Travis Gullett, M.D., an emergency physician, at Cleveland Clinic in Ohio, talks about a novel way to cut the time it takes to get heart attack patients life-saving care.
Interview conducted by Ivanhoe Broadcast News in November 2016.
What is actually happening when someone comes in with a heart attack?
Dr. Gullett: With a heart attack, what we are concerned about is called a STEMI a ST-segment Elevation Myocardial Infarction, so in a heart attack that actually have an infarct. An infarct is when the heart actually doesn’t give blood flow at which point you start to get destruction of the heart cells and then the heart cells start to die. It does two things, one the heart quits pumping as strong as it should; two because the heart is an electrical pump, the electrical circuitry that runs through the heart that makes it pump in the regular pattern that it should starts to get disrupted as well. As a heart attack, where there is not enough blood flow the heart stops pumping, as well as it should, but it quits functioning from an electrical prospective which things can quickly deteriorate into a fatal rhythm where the heart stops beating, either due to strength or due to the electrical component. What we are fighting against is essentially a heart attack and the heart just quits working.
It’s just a race against time. So as an emergency physician, when people come into the ER with a heart attack what is the first priority?
Dr. Gullett: The first priority actually starts even before that, so chest pain. Chest pain, abdominal pain are the two leading causes of people coming to the emergency department so in any given day up to a fifth of the patients might come in with a chest pain complaints or complaints that might be similar to chest pain or the person with nausea, vague arm pain, not feeling well; because not all heart attacks have pain with them. What we try to do is screen out those patients, so any patient that might be considered for having a heart attack we get an EKG within ten minutes and have the ED attending, or ED staff physician read it. The whole goal is to catch who is having a heart attack. That is what starts the process once we know someone is having a heart attack and we are looking for subjective criteria on an EKG. That is when you spring into action, as far as trying to get medications on board and coordinating with our colleagues to get the patients to the catheterization lab. The whole goal is if there is a blockage we want to open it. Sometimes, we can use medications to do that but the primary means is actually a heart catheterization where someone actually goes in with a small guide wire, floats it up to the heart and opens it. Basically, a fancy plumber and so we try to take care of the heart that way.
What role does the emergency department play in getting a heart attack patient treated as quickly as possible?
Dr. Gullett: The first step is early recognition, once you know you have a heart attack then time is the utter upmost importance. Once we know it is a heart attack the first thing is the contact our cardiology colleagues to let them know to get that cath lab ready and set to go. The next step is to get the patient ready for the cath lab as well as to go ahead and start the process of getting medications onboard. We will get pads in place on the chest, on the back, in case the heart goes into a bad rhythm; and we can shock it, keep it pumping like it should, blood work, and IV’s. If we have time we will even go ahead and shave and prep either the wrist or the groin depending where they are going to do the catheterization. Our goal really is to get the patient ready to get the initial medications on board involving an aspirin, an anti platelet agent, often times Heparin so once we know it is the right patient to go ahead and get them ready to go.
One of the things we were talking about is the door-to-balloon time, can you explain it for people who may not know what that means, what is door-to-balloon time?
Dr. Gullett: Door-to-balloon time basically takes the time you hit the front door of the hospital of the emergency department, just physically walking in to the time when the device in the heart is actually opening up the blood flow. What we found is, if you measure a whole bunch of steps in between, time to EKG, time to aspirin, time to ED providers; time to this time for that you can start to look at small details but our whole goal is to get the higher liabilities system so what do we as a global marker have for how are we doing. For us the door for the balloon time really measures that start to finish process of once we have our first contact with the patient, then to our next, blockages actually that they are opened and that really gives us some marker for how well we are doing as a system.
Can you talk a little bit about what kind of a difference and outcomes can be achieved or either maybe even you have seen as that door-to-balloon time improves?
Dr. Gullett: Yeah, so the cardiology literature what we have seen is the faster you can open up blood flow to the heart, the better the heart does. We are racing against morbidity and mortality being so mortality we want to prevent that but also morbidity.
