For residents of Salt Lake Valley, the Intermountain Heart Institute provides advanced heart care, including coronary stenting and open-heart surgery, at a single, high-volume hub — Intermountain Medical Center. While some patients come to the heart institute from Intermountain's emergency department or other departments within the center, others arrive from four transfer hospitals, which lack catheterization laboratories.
However they arrive at the institute, patients with heart attacks (myocardial infarction, or MI) benefit significantly from optimal care. A subset of these patients have a type of MI called ST elevation MI, or STEMI, which requires opening of the blocked artery. A STEMI heart attack is a high-risk medical emergency that requires rapid diagnosis and treatment. The national standard of care is that every STEMI heart attack patient should receive life-saving balloon therapy within 90 minutes of arrival. This is also referred to as door-to-balloon time.
We at Intermountain Heart Institute took a proactive step: We decided we would achieve the standard door-to-balloon time for patients who initially arrive at the four transfer hospitals — LDS Hospital, Alta View Hospital, Riverton Hospital and Park City Medical Center. Doing so meant that all patients diagnosed with a STEMI heart attack at any of these hospitals would need to be treated within the 90-minute window — transportation included.
Meeting the 90-Minute Deadline
It was an extraordinarily ambitious challenge to take this step, given that the four transfer hospitals, all part of the Intermountain Healthcare system, are located between eight and 34 miles from Intermountain Medical Center. We had to design and implement a process that would maximize efficiency by clarifying authority, streamlining communications and ensuring seamless transitions at every step along the way.
The result is that we have surpassed the 90-minute standard 100 percent of the time, for three consecutive years, for the five hospitals connected by this intricate hub-and-spoke system. It's a remarkable feat, particularly as the average time is around 65 minutes. We now hope that the lessons we learned will be helpful as other systems around the country address similar circumstances. Indeed, the national reported average door-to-balloon time for patients who are transferred from another hospital is 145 minutes — well above the national standard of 90 minutes.
As a result of successful acute treatment of these patients with a STEMI, along with continued excellence in hospital care, the Intermountain Heart Institute has had less than half the national MI mortality, along with less than half the 30-day readmission rate. In fact, the institute was recognized last year by Medicare for having the lowest 30-day readmission rate for MI patients.
The challenge for Intermountain Healthcare was multifaceted. Successful implementation requires a close partnership and efficient communication between hospitals as well as between departments and participating service lines — including EDs, emergency medical services, the coronary intensive care unit and the catheterization lab, among others.
Achieving 100 percent compliance for three years in a row for all five hospitals has required a finely orchestrated initiative involving many people. The lessons we've learned include the following:
First, it took 30 people meeting every other week for six months to put the needed processes in place. The STEMI team was composed of physicians, nurses, cath lab technicians, paramedics, hospital operators, administrators and even nonmedical personnel. They represented the five hospitals involved and each step in the door-to-balloon sequence (from arrival at a hospital to the inflation of the balloon). For every step in that sequence, each team member had to be satisfied with the plan if we were to achieve 100 percent compliance.
Second, we had to simplify communications and authorize action. We designated the charge nurse in the coronary ICU at the Intermountain Heart Institute as the person who could activate the cath lab and alert the technician and intervention cardiologist, and who would need to be called in to respond to the emergency. We authorized the ED doctor in charge at any of the hospitals to call the charge nurse and set the process in motion. We also trained the EKG technicians in the EDs to recognize a heart attack, and we authorized them to take troubling observations directly to the doctor.
We set up the process and authorized those who could speed it up to act without unnecessary time-consuming steps in the middle. We also required that all communications take place on the telephone so it was immediately clear whether the communication had been received and acted upon. At 8 a.m. every morning, the charge nurse placed an initial call to the cath lab technician and intervention cardiologist on duty to ensure that they were ready and on call.
Third, we set 80 minutes as the goal, not 90 minutes, because every process has 10 percent leeway, and we could not afford going over by even 10 minutes. We also assigned timelines to each step in the door-to-balloon sequence. If a patient was treated in more than 80 minutes, we drilled down to see where the lost time occurred.
Fourth, we required rapid feedback to the STEMI team on the results of every case, no matter how long the case took, to ensure that we understood every step of the way. We analyzed those results and refined the process as needed. When we saw delay-prone steps in the protocol, we developed automatic safety nets so that human error could occur, but we had a backup mechanism to ensure that rapid treatment continued.
Down to 55 Minutes
At Intermountain Healthcare we are firm believers that you manage what you measure, and we designed and measured every step in this process and every case that arose. In all, about 100 people have been involved in the process over three years, with Kent Meredith, M.D., a cardiologist, leading the STEMI team, and David Barnes, M.D., chair of emergency medicine at Intermountain Medical Center, serving as the emergency department lead. About 225 patients have been treated annually by this process.
Overall, the average door-to-balloon time for STEMI patients at Intermountain Medical Center is 55 minutes; the fastest time recorded was 11 minutes. Our STEMI mortality rate is 4 percent, compared with 15 percent nationally.
For STEMI patients, minutes matter to the ultimate health of the patient. It's inspiring and rewarding to create and implement a system that can achieve perfection of this kind, especially when it's carried out by a multidisciplinary team of caregivers from multiple venues. It underscores how the combination of a learning health care system, clear channels of communication and authority, and management by measurement can achieve spectacular results.