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Research led by a Carolinas HealthCare System emergency physician, along with physicians and nurses representing the state of North Carolina, resulted in an article published in Circulation: The Journal of the American Heart Association assessing the appropriate activation of cardiac catheterization labs in a Code STEMI situation.
Results show that no more than 15 percent of the cath labs had to be cancelled after activation, confirming the STEMI system is working well. The collaborative research effort is the first of its kind in the United States to look at cath lab activations from a multi-system perspective.
Carolinas Medical Center, the Level I Trauma center at Carolinas HealthCare System, is leading the nation in treatment times for heart attack patients. In the most recent data set from Mission: Lifeline, the median time from hospital arrival until reperfusion is 42 minutes, with the state and national average timed at 59 minutes. The data sets looks at patients who arrived by ambulance and those who presented to the emergency department without using EMS services.
For STEMI patients who are transferred to Carolinas Medical Center from referral hospitals, the median time from arrival at the referral hospital until reperfusion at Carolinas Medical Center is 87.5 minutes, with the national median time being 110 minutes. Guidelines recommend treatment times within 90 minutes of arrival at the referral hospital, and with processes in place the cases at Carolinas Medical Center this goal is accomplished for 75 percent of patients. This goal is achieved in 37 percent of patients treated in North Carolina and only 27 percent of patients in the nation as a whole.
“This research is unique in that it was a collaboration among emergency medicine physicians and cardiologists to assess process in the care of heart attack patients,” said J. Lee Garvey, MD, principle investigator and Director of Emergency Cardiac Care in the Department of Emergency Medicine at Carolinas Medical Center. “By looking at the continuum of care from ambulance transport to cath lab interventions, we hope to continually streamline our processes to care for our patients in the fastest time possible.”
The article was published in and Dr. Garvey led the research based on a program called Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE). RACE is a state-wide program dedicated to enhancing the care of heart attack patients, and involves activating the STEMI system at the earliest opportunity. Door to balloon times are shown to improve when the EMTs can read and interpret an EKG, most times without a cardiology consultation.
This particular study looked at approximately 3,900 cases in 14 hospitals over 13 month period, assessing the patient’s diagnoses and treatment and whether activation of the cath lab was appropriate by the EMT’s. The study showed that 85 percent of STEMI activation was appropriate and patients either needed an intervention or a stent. Fifteen percent of the activations were inappropriate and involved misinterpretations of the EKG in the ambulance and in the emergency department. Five percent of those activations were inappropriate because of the patient’s age, illness, complications or refusal of treatment.
The study helped researchers see how different systems across the state were activated and the difference in appropriateness of activation. Findings also show that there is improvement in collaboration among hospital systems in North Carolina. As a result of the inappropriate activation findings, Dr. Garvey and his team are working to better educate EMTs and ED staff on appropriate interpretations of EKGs.
“We are moving in the right direction in terms of decreasing treatment times for heart attack patients across the state of North Carolina,” he added. “Our next step is to assemble a national working group to determine uniform definitions for care in hopes to better align our system with others in the nation.”