By Staff
SOUTH BEND, Ind. – Dec. 14, 2006, was just like any other Thursday for John Snyder of Niles, who in just two weeks would be celebrating his first full year of retirement.
The unseasonably mild pre-Christmas weather allowed Snyder to get some exercise in his favorite way – a four-mile bike ride through the rolling hills of Southwest Michigan.
"On my dad's side of the family, four of my uncles had heart problems," Snyder said. "So I try to do what's right in getting exercise by taking nice bike rides."
When Snyder returned from his ride, he sat down at his computer experiencing some unusual tightness in his chest. Thinking it was cold air he had taken in, he tried to ignore it – until the tightness persisted, turning to what he called "terrific pain" after just five minutes.
"I told my wife to call an ambulance," he said. "Something is drastically wrong."
While in the ambulance, the EMS crew asked him where he wanted to be taken for treatment. Though "very groggy" by admission, he was able to give a rather emphatic reply: "I want to go to Saint Joe Regional Medical Center," he said.
What followed, literally minutes later, was nothing short of incredible.
At 2:13 p.m., the EMS called SJRMC/South Bend as the 12-lead EKG was started. Immediately, Saint Joseph's Emergency Dr. Bruce Harley called Dr. Turk in the CathLab. At 2:22, Snyder arrived at the South Bend ER and was cared for by Dr. Harley and Saint Joseph's Elizabeth Berger, and Heather Pepper. By 2:27, the EKG was complete. At 2:33, Snyder was in the CathLab, only 11 minutes from the time he arrived in the ER.
By 2:50, Snyder was receiving Percutaneous Coronary Intervention (PCI), and the blockage in his artery had been cleared – an astonishing 28 minutes from his time of arrival.
"They said it was a record," Snyder said. "All I know is that everything was precision, precision, precision – and professionalism. And the treatment I received afterward was fantastic. This is why I tell everyone I know, 'if you're having a health problem, go to Saint Joseph Regional Medical Center.'"
The Need For Speed
In medical jargon, it's called Acute Myocardial Infarction (AMI). You and I know it as a heart attack.
Understanding it isn't quite as complex as one may think, as a heart attack simply is the death of heart muscle from the sudden blockage of a coronary artery, a blood vessel that supplies the heart muscle with blood and oxygen.
Blockage of a coronary artery deprives the heart muscle of blood and oxygen, causing injury to the heart muscle, which causes chest pain and pressure. If blood flow is not restored within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur.
"That's why speed is so crucial when treating heart attacks," said Saint Joseph Regional Medical Center's Dr. Farid Jalinous. "The heart muscle continues to die, permanently replaced by scar tissue. It cannot be repaired because dead is dead."
SJRMC Introduces
913 CODE STEMI
According to the American Heart Association, nearly one million Americans suffer a heart attack each year. Four hundred thousand of them die as a result of their heart attack. This roughly means that every 65 seconds, an American dies of a heart attack.
These sobering statistics prompted Saint Joseph's AMI Taskforce to spearhead a collaborative system with Saint Joseph's Emergency Department and Catheterization Laboratory (CathLab), and the local EMS communities, giving heart attack patients the best possible chance for survival. SJRMC's initiative was met due to the commitment of the hospital's Dr. Jalinous, Dr. Ashfaq Turk, and Dr. Josephine Randazzo, representing Cardiology for each of SJRMC's campuses (South Bend, Mishawaka, and Plymouth), and Dr. Jon Shenk, serving as the ED liaison, and Dr. Bruce Speicher, serving as the EMS liaison.
"Our system is an entirely coordinated effort between the EMS units, ER, CathLab, and Cardiologists," Dr. Turk explained. "And it's the result of meeting after meeting after meeting, this tremendous coordination, and the wonderful support of the Saint Joseph Administration."
The AMI Taskforce began meeting monthly at the end of 2004 and their perseverance and teamwork led to the 913 CODE STEMI (ST-Segment Elevation Myocardial Infarction) – Saint Joseph's activation system for heart attack emergencies. SJRMC implemented the system on Jan. 1, 2006.
How It Works
In order for 913 CODE STEMI to work, coordination between all departments involved is critical.
"What is truly a thing of beauty is the amount of pride everyone takes in their role," said Dr. Jalinous. "It's not rocket science – it's an incredible human effort."
