Cardiac & Resuscitation, News, Patient Care

Houston Cardiac Patients to Bypass ER Delays

HOUSTON — For people suffering a heart attack, every minute counts.

Quick treatment is so important that Houston Fire Department paramedics plan to transport such patients only to hospitals with streamlined emergency procedures, so a life-saving angioplasty can be performed within 90 minutes.

Until recently, few hospitals met the American College of Cardiology standard.

Now, it has become a priority in Houston and nationwide, with hospitals scrambling to decrease “door-to-balloon” time — the minutes it takes to transport a patient from the ambulance into the catheterization laboratory and inflate a balloon inside the artery to restore blood flow to the heart.

“If this works out the way we all hope it will, there won’t be any (local hospitals) with bad times,” said Dr. David Persse, physician-director of Houston Fire Department Emergency Medical Services, which responds to 911 calls within the city.

Beginning as early as fall, he hopes to direct his paramedics to transport patients only to hospitals that comply with the standard.

As many as half of the 865,000 people who have heart attacks each year suffer from serious artery blockages best treated with angioplasty, a procedure used to clear those obstructions, according to the American Heart Association. Patients who have blockages that can’t be remedied with angioplasty sometimes undergo bypass surgery.

Most hospitals that manage to treat patients within 90 minutes do so by allowing heart attack patients to bypass the emergency room, where delays often occur, and go directly from the ambulance to the catheterization lab.

The process worked for Richard Watrous, 49, who suffered a heart attack in February.

The Dallas resident was preparing for an awards reception at a Houston hotel when he felt pressure, which gradually turned to pain, in his chest. He called 911 and was picked up by Houston Fire Department paramedics, who examined him in the ambulance.

“My EMT looked at me and said, ‘It ain’t gas,’ ” Watrous said.

The paramedics transported him to Memorial Hermann-The Texas Medical Center, a local forerunner in fast door-to-balloon time.

There, Watrous thought he would have to wait in the emergency room while doctors decided whether he needed surgery.

“I was surprised I went straight from the ambulance into the cath lab,” said Watrous, who underwent an angioplasty and has since mostly recovered.

Skipping the ER

Patients like Watrous skip the emergency room because they’re diagnosed en route to the hospital rather than on arrival.

Inside the ambulance, paramedics perform a diagnostic test known as an electrocardiogram, or EKG, and relay the results via cell phone to an emergency room physician.

The physician determines whether the patient is, indeed, suffering a heart attack and whether angioplasty is the proper treatment.

The doctor then pages the angioplasty team so members can make their way to the operating room and prepare for the procedure.

“We will be standing in the cath lab, waiting for the patient to show up,” said Dr. James McCarthy, Memorial Hermann’s director of emergency medical services and a professor at the University of Texas Medical School at Houston.

At hospitals that have not yet streamlined the process, it can take longer than the recommended 90 minutes — sometimes even hours — to admit a patient, diagnose him or her and give the cath lab team time to prepare and perform an angioplasty.

There’s evidence that mobilizing quickly improves patient outcomes.

For each 30-minute treatment delay, risk of death within a year increases by more than 7 percent, according to an article published in the American Heart Association journal Circulation in 2004.

Swift treatment also means less damage to the heart muscle.

“Time is muscle,” said Bryan Croft, vice president of operations for the Methodist DeBakey Heart and Vascular Center, where door-to-balloon times have improved drastically during the last year.

Online comparisons

Like other hospitals across the country, Methodist felt pressure not only from Houston paramedics but also from a U.S. government-run Web site called Hospital Compare.

Created in 2005, the Web site allows consumers to compare hospital performance on specific care measures, such as door-to-balloon time.

Because patients transported by ambulance can ask paramedics to take them to a specific facility, well-informed consumers can steer toward what they think is the best hospital.

That means potential customer loss for hospitals if door-to-balloon times aren’t up to par.

A comparison of Houston-area hospitals on the Web site shows that from July 2006 to June 2007, the latest data available, only a small percentage performed an angioplasty within 90 minutes for at least 75 percent of their patients, as recommended by the American College of Cardiology.

Among the hospitals that treated nearly all patients within that time frame were Memorial Hermann, Clear Lake Regional Medical Center and Conroe Regional Medical Center.

Improvements, however, have occurred so rapidly in the Houston area during the last year that the online data is outdated, administrators at many hospitals say.

Improving the time

St. Luke’s Episcopal Hospital, for example, has met the 90-minute window for the last 10 months, said the hospital’s vice president, Mike Reno.

Hospital staff streamlined the process so patients could go directly to the cath lab, partly because they were “shocked and dismayed” at their statistics on the Web site, he said.

Several other hospitals, including Methodist and Memorial Hermann Memorial City Medical Center, also now meet the standard, physicians said.

Across the country, an increasing number of hospitals are treating patients within 90 minutes, said Dr. Ralph Brindis, vice president of the American College of Cardiology.

Some were motivated by a study published in the New England Journal of Medicine in 2006 that showed only one-third of patients nationwide were being treated within that time frame.

But few communities go so far as to transport patients only to facilities that meet the standard, said Brindis, who supports the concept as planned in Houston.

“The goal here is not to be punitive to hospitals,” he said. “The goal here is to raise the bar of all the hospitals.”

To some extent, Houston Fire Department paramedics already favor hospitals that are known to treat heart attack patients quickly.

They decide where to transport patients based on several factors, including location, patient preference (or where his or her cardiologist practices) and whether a hospital is equipped to treat the patient.

When patients are transported to the Texas Medical Center and don’t have a hospital preference, paramedics often take them to Memorial Hermann because of its track record, Persse said. That has sparked complaints from other hospitals.

“(Paramedics) know from personal experience, if they go down to Hermann, they often go right to the cath lab,” he said.

Chronicle reporter Lynn Cook contributed to this report.

[email protected]