When it comes to treating patients who have suffered a myocardial infarction, time is muscle, according to a common saying in cardiac care circles. In recent years time has become so important that hospitals publicly report door-to-balloon times the interval from the patients arrival at the hospital to inflation of the balloon to restore blood flow. Reimbursements from the Centers for Medicare & Medicaid Services are tied to meeting the goal of 90 minutes or less for door-to-balloon times.
Last year researchers published surprising results from a study that explored whether faster door-to-balloon times are saving lives for patients who suffer a ST segment elevation myocardial infarction, in which blood flow is completely blocked to a portion of the heart.
The results, which were published in the Sept. 5 issue of the New England Journal of Medicine, showed that even though the door-to-balloon times decreased from 83 minutes to 67 minutes between July 2005 and June 2009 at 515 hospitals nationwide, the mortality rate for patients in those facilities did not change.
I was disappointed because hospitals are spending considerable time, effort and resources to try and get the door-to-balloon times down, and wed like to believe it is making an impact, said Daniel Menees, MD, FACC, the lead investigator and an assistant professor of internal medicine at University of Michigan Hospital and Health Systems. It makes intuitive sense that the sooner we open the artery, the better, but I really wanted tangible proof that this is decreasing mortality rates.
For nurses such as Holli DeVon, RN, PhD, FAHA, FAAN, an associate professor in the department of biobehavioral health science at the University of Illinois at Chicago, the findings confirmed her research hypothesis that hospital efficiency may not be the primary problem when it comes to saving more lives after a MI.
The authors concluded that perhaps it is time to stop focusing on the hospital delay time and focus more on pre-hospital time, which is my area of interest, said DeVon, a Fellow of the American Heart Associations Council on Cardiovascular and Stroke Nursing. I believe most patients wait too long to go to the emergency department or call EMS, and they control a good part of how quickly they receive care.
Reasons people wait
To determine the impact of faster door-to-balloon times, Menees and his fellow researchers analyzed data from more than 96,000 admissions for patients undergoing primary percutaneous coronary intervention for STEMI. Although the median door-to-balloon times decreased by 16 minutes between the first and last year, there was no significant change in in-hospital mortality rates, which hovered around 4.7%.
DeVons research suggests the benefits of these faster times may be lost because many patients wait hours to seek medical attention. In a 2010 report in the Journal of Cardiovascular Nursing, DeVon and her colleagues studied 256 patients from cardiac step-down units at two large urban medical centers in Milwaukee. They found that the median time from symptom onset to arrival in the hospital was 6 hours for men (average age 62) and 9.5 hours for women (average age 67). If blood flow is not restored within two to three hours after the onset of symptoms, there is little benefit to the heart, she said.
People may wait because they are worried about being embarrassed if it is not a heart attack and they go to the ED, DeVon said. People worry about the cost and about missing time from work. One of the reasons women wait longer is because they are more frequently caregivers and have a responsibility to children, parents or spouses.
By studying the barriers to seeking treatment for a MI, DeVon, who has done a series of studies of symptoms during acute coronary syndrome, hopes to spark discussions about how hospitals and communities can overcome these obstacles. For grandmothers who are providing childcare, for example, she suggests a daycare in the ED. I have had patients tell me, I could not come until after 5 p.m. because my daughter doesnt get off until 5, and she wont get paid if she doesnt work.
If the cost of parking at an urban hospital is a barrier for some, hospitals conceivably could find donors willing to create a fund to cover the cost of parking, DeVon said.
Another reason people may delay seeking treatment is the fact that the symptoms may not be clearly linked to this serious condition.
We tend to view a heart attack as having obvious symptoms such as severe and ongoing chest pain, but many symptoms are more subtle, said Debra Moser, RN, DNSc, FAAN, director of the Center for Biobehavioral Research in Self-Management of Cardiopulmonary Disease at the University of Kentuckys College of Nursing. People may have mild chest pain or no chest pain, shortness of breath, back pain, pain in other areas, anxiety or excessive fatigue.
Moser believes educating patients about these more mild symptoms is critical, and a possible opportunity to do this is when they are in the hospital.
If they are in the hospital, they are usually more receptive because they feel vulnerable, Moser said. We have to tell them that cardiopulmonary disease is chronic. They often get the wrong message that they are fixed after angioplasty, but they can still have another event and need to pay attention to symptoms. They also need to recognize that they may have similar or different symptoms.
Other possible settings for education include cardiac rehabilitation at a clinic or doctors office and community education programs, Moser said.
Disadvantages of faster times
For some nurses, the studys findings were good news because the pressure to achieve faster door-to-balloon times can have consequences.
The results of the study didnt surprise me, and they also support the thought a lot of us have that we are doing a disservice to the patient if we go too quickly, said Barry Allen, RN-BC, BSN, manager of cardiology services at Baylor Medical Center in Irving, Texas.
If caregivers are rushing to move patients to the cath lab, it is harder to take time to ask important questions about a patients medical history, Allen said. You can get so much valuable information during that time that may help with the treatment, such as whether the patient had a stent, is on blood thinner, has any terminal illnesses, and the list goes on and on. This information may even change whether or not we bring them to the lab.
Menees agrees. In an effort to speed up efficiency, he has seen the false activation rate increase for the MI team at his hospital. Physicians can misinterpret the EKG because they have to make a quick decision and there is a lot of pressure, and chest pain may not be an acute myocardial infarction, Menees said. Are we working too hard to work too fast?
One way to avoid a rushed decision is to encourage patients to call 911 rather than drive to the hospital, Allen said. EMS providers transmit the EKG while en route to Baylor. They also are trained to read the EKG, allowing the physician in the ED to begin collecting information long before the patient arrives.
Calling 911 is the best thing because then patients have skilled, trained professionals who can do things like resuscitate a sick patient and communicate with the ED earlier, Allen said.
The take-away message
Although the long-term impact of Menees findings is not clear, he hopes his results wont give caregivers the wrong message. Speed is still an important factor, and when I am on call, I still come in as soon as possible and try to get the patients on the table quickly, he said.
This concept particularly is important for patients who survive an MI, a group that was not covered in the study. Mortality and quality of life after a heart attack are two separate issues, Allen explained. Each minute that passes by can lead to more cellular death and tissue scarring, which makes it difficult for the heart to pump effectively. For patients who survive, heart failure can lead to another set of issues, such as shortness of breath, leg swelling and difficulty with physical activity.
The study also illustrates that when hospitals are motivated to improve an aspect of care, significant change is possible. During the four-year study, the percentage of patients with door-to-balloon times of 90 minutes or less increased significantly, from 60% to 83%.
That is amazing, DeVon said. We have made great strides. Now that weve done about as much we can do in hospital, we need to focus on things outside the hospital. This may be more difficult to control and research, but it is entirely possible, especially when you consider what we have achieved so far.
Read the New England Journal of Medicine study: www.nejm.org/doi/full/10.1056/NEJMoa1208200