Allegheny Health Network Partners with Region’s EMS Providers to Advance Treatment of Heart Attack Patients

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“First Contact-to-Balloon” Initiative Accelerates Patient Diagnosis, Empowers EMS to Activate Hospital Cardiac Teams

Bruce MacLeod, MD, Chair, Department of Emergency Medicine, West Penn Hospital and Co-Chair of American Heart Association's Mission Lifeline Program

"By raising the bar even further and shifting the focus of our Network-wide strategy...we believe we can set a standard that dramatically improves the treatment of heart attacks across our region."

When a heart attack strikes, time is never on the victim’s side. Without swift treatment to restore blood flow to the heart, a patient’s chances of survival or escaping serious cardiovascular injury diminish by the minute. That’s particularly true for a dangerous type of heart attack called ST-elevation myocardial infarction (STEMI), in which a coronary artery is completely blocked.

Allegheny Health Network physician leaders announced today that they are standardizing a newer concept in heart attack care that seeks to improve STEMI outcomes by enabling Emergency Medical Services (EMS) providers throughout western Pennsylvania to diagnose patients from the field and alert hospital cardiac catheterization teams to begin preparing for their arrival.

The “First Contact-to-balloon” initiative, also called EMS-to-Balloon (E2B), builds on the concept of “door-to-balloon time” and pushes STEMI care to the next level, said Thomas Campbell, MD, Chair of the Department of Emergency Medicine at Allegheny Health Network.

National guidelines established by the American Heart Association call for a “door-to-balloon time” – the time it takes from when a patient arrives at the hospital emergency department to when their blocked blood vessel is opened with a balloon catheter – of 90 minutes or less.

“First Contact marks a major change in how we have traditionally approached the broader management of patients who suffer a heart attack outside the hospital,” Dr. Campbell said. “Time is the most important factor in determining who survives a heart attack, and “First Contact” protocols have shown the capacity to very effectively shorten the time it takes for patients to receive the treatment they need.”

All Allegheny Health Network hospitals with cardiac catheterization labs are participating in the “First Contact” program, including Allegheny General Hospital, Forbes Hospital, Jefferson Hospital, Saint Vincent Hospital and West Penn Hospital.

Several of those hospitals, including Forbes, Jefferson and Saint Vincent already have well established STEMI “first contact” protocols with EMS in their respective communities. Participating EMS providers in these programs can digitally transmit patient electrocardiogram results to hospital medical teams while en-route for timely assessment of the patient’s needs before arrival.

Electrocardiograms interpret the heart’s electrical activity via electrodes that are attached to the surface of the skin. The technology measures the rate and regularity of heart beats, the size and position of the heart’s chambers and the presence of any heart damage.

At Saint Vincent, such collaboration with EMS has reduced the average door-to-balloon time to 45 minutes. At Forbes, the average is 65 minutes and at Jefferson it’s 66 minutes – all significantly below the AHA’s 90 minute benchmark.

“By investing in the capabilities of EMS providers, we have greatly enhanced the quality of healthcare available to those who live in our communities. Without question, this unique collaboration has helped save lives,” said Adrian D’Amico, MD, Chair, Department of Emergency Medicine at Forbes Hospital.    

Allegheny Health Network is looking to not only expand the success of programs like those at Forbes, Jefferson and Saint Vincent across all of its hospitals but to now target an even more aggressive 90-minute goal from the time someone experiencing heart attack symptoms is first seen by an EMS provider to the time treatment is rendered.

“By raising the bar even further and shifting the focus of our Network -wide strategy to what we can do better prior to patients arriving at the hospital door, we believe we can set a standard that dramatically improves the treatment of heart attack across our region,” said Bruce MacLeod, MD,Chair of the Department of Emergency Medicine at West Penn Hospital and Co-Chair of the American Heart Association’s Mission: Lifeline program.

“We saw that the biggest potential opportunity to further expedite the care of STEMI patients was to recognize the advanced capabilities of our EMS colleagues and empower them to play an even more prominent role in diagnosing STEMI and initiating the treatment process.”

Dr. MacLeod said that early results of this expanded protocol at the Network’s city hospitals have been extremely encouraging.

At Allegheny General Hospital, for example, door-to-balloon times have averaged 72 minutes with traditional activation of the cath lab once a patient arrives in the emergency department. Patients treated via the “first contact” protocol since May have averaged 57 minutes.

“Fifteen minutes is a significant improvement in heart attack care,” said Robert McCaughan, Vice President of Pre-Hospital Care Services at Allegheny Health Network. “Our goal, however, is to keep lowering the first contact-to-balloon averages at all of our hospitals to the greatest extent possible."

Allegheny Health Network’s expansion of the “first contact” protocol comes just as national researchers and leading medical associations are questioning whether door-to-balloon initiatives are improving heart attack care - and whether a “first contact” focused system would be the more effective approach.

A University of Michigan study published in the September 5, 2013 New England Journal of Medicine suggests that though national door-to-balloon times have dropped significantly, the faster response has not improved overall patient mortality.

The study concluded that time between the patient’s onset of symptoms and treatment is more critical than the time between a patient’s arrival in the emergency room and treatment.

“From the very second a heart attack begins, the patient’s clock begins ticking and the longer it ticks prior to treatment, the more limited our ability to minimize injury to the heart and achieve a good outcome becomes. We are extremely proud of the work we have done with EMS providers in Erie to accelerate and improve the care of heart attack victims, and we also look forward to collaborating with our Allegheny Health Network colleagues on efforts to enhance those protocols even further,” said Casey Becker, MD, an interventional cardiologist at Saint Vincent Hospital.

A 2012 analysis by the AHA found that pre-hospital ECGs shortened door-to-balloon time by two-thirds and EMS personnel correctly identified 85 percent of patients with STEMI using the portable ECG.
Those findings provide a great deal of confidence in the ability of EMS to have a profound impact on outcomes in the setting of STEMI, said Daniel A. Rubin, MD, Medical Director of the Cardiac Catheterization Laboratory at Jefferson Hospital.

“First Contact requires a significant amount of teamwork and trust among EMS providers, emergency medicine specialists and cardiovascular specialists,” Dr. Rubin said. “Our region is extremely fortunate to have such an outstanding group of well trained, experienced EMS providers to help lead this important initiative.”

Under the direction of Dr. Rubin and his colleagues at Jefferson’s Heart Institute, the hospital in August became the state’s first to be named an American Heart Association’s Mission: Lifeline® Heart Attack Receiving Center. Both Saint Vincent and Allegheny General have also since received the designation, which recognizes hospitals that are uniquely qualified, equipped and committed to improving STEMI care.

“Allegheny Health Network’s hospitals have helped pioneer many breakthroughs in the treatment of coronary artery disease over the past three decades, from new disease-fighting medications to life-saving procedures such as balloon angioplasty and coronary artery stent implantation,” said Srinivas Murali, MD, Director, AGH Division of Cardiovascular Medicine, and Medical Director, Allegheny Health Network Cardiovascular Institute.

“We are confident that ‘First Contact’ will be yet another milestone in our Network’s legacy of innovation that improves the outcomes of patients who suffer from this prevalent, life threatening cardiovascular injury.”

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