SummaryThe Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments project is a statewide system that allows for early initiation of evidence-based treatment and prompt transfer of heart attack patients through coordinated plans to diagnose and treat ST segment elevation myocardial infarction in every emergency medical service and emergency department in North Carolina. Emergency medical technicians are trained to diagnose ST segment elevation myocardial infarction by symptoms and electrocardiogram and to activate emergency cardiac catheterization facilities when indicated. Emergency departments establish protocols for prompt electrocardiogram performance on patients who present with possible symptoms of myocardial infarction, and emergency physicians initiate prespecified reperfusion protocols without cardiology consultation. In hospitals where urgent primary coronary angiography is not available, protocols include plans for fibrinolytic (clot-dissolving) medication or rapid transfer of patients to hospitals with cardiac catheterization facilities. The program has led to a decline in the number of patients who do not receive appropriate therapy, earlier initiation of balloon angioplasty and fibrinolytic therapy, faster transfer of patients from hospitals that do not offer angioplasty to those that do, and lower mortality rates with few inappropriate activations of cardiac catheterization teams.
See the References section for two new published studies; the Results section for additional data regarding the decline in the number of patients not receiving appropriate therapy, improved therapy initiation times, and lower mortality rates; and the Adoption Considerations section regarding monitoring activations (updated September 2012).Moderate: The evidence consists of pre- and post-implementation comparisons of key outcome measures for 6,841 patients at 119 North Carolina hospitals, including door-to-balloon time, door-to-needle time, time spent at the transfer hospital, and mortality rates of guideline-treated versus non-guideline-treated patients.
Developing OrganizationsDuke Clinical Research Institute; Duke University Medical Center
Date First Implemented2003
The program began at Duke University Medical Center in 2003. It expanded statewide in 2005, with all North Carolina hospitals joining in 2007.
Problem AddressedPatients experiencing an acute myocardial infarction (AMI) or heart attack should receive recommended treatment such as balloon angioplasty (also known as percutaneous coronary intervention or PCI) or fibrinolytic (clot-dissolving) medications within recommended timeframes, yet these goals are frequently not met. Although certain interventions—prehospital assessment by emergency medical service (EMS) personnel and early activation of AMI teams—can increase the odds of timely treatment, few systems exist to coordinate the care of AMI patients across settings and hospitals.
- Benefits of timely initiation of treatment: American College of Cardiology/American Heart Association guidelines recommend that patients with ST segment elevation myocardial infarction receive PCI within 90 minutes of hospital arrival ("door-to-balloon" time) or, if timely PCI is not available at that hospital or another facility, fibrinolytic therapy within 30 minutes of arrival ("door-to-needle" time); the guidelines are based on evidence from numerous clinical trials demonstrating improved outcomes with prompt treatment.1
- Failure to provide timely care: In 2007, only 51 percent of patients presenting with an AMI had a door-to-balloon time of less than 90 minutes.2 In some cases, delays in PCI initiation stem from the need to transfer a patient to a distant hospital that performs the procedure; in North Carolina, only 15 of the 101 counties in the state have hospitals that perform PCI.3 Patients who lack access to timely PCI therapy should receive fibrinolytic therapy instead, but less than half of these patients receive such therapy within the recommended door-to-needle time of 30 minutes or less.4
- Largely unrealized benefits of coordination and collaboration: Hospitals that have EMS personnel administer an electrocardiogram (ECG) en route to the hospital and transmit the results to the emergency department (ED) physician have significantly lower door-to-balloon times than those that do not.5 In addition, hospitals that have a system for activating the AMI team while the patient is en route via ambulance and/or that empower the ED physician to activate the AMI team have shorter door-to-balloon times than those that employ more traditional methods (i.e., waiting for the patient to arrive via ambulance, paging an interventional cardiologist, waiting for the cardiologist to assess and diagnose the patient, and then activating the AMI team).5,6 Unfortunately, relatively few systems and regions have processes in place to allow this type of collaboration and coordination to occur on a routine basis.
Description of the Innovative ActivityThe Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project is a statewide system that allows for early initiation of evidence-based treatment and prompt transfer of heart attack patients through coordinated plans to diagnose and treat ST segment elevation myocardial infarction in every EMS and ED in North Carolina. The system involves diagnosis and sometimes initiation of treatment by trained EMS personnel for heart attack patients before hospital arrival; early activation of an AMI team and other processes at the hospital receiving the patient; and development of a plan by hospitals not offering PCI for dealing with heart attack patients (e.g., by transferring them to those that offer PCI or initiating clot-dissolving therapy onsite). The RACE project outlines broad strategies (described below) for how to reduce door-to-treatment time, although adopting hospitals have some flexibility in how to implement them.
