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Streamlined ER Treatment Cuts Heart Disease Death Rate Nationwide
The New York Times has taken an in-depth look at changes in U.S. emergency rooms (ERs) that have led to a 38% decline in the death rate from coronary heart disease from 2003 to 2013.
With little fanfare, hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart, the Times reports. Driven by a nationwide campaign led by the American College of Cardiology, hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to ERs and summoning medical teams with a single call that sets off all beepers at once.
Between 2003 and 2013, the death rate from coronary heart disease fell about 38%, according to data from the Centers for Disease Control and Prevention. The National Heart, Lung, and Blood Institute credited this decline to better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments — and faster care of people experiencing a heart attack.
Today, nearly all hospitals treat at least half of their heart attack patients in 61 minutes or less, according to recent data from the American College of Cardiology. At Yale–New Haven Hospital, where half the patients used to have to wait at least 150 minutes before their arteries were opened, the median time is now 57 minutes. At the Mayo Clinic and at major academic centers, such as New York-Presbyterian Hospital, it is 50 minutes.
The improvements in heart attack treatment have spilled over into the care of stroke patients, the Times says. For strokes, too, the time it takes to be treated with clot-dissolving tissue plasminogen activator (tPA) is crucial. Neurologists began to copy the cardiologists.
“Heart disease mortality is dropping like a stone. This is a reason why,” said Dr. Eric Peterson, a cardiology researcher at Duke University. “And stroke has fallen to fifth as a major killer. This is a reason why.”
The heart story began nearly a decade ago, when a Yale cardiologist, Harlan Krumholz, MD, and his colleagues looked at a Medicare database that showed how long it took hospitals across the country to open heart patients’ arteries. The researchers visited the 11 best- performing hospitals and recorded every detail of how the centers got things done. They ended up with a short list of what the top performers had in common. The list included paramedics transmitting electrocardiogram readings to ERs; ER doctors deciding whether a person was likely having a heart attack; and hospital operators summoning treatment teams with a single phone call. The stellar hospitals also continually measured performance.
Krumholz was particularly struck by the fact that interventional cardiologists were giving up the power to decide whether they and the entire staff required to open an artery needed to dash in, often in the middle of the night. At Yale and most other places, Krumholz noted, the procedures had been very different, with a long telephone chain of doctors and other staff members called one by one as precious minutes ticked by.
The researchers then surveyed 365 hospitals and discovered that those that had used one or more of six specific strategies to cut down on the time it took to get patients to the treatment room and open their arteries did better than those that had not, and that as more strategies were used, patients were being treated increasingly faster.
Krumholz and his colleagues persuaded the New England Journal of Medicine to publish their already-accepted paper during the same week in November 2006 that the American College of Cardiology announced a national campaign to get hospitals to change their ways. Twelve hundred hospitals committed to doing so.
Doctors and hospitals began competing to see who could have the best treatment times. Within a few years, the times need to open heart patients’ arteries were dropping all over the nation.
Sources: FierceHealthcare; June 22, 2015; New York Times; June 19, 2015; and NEJM; November 30, 2006.