That incredible human effort begins with the EMS teams who bring the patients with chest pain suspicious of cardiac origin to the Emergency Room. EMS at South Bend, Mishawaka, and Plymouth have been educated and trained to implement chest pain protocol, which includes doing a 12-lead electrocardiogram (EKG), a test that measures the electrical activity of the heartbeat. The EMS teams have been instructed to call the ER at all three Saint Joseph campuses to notify the ER physician of a STEMI coming in. As the patient is in route, the EKG result can be faxed from the ambulance to the ER.
"The ER already knows what is going on before the patient arrives," said Dr. Turk. "This makes the ER such an important link in the chain and they have been excellent in getting a jump start on things."
The ER physician activates a 913 STEMI call based on the EMS call in and EKG result. If the patient is a walk-in, the ED physician activates the 913 page as soon as the EKG is completed showing the ST elevation, which indicates a heart attack. The ER physician pushes one button on the telephone that alerts the cardiac CathLab team. They have 30 minutes to arrive.
SJRMC Compared To National Times
In November, 2006, a national study found that only one-third of hospitals provide emergency care to heart attack patients quickly enough to meet scientific guidelines for saving lives, standardized by the American College of Cardiology (ACC).
Studies show that reopening clogged arteries with Percutaneous Coronary Intervention (PCI), inflating a tiny balloon at the site of the blockage, can increase a patient's chance of surviving a heart attack by 60 percent, but only if it is done within 90 minutes of the patient's arrival at the hospital. This is the door-to-PCI time gold standard.
The study, sponsored by the National Heart, Lung, and Blood Institute, reported that only 35 percent of hospitals in the United States meet the 90-minute, or less, gold standard door-to-PCI time. Nearly half of US hospitals have a time between 91 to 120 minutes, 13 percent came in at 121 to 150 minutes, and 4 percent topped 150.
Since Saint Joseph implemented its 913 CODE STEMI system, it has seen over 80 heart attack patients. The average times in each of the phases involved from door-to-PCI put Saint Joseph well above the 35 percent of US hospitals meeting the gold standard. Here's why:
Average Times Since Jan. 1, 2006
ER Arrival to EKG Time – 5 minutes
ER Physician Exam from EKG Completion – 3 minutes
ER Arrival to CathLab Arrival – 45 minutes
ER Arrival to PCI – 80 minutes
Eighty-two percent of heart attack patients SJRMC treated in 2006 had a door-to-PCI time less than 90 minutes.
"This protocol is great representation of the true team efforts to deliver higher quality care and better clinical outcomes across disciplines, both within Saint Joseph's Emergency Room and CathLab, and the community through solid support of our local EMS," said Chris Karam, SJRMC's Vice President of Clinical Services.
Time, commitment, a total team effort, and even a little luck, all factor into Saint Joseph's successes in treating heart attacks. But luck is a luxury and never a given.
"Oh, sure, we're more fortunate during the day because there are just more people here and things are readily in place," Dr. Jalinous explained. "But what is really impressive is the numbers we are turning out in the middle of the night when it can be tough to get a hold of people."
During the nighttime hours, Saint Joseph's average door-to-PCI time is just over 70 minutes.
"This is incredible and just shows the pride and dedication from everyone involved," said Dr. Jalinous.
The last 10 patients Saint Joseph treated in 2006 experienced an average time of 60 minutes.
"One Hour Across The Board"
Even if it's just a handshake or a pat on the back, Mr. Snyder's case is cause for some type of celebration, and the EMS, Saint Joseph's ER, and CathLab deserve all the accolades. But Saint Joseph's 913 STEMI CODE team will not rest on its laurels.
"This is by far the fastest ER arrival to PCI time I have ever heard of," said Keely Paston, SJRMC's Quality Care Coordinator. "It's the culmination of hard work in progress from a great team that began in 2004. We are always looking for ways to improve patient outcomes."
Every month, each case is evaluated so the team can determine where those improvements can be made insuring the most efficient and safe treatment.
"By attacking each facet of treatment separately, yet in precise coordination, we've been able to establish a realistic goal here of one hour across the board – one hour, or less, for every case," said Dr. Jalinous. "That's how it has to be because when you are dealing with heart attacks, time is muscle. Time is muscle."