- Diagnosis and sometimes initiation of treatment by trained EMS personnel: Based on training provided by the RACE program, EMS paramedics across the state conduct an ECG in the ambulance to facilitate early recognition of ST segment elevation myocardial infarction. Paramedics in some counties may also be empowered to initiate fibrinolytic therapy in the ambulance.
- Activation of AMI team, other processes at receiving hospital: If a patient has an elevated ST segment, paramedics call a dedicated telephone line so that the AMI team can be activated while the ambulance is en route to the hospital. The person who answers the call collects relevant information on the patient, including symptoms and ECG results; reserves the cardiac catheterization suite; activates the AMI team; and notifies an inpatient unit that a bed will be required. (Hospitals offering PCI services must accept heart attack patients regardless of inpatient bed availability.) Depending on the hospital, the line may be staffed by a nurse, an ED physician carrying a cell phone, or call center staff.
- ED order sets for patients presenting in ED (not in an ambulance): When a patient with heart attack symptoms presents directly to a hospital's ED (i.e., not in an ambulance), the ED clinicians perform an ECG. If the results indicate ST segment elevation, the ED clinicians access an order set that prompts them to directly activate the AMI team, order laboratory work, and initiate basic medications (e.g., aspirin) as quickly as possible, with the goal of initiating PCI within 90 minutes. The order set is based on care steps recommended by the American College of Cardiology/American Heart Association guidelines.1
- Plan for non-PCI hospitals: Participating hospitals that do not offer PCI develop a plan to ensure optimal AMI care (as defined by the American College of Cardiology/American Heart Association guidelines).1 Each hospital's plan specifies whether heart attack patients will be transferred to a regional hospital (because PCI can be safely and effectively initiated within 90 minutes) or whether patients will be retained and given timely fibrinolytic therapy onsite. The plan takes into consideration estimated travel time to the nearest facility offering PCI and available resources to transport patients. Approximately 15 hospitals employ a “mixed” strategy through which patients may or may not be transferred depending on variable conditions that influence transfer times (e.g., weather conditions in mountainous regions).
- Ongoing performance tracking and reporting to stimulate improvement: All participating hospitals submit data to the American College of Cardiology’s national heart attack registry (known as Action Registry) and submit various data to the Duke Clinical Research Institute, which produces and distributes quarterly RACE comparative performance reports that help to stimulate ongoing quality improvement.
References/Related Articles(added September 2012) Garvey JL, Monk L, Granger CB, et al. Rates of cardiac catheterization cancelation for ST-segment elevation myocardial infarction after activation by emergency medical services or emergency physicians: results from the North Carolina Catheterization Laboratory Activation Registry. Circulation. 2012 Jan 17;125(2):308-13. [PubMed]
(added September 2012) Jollis JG, Al-Khalidi HR, Monk L, et al. Expansion of a regional ST-segment-elevation myocardial infarction system to an entire state. Circulation. 2012 Jul 10;126(2):189-95. [PubMed]
Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA. 2007;298(20):2371-80. [PubMed]
The Robert Wood Johnson Foundation. Treating Patients More Quickly with RACE. August 11, 2009. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=47131.
Duke University Health System. Duke’s RACE to Save Lives. May 12, 2009. Available at: http://www.dukehealth.org/health_library/health_articles/dukes_race_to_save_lives.
Contact the InnovatorLisa Monk MSN, RN, CPHQ
RACE ER State Project Leader
c/o Duke Clinical Research Institute
ATTN: Catherine Dalsing
2400 Pratt St.
Durham, NC 27705
Innovator DisclosuresMonk has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsThe program has led to fewer patients who do not receive appropriate therapy, earlier initiation of PCI and fibrinolytic therapy for heart attack patients, faster transfer of patients from hospitals that do not offer PCI to those that do, and lower mortality. A relatively low rate of inappropriate cardiac catheterization laboratory activations has occurred.
