Let’s Imitate Fedex for Managing Some Heart Attacks

Fedex should become our national model for improving the time interval between someone coming to the emergency department needing a stent or a balloon procedure to open up their heart's arteries and being transferred to a facility that can undertake this procedure.  That's Rick's opinion in this week's podcast as we discuss 'door in door out' times and our really pathetic national performance, as described in this issue of Archives of Internal Medicine.

So let's back up and describe the scenario:  when someone comes to the emergency department having an apparent heart attack that requires opening up clogged arteries, the usual treatment is percutaneous coronary intervention, abbreviated PCI.  This means placing a stent in the blocked area of the vessel or perhaps using a balloon to open it.  But not all facilities are capable of doing these procedures, so national guidelines establish an optimal door in door out time to transfer the person of under 30 minutes.  That's clearly because the earlier the vessel is opened the better the outcome:  significantly reduced mortality.  Those who spend more than 30 minutes waiting to transfer to an appropriate facility experience a 56% increased risk of death, according to this study.

Data examined in this analysis were from the Centers for Medicare and Medicaid Services and included almost 14,000 patients from over 1000 hospitals.  Less than 10% experienced a transfer within the 30 minute window!  Appallingly, more than 31% languished in the emergency department longer than 90 minutes before transfer, with women and African-Americans more at risk for this delay.  Yikes.  How do we account for this atrocious performance?

Unfortunately, this database does not allow for much in the way of causative factors, but Rick points out that it is possible to use clot busting drugs, also known as fibrinolytic therapy, in the majority of people in whom PCI cannot be done in a timely manner.  Indeed, in this study 75% of the patients have no evidence of contraindication to the use of clot busting drugs, that is, such a strategy appeared to be safe.  Seems like that's one possibility that should be considered immediately if transfer or PCI is not happening.

Clearly, we need to examine our national treatment patterns closely and develop solutions to this problem.  One obvious one is to invest emergency responders with the ability to assess the likelihood that PCI is required en route and take the patient to a hospital with that capability right away, rather than go to the closest hospital.  Rick points out, however, that about half of people either drive themselves to the hospital when they suspect they're having a heart attack or enlist someone else to drive them.  This sounds like a public health education effort is needed to me:  if you're taking yourself, go to a regional heart center or a large academic medical center if possible.  It's worth noting that it's always best to have your heart attack Monday through Friday, preferably during business hours, of course.  A revamp of the system and establishment of regional centers may overcome that problem too, since staffing can be assured so PCI is possible.

Other topics this week include two from NEJM:  even when prescriptions are fully paid for people don't take them, and four common medications that cause the majority of emergency hospitalizations in seniors.  And a study from the Lancet showing that many people are perfectly capable of both monitoring and managing their blood thinning medications at home.  Until next week, y'all live well.

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