The faster we can get someone to the cath and get the artery opened up the better the patient is going to do; and ultimately we want to do what is right for the patient. Once the heart starts to lose blood flow and starts to have ischemia and so that lack of blood flow to the cells, the cells start dying and as that progresses the heart doesn’t pump as well, the electrical part of the heart doesn’t work as well. We want to prevent death but then make sure that we can get someone’s heart to function as well as possible after the blood flow is restored. Cardiology has been looking at this for years and now the faster we can get blood flow restored to the heart the better the heart is going to do.
We are talking about what kind of protocols that can be put in place to improve that door-to-balloon time.
Dr. Gullett: For us we wanted a higher liability system, so somewhere to the airline industry, the nuclear reactors, what we can do to make the patients get the same excellent care each and every time with little variance as well as little room for error. What we found is the process really depended on which ED physician was here, which cardiologist was on, when was it, was it daytime, nighttime, the weekend, a holiday and the process vary for every patient. We took a step back, looked at the process as a whole and really coordinated with cardiologist and said look our end goal is what’s right for the patient and so for us we tried to standardize the process, we tried to take out the unnecessary steps and then try to get an agreement on what are some of the core things that we are going to do. What are going to be the medicines we are going to give, how do you want the patient prepped and let’s work on sequencing those things to make sure that the patients had a standard way of going up to the cath lab.
Can you talk a little bit about how you have seen the protocol work, is it working and is it reducing the time?
Dr. Gullett: The protocols work great. The biggest thing we did is we got an agreement and we built up a culture that we are supportive of it. The first thing we did was we sat down with the cardiology, so between the ED and cardiology we knew the literature on both sides of the fence, but let’s put it together and do the right thing for the patient. Once we did that we came up with a theory for how we thought it should work, printed that out it was like a three-fold page paper and then took it to the front line. We took it to our nurses, our paramedics, our physicians, the cardiology fellows, cardiology cath lab, and went through about seventeen revisions before we had it mapped out to what was going to work best. What we found is when you bring positive improvements you need to listen to the people doing the process to make sure you are continuously, improving, revising and making sure it is the most efficient thing. One of the results is in our times, so we may be able to see a reduction in times. We went from probably seventies to eighties as a median time and now to our current median time is forty-nine minutes.
What would you say to other health systems that might be looking at or trying to reach or reduce their time, what can we learn from the protocol here?
Dr. Gullett: As far as the protocol, what we have learned is a couple of things; one make sure all your physicians are talking; two take a step back and look at your process just because it is the way it is always done don’t mean it is the way you should continue to do it; three really involve the caregivers that are involved in the process. For us listening to the paramedics, what IV can you get in, what can you get in quickly, to our pharmacist, where do we have the medicines, how can we easy get it, how could we easily grab it. The other thing is we took the checklist concept, we wanted it to be a real time decision support tool so checklists has been used for years; how about we wanted to make it actionable as well as a helpful guide for decision making process. For us as opposed to the operating room where they do a signed time-out at the very beginning of the procedure, for us the biggest thing we found was done as a time out, once we were done in the ED before going up to the cath lab make sure we hit each of the steps to make sure all of the right things were done and that it was safe for the patient to be transported.
Dr. Gullett: What I would say is the biggest thing in healthcare we are trying to make process improvements, what’s the right thing for the patient and what is the right thing for the patient family. If we can get somebody home to their love ones to their spouse, to their kids, if we can make sure that not only do they go home but can they still work, can they still go for a jog, can they still do the things they want to do. Ultimately, if we are not making a difference for the patient, we are not making a difference. For us overall we want to effect the outcomes for our patients, it wasn’t just a number; our numbers was good, they were satisfactory. They meet the requirements that needed to be done but we knew we could do better. We knew our patients deserved more and for us is really doing what is the right thing for the patient, and stretching, and pushing our system. Once we achieved the numbers we wanted, to get our numbers under 60-minutes we set a new goal of 45, so this past year we have been working to try to get closer to the 45, and as we have been doing that we have been transparent. Our numbers get posted at the front door of the ED. That way patients can see it, nurses, paramedics, physicians; everybody knows that we let people know how we are doing and that we are trying to improve.
END OF INTERVIEW
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