Moderate: The evidence consists of pre- and post-implementation comparisons of key outcome measures for 6,841 patients at 119 North Carolina hospitals, including door-to-balloon time, door-to-needle time, time spent at the transfer hospital, and mortality rates of guideline-treated versus non-guideline-treated patients.
- Fewer patients not receiving appropriate therapy: Information provided in September 2012 indicates that an analysis of 6,841 patients with ST segment elevation myocardial infarction treated between July 2008 and December 2009 found that the rate of patients not receiving reperfusion fell from 5.4 to 4.0 percent.7
- Quicker initiation of PCI and fibrinolytic therapy: Between 2005 and 2007, the median door-to-balloon time for all arriving AMI patients at hospitals that offer PCI decreased 13 percent, from 85 to 74 minutes. For patients being transferred from other facilities, the median door-to-balloon time decreased 29 percent, from 149 to 106 minutes. The median door-to-needle time within hospitals that do not offer PCI (but choose to treat patients onsite with fibrinolytic therapy) decreased 17 percent, from 35 to 29 minutes. Information provided in September 2012 indicates that between July 2008 and December 2009, door-to-device time for all hospitals that adopted a "transfer for PCI" reperfusion strategy fell from 117 to 103 minutes, and times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes.7 Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes; 91 percent of EMS-transported patients were treated within 90 minutes, and 52 percent were treated within 60 minutes.7
- Quicker transfers: For patients being transferred, the median time spent at the "transfer" hospital (i.e., the hospital that transfers the patient to another facility) decreased 41 percent, from 120 to 71 minutes.
- Lower mortality: Information provided in September 2012 indicates that patients treated within guideline goals had a mortality of 2.2 percent compared with 5.7 percent for patients who exceeded guideline recommendations.7
- Relatively low rate of inappropriate cardiac catheterization laboratory activations: Information provided in September 2012 indicates that the program is associated with a relatively low rate of inappropriate cardiac catheterization laboratory activations (15 percent); reasons for inappropriate activations included ECG reinterpretation and misidentification of the patient as a cardiac catheterization candidate.8
Context of the InnovationThe Duke University Health System, a large academic tertiary and quaternary care system, includes four hospitals: Duke University Hospital, Duke University Medical Center, Durham Regional Hospital, and Duke Raleigh Hospital. In fiscal year 2009, the system had more than 63,000 admissions and performed 1,037 angioplasties. In 2003, researchers at the Duke University Medical Center developed the RACE system as an internal quality improvement project after analyzing data that indicated the potential to improve door-to-balloon times. Given the success of the project, Duke sought funding to expand the system statewide, an effort that began in 2005 with 10 PCI centers and 55 transfer hospitals. As of 2010, RACE includes all North Carolina hospitals, including 21 PCI centers, 98 transfer hospitals, and 500 emergency medical systems.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Securing support from EMS and hospital leaders: The RACE team, including two Duke physicians (coinvestigators of the original RACE project) and a RACE project director, approached the North Carolina Office of EMS to ask for its support and participation in the project. After securing this support, the team approached administrators and physicians (often cardiac service directors) at selected hospitals offering PCI to explain the program and gauge their interest in joining. The team presented information to demonstrate the program's potential benefits, including statewide heart attack rates, national guidelines for care of patients experiencing ST segment elevation myocardial infarction, and the success that Duke had achieved with the RACE strategies to date.
- Assigning local RACE coordinators: Each participating hospital offering PCI designated a RACE coordinator to be responsible for implementing the strategies and overseeing ongoing coordination, education, and data collection activities.
- Conducting intake surveys: The RACE team conducted intake surveys at EMS agencies, hospitals, and transfer hospitals to evaluate current regional systems of heart attack care.
- Assisting with local and regional education, implementation: At meetings that included representatives from area EMS agencies and hospitals, the RACE team reviewed the American College of Cardiology/American Heart Association guidelines and Door-to-Balloon: An Alliance for Quality (commonly known as the D2B Alliance), a program launched by the American College of Cardiology to reduce the door-to-balloon times in U.S. hospitals performing primary PCI. The team also helped participants adapt RACE strategies within local regions.
Resources Used and Skills Needed
- Staffing: RACE program staff includes a full-time project leader (under contract), a part-time liaison with Mission: Lifeline (see the Tools and Other Resources section below), and two Duke physicians (coinvestigators of the original RACE project at Duke) who work part-time on the initiative.
