Coordinated Response, Quick Treatment Improves Outcomes for Deadly Heart Attacks
UNC REX Cardiologist James Jollis assisted with national study and demonstration project
RALEIGH, N.C. – A coordinated response among EMS paramedics and hospital clinicians reduces the time for crucial treatment for deadly heart attacks and helps save lives, according to a national demonstration project. The study involved one quarter of all patients suffering ST elevation myocardial infarction (STEMI) in the United States across 16 regions, including New York City, Houston, Denver and Saint Louis, and extended procedures and protocols developed in North Carolina and Wake County.
The study was conducted by the American Heart Association and Duke Clinical Research Institute including James Jollis from UNC REX Healthcare, Mayme Lou Roettig and Christopher Granger from Duke, B. Hadley Wilson and J. Lee Garvey from Carolinas Medical Center, and Claire Corbett from New Hanover Regional.
Treatment response times improved the most when trained paramedics diagnosed acute myocardial infarction in the field and activated cardiac catheterization laboratories such as UNC REX prior to patient arrival. This approach allowed patients to be quickly treated upon arrival. The study was published Monday in the American Heart Association’s journal, Circulation.
“The good news is that Wake County is one of the best-performing in the country, and is recognized as a national model for this type of coordination,” said Dr. James Jollis, a cardiologist with North Carolina Heart & Vascular. “Ultimately, death from heart attack should become a rare event.”
At UNC REX, emergency providers coordinate care closely with Wake County EMS and cardiologists. The new North Carolina Heart & Vascular Hospital, which is under construction at UNC REX’s main Raleigh campus and scheduled to open early next year, will provide more opportunities for training and education. Cardiologists with North Carolina Heart & Vascular also have established heart-attack protocols at Johnston Health in Smithfield and Clayton, N.C., and Wayne Memorial in Goldsboro, N.C.
Jollis will discuss cardiac care in Wake County on Thursday, Aug. 4, at an event to celebrate the 40th anniversary of Wake County EMS. The free celebration is open to the public and will start at 7 p.m. at the Duke Energy Center for the Performing Arts. It will include music, a video history presentation and other guest speakers. Visit the WakeGOV website for more information.
“In this area, if you call 911, the paramedics are capable of diagnosing heart attacks and getting you to the right hospital very quickly,” Jollis said. “Fortunately, the Wake County Commissioners and Wake County EMS have long supported careful coordination between paramedics and hospitals. We have a single EMS system, funding to provide great training for paramedics, and the hospitals’ commitment to the community to work in a collaborative fashion. Not every part of the country has such a seamless system, but improvements continue to be made.”
“In our community we're able to take good and effective care of people with acute cardiac events because of great coordination with our partner hospitals,” said Dr. Jose Cabanas, Wake County EMS director. “The success is due to hospitals and EMS collaborating on a system of care, including the ability to regularly share data and identify areas to make more efficient."
The American Heart Association Mission: Lifeline STEMI Systems Accelerator demonstration project created regional care systems aimed at increasing the number of people treated within national guideline recommendations. Historically, of the more than 250,000 people who have a STEMI each year, up to half aren’t treated within the recommended time.
Often considered the most deadly type of heart attack, STEMI happens when the blood supply to the heart is completely blocked. Quickly opening the blocked artery at a hospital that performs percutaneous coronary interventions (PCI) can restore normal blood flow and minimize heart damage.
Carried out between July 2012 and December 2013, the AHA demonstration project was the largest effort to organize regional STEMI care ever attempted in the U.S. The demonstration involved 484 hospitals and 1,253 EMS agencies in 16 regions in the country, treating 23,809 patients presenting with STEMI. There were 11,765 patients transported by EMS and 6502 self-transported directly to PCI-capable hospitals, while 5,542 patients transferred from another facility.
During the time of the demonstration project, there was a modest but significant increase in the proportion of patients meeting the guideline goals. According to Jollis, the problem is a lack of coordination among health care professionals who care for STEMI patients before and after they get to the hospital, as well as diverse treatment plans among the 15,000 EMS agencies and 5,200 acute care hospitals in the United States.
“Paramedics using a 12-lead EKG can immediately recognize if an artery is blocked, so we want to empower paramedics to diagnose STEMI in the field and notify the hospital to activate the heart catheterization team immediately,” Jollis said. “During the transfer to the hospital, the lab is getting ramped up to help the patient, and, ideally, the patient goes right to the lab upon arrival for treatment. That’s the perfect system.”
Improvements among regions varied and overall increases were modest, in part, because all 484 hospitals and 1,253 emergency medical systems were counted in the primary measure, including systems that were slower to incorporate the protocols and systematic changes within the relatively short time window of the intervention, Jollis said.
“In line with the fullest implementation of the project, we began to observe trends toward lower in-hospital mortality compared with national data toward the end of our measurement period,” Jollis said. “The long-term goal is to have this protocol in place for every STEMI patient who suffers a heart attack in the community.”
Read more about the AHA study and demonstration project.