Heart attack victims in Eastern and Central Kentucky are getting life-saving treatment more quickly, thanks to a national quality improvement study with cooperative involvement from several local hospitals. The year-long study, called Accelerator-2, took place in 12 metropolitan areas across the country under the umbrella of the American Heart Association.
Dr. Khaled Ziada
It focused on each region collaborating, developing and using the same procedures for EMS patients having a heart attack. The study’s goal was for 75 percent of heart attack patients to be undergoing an angioplasty within 90 minutes of contact with their first medical responder (EMS), which research shows significantly reduces in-hospital mortality rates.
“With every minute that passes, more heart muscle gets damaged, and you can’t get it back,” said Dr. Khaled Ziada, this region’s principal investigator and clinical chief of cardiology at Gill Heart and Vascular Institute, which is part of UK HealthCare. “And the longer time passes, the higher the risk of death.”
Hospitals had been working on reducing their times independently, but “it wasn’t organized and it wasn’t standardized,” Ziada said, and EMS protocol depended on which hospital the patient was taken to.
Nationally, at the beginning of the project, 67 percent of the patients were undergoing angioplasty within 90 minutes, Ziada said. By the end, it was 74 percent. The Central and Eastern Kentucky region, which has one of the highest rates of heart disease in the country, saw an even bigger improvement.
“Regionally, we were achieving the goal 64 percent of the time [when we started] and were able to improve to 77 percent. We were able to exceed the goal in our region.” — Dr. Khaled Ziada
“Regionally, we were achieving the goal 64 percent of the time [when we started] and were able to improve to 77 percent,” said Ziada. “We were able to exceed the goal in our region.”
For Central and Eastern Kentucky, the new protocol included further training and empowering EMS to diagnose a heart attack from the patient’s ECG reading and ready them for treatment. It also included letting the closest hospital with a heart catheterization lab know immediately that the patient was in route so a heart team could be assembled.
Fourteen regional facilities with heart cath labs and EMS agencies throughout Central and Eastern Kentucky took part in the study, including Baptist Health Lexington, Saint Joseph Hospital and UK HealthCare. In most circumstances, the three Lexington health care providers are fierce competitors, but representatives from all three hospitals agreed collaborating to save patients’ lives came first.
“It was a coordinated regional effort, as well as the three hospitals here,” said Megan Switzer, chest pain coordinator at Baptist Health Lexington. “We are not usually at the same table when we are talking about the care of patients, so it was really good to be able to collaborate with the hospitals here in town.”
One of the things that made agreeing on a standardized procedure easier was the availability of evidence-based information on the most effective treatment of heart attack patients, and the emphasis on time and early notification. “We asked EMS to make the diagnosis quickly, whether by air or by ground, off the ECG,” Ziada said. “We gave them Plan A and Plan B.”
Plan A was to get to the nearest hospital that does angioplasty, he said. Plan B, if they were too far, was to go to the nearest hospital for a clot-busting medicine or to be set up for transfer. “We created an algorithm that shows which is better to use at which time,” Ziada said.
Each participating hospital had a coordinator who collected data, gave performance feedback to EMS, and then sent the information to Ziada. In turn, Gill provided a feedback report to the hospitals and also forwarded the research to a national database. The data was submitted blind, so none of the participants could compare themselves to each other, only to the regional data as a whole and to national benchmarks. This reduced reluctance to participate and allowed hospitals and EMS agencies to focus on improving their own data.
“With the data, we could show them, and ourselves, where the weaknesses are,” Ziada said.
At Saint Joseph Hospital, the data collection helped identify that a disproportionate number of their heart attack patients were arriving by personal vehicle rather than EMS, said Paula Fox, director of Heart and Vascular Care for Saint Joseph and Saint Joseph East.
“That gave us a regional opportunity to do a public education campaign on why you should call 9-1-1,” she said. This led to finding out that in some smaller, more rural communities, people were reluctant to call EMS, because they had so few ambulances and worry about the time it will take for one to reach them. In turn, Fox said they are lobbying the state for legislation to promote EMS funding and expansion across the state.
"We were able to measure how we take care of heart attack patients in the region against other Accelerator projects across the nation, and we are able to establish what is appropriate and what is not." — Chuck O’Neal, deputy executive director of the Kentucky Board of EMS
Chuck O’Neal, deputy executive director of the Kentucky Board of EMS, said one of the most helpful aspects of the Accelerator project for EMS was the clear directive to get patients where they needed to go for the best long-term outcome rather than taking them to the nearest hospital. Also, as a result of the Accelerator projects, many hospitals in the region are now allowing EMS to take patients directly to their heart cath lab rather than the emergency room, saving more valuable time.
“I think the Accelerator project was phenomenal, and the lessons learned were phenomenal,” said O’Neal. “And we were able to measure how we take care of heart attack patients in the region against other Accelerator projects across the nation, and we are able to establish what is appropriate and what is not. We also were able to have a significant improvement in collaboration, and I’m certain it’s made a positive outcome in patients’ lives.”