- Costs: Data on program development costs are unavailable. Ongoing operational costs include the salaries and benefits of the staff members listed above, along with an annual payment of $5,200 to the Duke Clinical Research Institute for work related to the development of the quarterly data reports.
Funding SourcesAmerican College of Cardiology Foundation; American Heart Association; Sanofi-Aventis; Medtronic; Kate B. Reynolds Charitable Trust; Duke Clinical Research Institute; Genentech, Inc.; Phillips Corporation; Blue Cross Blue Shield of North Carolina; North Carolina Office of EMS
From 2005 to 2007, program coordinators at PCI hospitals received partial funding from the RACE project; since 2007, these coordinators have been funded through their home institutions.
Tools and Other ResourcesThe American College of Cardiology/American Heart Association guidelines for the management of patients with ST elevation myocardial infarction are available at http://www.guideline.gov/content.aspx?id=12192.
Information about the D2B Alliance is available at http://www.d2balliance.org.
The American Heart Association’s Mission: Lifeline project—a national project dedicated to improvements in ST segment elevation myocardial infarction care—uses RACE as one of its flagship models of care. Information about Mission: Lifeline is available at http://www.heart.org/missionlifeline.
Getting Started with This Innovation
- Ensure leader and staff support: Ensure that frontline staff and leaders from hospital administration, the ED, and the cardiology department support the program.
- Evaluate baseline processes: Evaluate current processes from the time a patient arrives in the ED until angioplasty begins. Key issues to consider include how long it takes for the patient to get an ECG and to be sent to the catheterization laboratory, and what can be done to speed up these processes (e.g., eliminating steps that create no value, such as unnecessary testing or taking of a history and physical).
- Be sensitive to competition within region: Urban areas may have multiple hospitals offering PCI in close proximity to one another, thus giving rise to “political” issues. Meeting regularly with representatives from all institutions (including the PCI hospitals, the transfer hospitals, and EMS agencies) can help to build trust, facilitate relationships, and maintain focus on optimal patient care. In addition, potential adopters should avoid trying to define referral relationships, instead letting participants develop their own affiliations to help in achieving timely care.
- Provide content- and process-specific education: All involved staff should be educated about heart attack care and guidelines and about institution-specific and regional reperfusion plans. On an ongoing basis, this information should be included in the orientation provided to new staff.
Sustaining This Innovation
- Collect and share data to facilitate improvement: Tracking and disseminating outcomes data will encourage participants to improve performance.
- Work to improve documentation: Documentation about prehospital care provided by EMS and at transfer hospitals may be incomplete. To address this issue, systems and processes should be created to ensure complete documentation and the transfer of all data to the receiving hospital, which can then make it part of the patient record.
- Continue to build relationships: Encourage regions to hold ongoing monthly meetings led by RACE coordinators that include representatives from all participating institutions. Attendees can discuss potential improvements to the quality and timeliness of patient care.
- Provide recognition to local and regional successes: Celebrate ongoing improvements through dissemination of success stories at the local and regional level; for example, the RACE team periodically e-mails participants with messages such as “Great job! You saved a life today!”
- Monitor activation of AMI teams for appropriateness: The RACE program results in the unneeded activation of AMI teams in situations where the patient is not actually having a heart attack. RACE maintains a catheterization laboratory activation registry that tracks instances in which AMI teams have been activated and then "canceled." Information provided in September 2012 indicates that the system has a relatively low rate of inappropriate activation.8
Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008;117(2):296-329. [PubMed]
Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.188209
McNamara RL, Herrin J, Bradley EH, et al. Hospital improvement in time to reperfusion in patients with acute myocardial infarction, 1999 to 2002. J Am Coll Cardiol. 2006;47(1):45-51. [PubMed]
Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355(22):2308-20. [PubMed]
Jollis JG, Al-Khalidi HR, Monk L, et al. Expansion of a regional ST-segment-elevation myocardial infarction system to an entire state. Circulation. 2012 Jul 10;126(2):189-95. [PubMed]
Garvey JL, Monk L, Granger CB, et al. Rates of cardiac catheterization cancelation for ST-segment elevation myocardial infarction after activation by emergency medical services or emergency physicians: results from the North Carolina Catheterization Laboratory Activation Registry. Circulation. 2012 Jan 17;125(2):308-13. [PubMed]
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Service Delivery Innovation Profile
Original publication: October 27, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 21, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 27, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.