Health Care Quarterly:

New help changes the game when a heart attack strikes

Recently implemented approaches to cardiac care often provide life-saving benefits for Southern Nevada patients who might not have survived a heart attack just a few years ago.

University Medical Center and other organizations across Southern Nevada have worked to help heart attack patients. We have experienced a tremendous shift in caring for patients who exhibit signs of ST-elevation myocardial infarction (STEMI). STEMI heart attacks occur when a patient’s coronary artery is completely blocked, cutting off the blood flow to a section of the heart and potentially resulting in significant and irreversible damage.

For STEMI patients, every minute counts. In most cases, STEMI patients require an angioplasty or stenting of the blocked vessels at a cardiac catheterization laboratory. This minimally invasive procedure involves the use of a catheter inserted through the arm or groin with an attached balloon that is guided to the coronary artery and inflated to open the artery, restoring the flow of blood. Cardiologists also typically insert a coronary stent, a small tube designed to prevent the artery from closing.

Years ago, Southern Nevada’s health care community took a disjointed approach to caring for these patients. EMS professionals could perform electrocardiogram (EKG) testing to identify patients with STEMIs before reaching the hospital, but they lacked the ability to initiate processes within the hospital, such as activating the cardiac catheterization lab team. Their primary objective was to get the patient to the hospital as quickly as possible. Once in the ER, the patient would be registered and receive an another evaluation. If the second EKG confirmed the prehospital test, the interventional cardiologist and the catheterization lab team would be notified. The cardiologist would want to review the EKG to confirm the diagnosis before making the decision to mobilize the necessary resources.

Even when teams executed this process flawlessly, it would still take anywhere from 20 to 30 minutes.

It became clear that Southern Nevada’s health care community required a more focused and collaborative strategy to provide faster access to definitive care, which is why local hospitals work alongside the American Heart Association, EMS agencies and additional key stakeholders to implement the Mission: Lifeline Regional STEMI Plan in Southern Nevada. The American Heart Association developed Mission: Lifeline to improve care for heart attack patients while promoting collaboration and focusing heavily on quality measures.

STEMI patients now have the advantage of receiving more coordinated care. EMS crews can activate a “Code STEMI” in the prehospital setting, sometimes within minutes of arriving at the patient’s side. This can provide a valuable head start for the cardiology team, especially during evening hours when some team members must be called in to the hospital.

Once the patient arrives in the emergency department, an emergency medicine physician analyzes the electrocardiogram performed by the EMS provider and transports the patient to the catheterization lab as quickly as possible. We do not waste time asking questions about the patient’s insurance or gathering any other information that is not immediately necessary. Our goal is to get the patient directly to the highly trained team waiting in the catheterization lab. There are cases in which the process occurs so quickly that the patient is never placed in an emergency department bed, and the EMS crews assist by transporting the patient directly to the catheterization lab, where they are able to witness the life-saving intervention being performed. That instantaneous feedback is priceless.

While we once sought to achieve a door-to-balloon time of 90 minutes for STEMI patients, a metric that primarily focused on the hospital side of the patient’s care, this goal has now changed in the wake of our continued focus on providing patients with more immediate intervention. The new benchmark established by the American Heart Association, known as “first-medical-contact-to-device-activation” time, recognizes the vital impact that EMS crews have in this process and incorporates the prehospital arena of care into the 90-minute treatment goal. As a result, the goal has now been shifted to allow just 90 minutes from the time that the first EMS crewmember arrives at the patient’s side to begin a procedure in a cardiac catheterization lab that is sometimes miles away from the patient.

As a result of our ongoing collaboration with many EMS agencies in Southern Nevada, UMC and our EMS partners frequently achieve first-medical-contact-to-device-activation times significantly less than 90 minutes. In fact, UMC had a median first-medical-contact-to-device-activation time of 69 minutes for non-transferred STEMI patients in the first and second quarters of 2016, which is more than three minutes faster than the national figure for the same quarters.

Christian Young, MD, FACEP is an emergency medicine physician at UMC, medical director for the Office of Emergency Medical Services and Trauma System of the Southern Nevada Health District, co-chair of the Mission: Lifeline Accelerator Program and assistant residency director for the Emergency Medic