Monday, November 13, 2006

Door-to-Balloon Time: Simple?

You feel heaviness in your chest, throat tightening. You pop and aspirin and have your wife (or husband) take you to the Emergency Room. You've just hit the "door." The story is classic and the ER, fortunately, expedites your evaluation. An electrocardiogram is performed and demonstrates and acute myocardial infarction pattern: a heart attack is in progress. "Guys, call the cath lab," the ER attending pleads.

"Er, sir, it's one in the morning."

"Well, then, call the cardiologist and get them here... yesterday!"

Calls are made. Beepers activated. A cardiologist is roused from sleep, young technicians fumble for their pants and car keys. You hurt like hell, sweat pouring from your brow. Traffic laws are ignored. Red lites make an effective effort to stall. Time is ticking. Faster. Faster!

The cardiologist arrives first, meds are increased, your blood pressure drops. The techs arrive, switches activated. Lites turned on. X-ray system booted. Gown. Hat. Mask. Booties. Scrub. Trays opened. "Call the ER, tell 'em we're ready."

"Okay." The phone is dialed.

"Shit! They have no one to transport the patient! You go!" The tech runs to the lab. IV's hang from every corner of your bed. Doctors look concerned. Minutes. Tick. Hurry. "Get the elevator!" A nurse runs ahead to call the elevator. Tick. Tick. Tick. The door opens. Your bed is pushed into the elevator. You feel and IV yanked from your arm. "Hold it!" the tech screems. His IV pole wheel just got caught in the gap between the floor and the elevator. You feel a warm fluid near your elbow. "Damn it, hold pressure!" The fluid is blood. An IV fell out. Heparin. "We'll get another IV when we get to the lab. Don't worry about it." Go! Go! First floor, second floor. Ding! The elevator door opens. "Easy on the way out of the elevator. Okay, we're clear."

You're hurried to the lab down the hall. Once there, you enter a foreign room, lites blaring. AC/DC's "Hell's Bells" shreaks in the background." You're lifted to the narrowest table ever. Stickers are applied to your shoulders, prongs plugged in your nose, a clip applied to your finger. A big cold jelly-fish-like pad applied to your chest on each side. Pants removed. Warm, wet soap applied to your groins. You hear the scrub sink, with its water running, in the distance. Soon it stops. Another gown worn, another set of gloves applied.

"You're going to feel a little sting down here," the cardiologist says as the anesthetic is applied. Another sting is felt at your forearm."

"Ouch!" The cardiologist pauses. "Did that hurt?"

"Not down there, on my arm!"

"Sorry, I was starting another IV," the tech confesses. The cardiologist continues. The artery entered. A catheter passed to the heart. The coronary artery engaged and contrast administered. "That one's okay," the cardiologist thinks. "JL4 guider." Catheter are exchanged. More die injected, shots taken. The cardiologist turns away, working at the table as quickly as he can. A balloon is prepped, then inserted. "Whisper wire." The lesion is crossed. Your chest is heavier now. The balloon inflated, deflated. Suddenly, the pressure subsides. You relax. "How are you feeling now?"


Door-to-balloon time. Simple in theory, yet not so simple in practice. Sweeping changes would have to be implemented in urban areas to achieve this. Techs and cardiologists, likely, would have to reside in-house when on call, or else live very close to their hospital, an impractical option in many cases. And while some recommendations by the American Heart Association and American College of Cardiology seem "simple" to some, their ramifications are significant to all. At least one doctor thinks this is a good idea:
"Thirty-five percent of patients in America have an artery opened in 90 minutes or less. Our goal is 75 percent," said Dr. Steven Nissen, president of the American College of Cardiology.

"Everybody we've asked to do this has said this is the right thing to do. Payers want it. Government wants it. Hospitals want it. Physicians want it."
Really? All physicians want this? All physicians want to live in the hospital waiting for that magic moment when an acute heart attack hits the door? How often does this happen? Five, maybe ten times a month? And how many occur after hours? Do all the techs want to live there waiting, too? Who will pay us for our time sitting, waiting?

While I do not argue that short door-to-balloon times save heart muscle, serious consideration of the costs to all involved, especially those doing the procedures, needs to be carefully examined. Presently we only get paid for doing the job - not waiting. The real people who are pushing this are the payors and hospitals. Why? Because patients do better, certainly, and costs fall. And their wallets swell.

But if "time is muscle," time waiting for a case is also lost money and personal lives to those doing the procedures.

So, who's gonna pay for all that waisted time?

The answer: Doctors.



Dr. A said...

Great post. I was hoping you would cover this today. I've been reading the news reports as well, and I was going to talk about this...

My small community hospital does not have a cath lab. What does that mean for my patients? Our nearest cath lab is a helicopter ride away.

So, does that mean that the helicopter has to be on the way as the ER doctor is interpreting the EKG from the data coming from the ambulance? Whatever happened to the history (like talking to the patient) and physical exam.

They're looking at a 90 minute window? It may take 90 minutes for a small community hospital to find an accepting physician at Big University Hospital and to arrange transport.

The lawyers are going to have a field day on this one. They love holding everyone up to ivory tower guidelines made at medical meetings.

shadowfax said...

I wouldn't be so pessimistic. As I noted over at Movin' Meat, from the ED point of view it's very feasible. In-house cardiology and techs are not a sine qua non of the goal (we don't have it and our time is 69 min), though they certainly would help. Why not start with simpler interventions that provide the most bang for the buck? Like advanced EMS protocols and ED activation of the cath lab. Those work great. And if it isn't already, there really ought to be a medical staff requirement that critical-specialists must be available within a certain time when on call.

Implement those things, and you may just find your organization within the performance standards. Then, if further improvements are needed, you can look at in-house status.

I do agree that if volumes are low, and in-house call is required, that it should be paid for. Since this will be a hospital P4P item, I would advocate that the compensation come from the facilities' Part A reimbursement.

Rogue Medic said...

With appropriate training and oversight there is not much reason for ED involvement in this. We spend a ridiculous amout on trauma activation by EMS (activation that often by-passes the ED) that has less than 10 percent of the trauma alerts emergently going to the OR. The whole justification for the trauma system was the "Golden Hour" from injury to surgery. A lot of places manage with level 3 trauma centers - staff not on the premises, but on-call. Similar arrangements can be made for cath lab availability. Trauma centers receive supplemental funding to offset costs.

The portion of EMS STEMI alerts being cathed is over 90 percent. Compare that to less than 10 percent of trauma alert patients in surgery emergently. Clearly, there is a lot of time to be saved in most systems. Some are already doing this and doing it well.