HOUSTON -- For people suffering a heart attack, every minute
counts.
Quick treatment is so important that Houston Fire Department
paramedics
plan to transport such patients only to hospitals with streamlined
emergency procedures, so a life-saving angioplasty can be performed
within 90 minutes.
Until recently, few hospitals met the American College of
Cardiology
standard.
Now, it has become a priority in Houston and nationwide, with
hospitals
scrambling to decrease "door-to-balloon" time -- the minutes it
takes to
transport a patient from the ambulance into the catheterization
laboratory and inflate a balloon inside the artery to restore blood
flow
to the heart.
"If this works out the way we all hope it will, there won't be
any
(local hospitals) with bad times," said Dr. David Persse,
physician-director of Houston Fire Department Emergency Medical
Services, which responds to 911 calls within the city.
Beginning as early as fall, he hopes to direct his paramedics to
transport patients only to hospitals that comply with the standard.
As many as half of the 865,000 people who have heart attacks
each year
suffer from serious artery blockages best treated with angioplasty,
a
procedure used to clear those obstructions, according to the
American
Heart Association. Patients who have blockages that can't be
remedied
with angioplasty sometimes undergo bypass surgery.
Most hospitals that manage to treat patients within 90 minutes
do so by
allowing heart attack patients to bypass the emergency room, where
delays often occur, and go directly from the ambulance to the
catheterization lab.
The process worked for Richard Watrous, 49, who suffered a heart
attack
in February.
The Dallas resident was preparing for an awards reception at a
Houston
hotel when he felt pressure, which gradually turned to pain, in his
chest. He called 911 and was picked up by Houston Fire Department
paramedics, who examined him in the ambulance.
"My EMT looked at me and said, 'It ain't gas,' " Watrous said.
The paramedics transported him to Memorial Hermann-The Texas
Medical
Center, a local forerunner in fast door-to-balloon time.
There, Watrous thought he would have to wait in the emergency
room while
doctors decided whether he needed surgery.
"I was surprised I went straight from the ambulance into the
cath lab,"
said Watrous, who underwent an angioplasty and has since mostly
recovered.
Patients like Watrous skip the emergency room because they're
diagnosed
en route to the hospital rather than on arrival.
Inside the ambulance, paramedics perform a diagnostic test known
as an
electrocardiogram, or EKG, and relay the results via cell phone to
an
emergency room physician.
The physician determines whether the patient is, indeed,
suffering a
heart attack and whether angioplasty is the proper treatment.
The doctor then pages the angioplasty team so members can make
their way
to the operating room and prepare for the procedure.
"We will be standing in the cath lab, waiting for the patient
to show
up," said Dr. James McCarthy, Memorial Hermann's director of
emergency
medical services and a professor at the University of Texas Medical
School at Houston.
At hospitals that have not yet streamlined the process, it can
take
longer than the recommended 90 minutes -- sometimes even hours -- to
admit
a patient, diagnose him or her and give the cath lab team time to
prepare and perform an angioplasty.
There's evidence that mobilizing quickly improves patient
outcomes.
For each 30-minute treatment delay, risk of death within a year
increases by more than 7 percent, according to an article published
in
the American Heart Association journal Circulation in 2004.
Swift treatment also means less damage to the heart muscle.
"Time is muscle," said Bryan Croft, vice president of
operations for the
Methodist DeBakey Heart and Vascular Center, where door-to-balloon
times
have improved drastically during the last year.
Like other hospitals across the country, Methodist felt pressure
not
only from Houston paramedics but also from a U.S. government-run
Web
site called Hospital Compare.
Created in 2005, the Web site allows consumers to compare
hospital
performance on specific care measures, such as door-to-balloon
time.
Because patients transported by ambulance can ask paramedics to
take
them to a specific facility, well-informed consumers can steer
toward
what they think is the best hospital.
That means potential customer loss for hospitals if
door-to-balloon
times aren't up to par.
A comparison of Houston-area hospitals on the Web site shows
that from
July 2006 to June 2007, the latest data available, only a small
percentage performed an angioplasty within 90 minutes for at least
75
percent of their patients, as recommended by the American College
of
Cardiology.
Among the hospitals that treated nearly all patients within that
time
frame were Memorial Hermann, Clear Lake Regional Medical Center and
Conroe Regional Medical Center.
Improvements, however, have occurred so rapidly in the Houston
area
during the last year that the online data is outdated,
administrators at
many hospitals say.
Improving the time
St. Luke's Episcopal Hospital, for example, has met the
90-minute window
for the last 10 months, said the hospital's vice president, Mike
Reno.
Hospital staff streamlined the process so patients could go
directly to
the cath lab, partly because they were "shocked and dismayed" at
their
statistics on the Web site, he said.
Several other hospitals, including Methodist and Memorial
Hermann
Memorial City Medical Center, also now meet the standard,
physicians
said.
Across the country, an increasing number of hospitals are
treating
patients within 90 minutes, said Dr. Ralph Brindis, vice president
of
the American College of Cardiology.
Some were motivated by a study published in the New England
Journal of
Medicine in 2006 that showed only one-third of patients nationwide
were
being treated within that time frame.
But few communities go so far as to transport patients only to
facilities that meet the standard, said Brindis, who supports the
concept as planned in Houston.
"The goal here is not to be punitive to hospitals," he said.
"The goal
here is to raise the bar of all the hospitals."
To some extent, Houston Fire Department paramedics already favor
hospitals that are known to treat heart attack patients quickly.
They decide where to transport patients based on several
factors,
including location, patient preference (or where his or her
cardiologist
practices) and whether a hospital is equipped to treat the patient.
When patients are transported to the Texas Medical Center and
don't have
a hospital preference, paramedics often take them to Memorial
Hermann
because of its track record, Persse said. That has sparked
complaints
from other hospitals.
"(Paramedics) know from personal experience, if they go down to
Hermann,
they often go right to the cath lab," he said.
Chronicle reporter Lynn Cook contributed to this report.
c.2008 Houston Chronicle