandoor-to-balloon time for patients arriving via the ED was 123 minutes and was69 minutes for those arriving via 911 calls.
In the case of ED routing, about an hour of time was saved with the newprotocol compared to previous reports on inter-hospital transfer of patientsfor PCI. However, by relying on paramedics to diagnose the STEMI, an extremelylow door-to-balloon time was achieved. As well, by proceeding directly to theHeart Institute, the paramedics were able to reduce traffic volume to EDs byabout 40%.
Other research directed by Dr. Le May has shown that PCI is superior toclot busting drugs in saving heart attack patients. In further findings,inserting a stent by angioplasty to improve blood flow was also much lesscostly than using a clot busting drug. Overall hospitalization costs werelower. So too was length of stay in hospital.
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