Patient Flow E-Newsletter
Volume 4, Issue 1
February/March
Special Focus Issue-Improving Cardiac Care

Perspectives
When Affairs of the Heart Meet ED Crowding: A National Solution for Cardiac Patient Throughput

As an interventional cardiologist at one of the nation's largest health care complexes, I am primarily concerned with affairs of the heart - and one of the most critical health problems that I am faced with these days is ST-segment myocardial infarction, or STEMI. With an aging population and the increasing prevalence of heart disease, already over-burdened emergency departments (ED) are increasingly being called upon to overcome yet another challenge: quickly ushering acutely-ill cardiac patients through a crowded ED and into cardiac catheterization labs and units in record times, often with decidedly mixed success.

Being the most dangerous form of an acute coronary syndrome, STEMI occurs when there is complete blockage in an artery of the heart with thrombus. When this occurs, it is critical to reopen the blocked artery quickly to avoid greater damage to the heart muscle and the risk of death or disability. Based on evidence from the last decade, widely accepted guidelines recommend the use of primary percutaneous coronary intervention (PCI) for STEMI patients within the first 90 minutes of arrival at the hospital. Without prompt treatment, as the oft repeated health care mantra states, "treatment delayed is treatment denied." And that can have deadly consequences.

Unfortunately, the current realities of our EDs and catheterization labs do not always result in rapid treatment for STEMI patients. It is generally accepted that less than half of STEMI patients receive primary PCI within the 90-minute timeframe in the United States. Given our healthcare resources and access to advanced technologies and devices, I believe the failure to deliver primary PCI in a timely manner is unacceptable. With that in mind, a lot of thought has been given to changes that might improve times in primary PCI both before and after one arrives at the hospital. One solution that is frequently brought up is STEMI regionalization.

Similar to trauma regionalization, the concept of STEMI regionalization calls for developing specific hospitals with cardiac expertise where identified STEMI patients can be treated earlier and more comprehensively than at the average facility. Under regionalization, for example, suspected STEMI patients could be evaluated through pre-hospital EKG screening, administered in the ambulance en route to the hospital. If STEMI is diagnosed, dependent on the patient's condition, the decision could be made to bypass a closer hospital and its ED and head toward the specialized hospital. This designated hospital would always have a catheterization lab ready to provide primary PCI rapidly as well as the necessary care that follows afterward.

To me, the idea of a regionalized system for STEMI patients has intuitive appeal because of the need for catheterization labs that are ready to operate at all times. Catheterization labs that are able to provide primary PCI immediately and around-the-clock are not available in every hospital in the country because of their substantial resource requirements. This may result in significant delays in treatment when STEMI cases present to hospitals that do not typically perform primary PCI. Should the patient need to be transferred from one hospital ED to another hospital for primary PCI, which is not uncommon, the delay may be up to four hours. This is certainly a concern when patients drive themselves to their local hospital and avoid using the emergency medical system all together.

With these delays, it is easy to understand how precious minutes for STEMI patients can be wasted in a crowded ED of a hospital. When primary PCI is delayed in STEMI patients either in the ED or cath lab, the health of the patient is compromised and hospital resources are not used as efficiently as possible. STEMI regionalization offers the opportunity for local communities to better coordinate emergency medical services, maximizing the allocation and effectiveness of specialized resources such as cath labs, and providing higher quality care to all patients.

Like all changes in the health care system, implementing a system of STEMI regionalization would be extremely challenging and require a radical reformation of how we deliver emergency care. Unlike some European countries which have shown relative success in regionalization, hospital networks in the United States are poorly connected, and many regions have pre-hospital emergency medical services that are unable to handle STEMI patients efficiently. And to be sure, a regionalized system of STEMI care would be difficult to develop given the political and economic hurdles especially as hospitals find themselves competing for and heavily reliant upon the revenue from cardiac patients.

Regardless of these issues, I believe that if there is a more timely way for us to provide primary PCI when someone comes through the doors of an institution, then we must seriously consider it. The simple fact is that providing primary PCI in a rapid and safe manner saves lives. Only when cardiologists, emergency physicians, emergency medical technicians and other hospital staff in a given community come together to discuss ways to work better together to improve the overall system will we be able to provide patients with the best possible care when they need it.

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Brahmajee Nallamothu, M.D., M.P.H.
Assistant Professor
University of Michigan Medical School
Ann Arbor, Michigan