“When Every Second Counts, Think Heart First!”

A Community “Blessing” Blessing Hospital is a 426-bed community-based healthcare organization in Quincy, Illinois. Quincy may be a town with a population of just 42,000, but it is the primary medical hub for a region comprised of nearly 400,000 people living in west central Illinois, northeast Missouri, and southwest Iowa. Because its service area includes 18 counties, Blessing Hospital developed a system for one-call referral, public education, and standardization of treatment protocols for the treatment of ST-segment elevation myocardial infarction (STEMI). The program, called Heart First, was designed to deliver quick coordinated help for people experiencing symptoms of a heart attack. Heart First was formulated directly from evidence-based guidelines developed by expert consensus from the American College of Cardiology (ACC) and the American Heart Association (AHA).1 Most recently, the Society of Chest Pain Centers is using the Heart First Program as one example of best practices. The Heart First program also received national recognition from the Best Practices in Emergency Services, a leading national newsletter for EMS administrators and fire chiefs focusing on best practices and innovation in the delivery of emergency services (May 2009). Background To increase survival rates for heart attack, the public must rapidly access emergency medical services by dialing 9-1-1. This is especially important to us at Blessing Hospital, as we provide the most comprehensive cardiology services to patients from as far away as 100 miles. Before implementation of our Heart First program, the majority of cardiac patients arrived at our emergency department (ED) by car. Repeated published research shows many STEMI patients have better outcomes when treated within 90 minutes. As administrator of the Heart & Vascular Center at Blessing Hospital, I was asked to work with our cardiac cath lab (CCL) medical director, Dr. Steven Krause, to reduce door-to-balloon (D2B) time for STEMI patients to less than the national benchmark of 90 minutes. To outperform the 90-minute mark, the Heart First program focused on four core components: 1. Community education and awareness to promote the use of 9-1-1 services during a heart attack or stroke. 2. A one-call referral process for Emergency Medical Services (EMS) and clinicians to rapidly access our cardiology services. 3. Standardization of medical protocols formulated from evidence-based guidelines developed by expert consensus from the ACC and AHA. 4. Data collection and review with process improvement. The Heart First program uses a collaborative, multi-disciplinary team approach when treating STEMI, involving our entire cardiology team: emergency medical services (EMS), the ED, cardiology clinicians – cardiovascular unit (CVU), CCL staff, staff cardiologists – CVU, non-invasive cardiology (NIC), employee education, the rapid response team, and cardiac rehabilitation staff. The Heart First Program Changing community behaviors is difficult at best, but placing a loved one having a heart attack in a vehicle for self-transport to the ED was a culture we had to address. Research affirms people need to hear a message multiple times before embracing change. As such, we developed an aggressive marketing program to promote Heart First, including advertising on billboards, radio and newspapers. The Heart First advertisements advocate the idea that “every second counts” during a heart attack and encourages patients to call 9-1-1 and ask to be taken to Blessing Hospital. Blessing also is active in a variety of community events where volunteers hand out Heart Care kits including chewable aspirin, information on warning signs and symptoms of heart attack, and step by step instructions on what to do in the event of a heart attack, including calling 9-1-1. We also initiated significant changes at Blessing Hospital to streamline access to cardiology services, thus reducing our door-to-balloon time. The Heart First toll-free telephone hot line rings directly into the Blessing ED, and provides EMS and area hospitals a toll-free number to call 24/7 when they are sending a potential heart attack patient to Blessing Hospital. When the Blessing Hospital ED answers the Heart First line, they know a critical heart patient will soon be arriving by ambulance or helicopter. The ED fields all Heart First hotline calls and immediately accepts care of the patients. One call to the Heart First line activates the entire interventional team. This ensures that when a Heart First/STEMI patient arrives, our cardiology team is there to rapidly assess the patient and escort them directly to the CCL. Since ECG transmission during EMS transport is not always reliable in all areas, paramedics now are encouraged to identify obvious STEMIs in the field. To help identify STEMIs reliably in field, Blessing Hospital has worked with county EMS to ensure paramedics are confident in their ability to identify ST elevation on ECG. STEMI Prep Team After implementing the Heart First program, we identified the need for a STEMI prep team. Our CCL occasionally experienced a patient being delivered to the lab still wearing street clothes, potentially wasting critical — if not lifesaving — minutes. Implementing this team ensured we had additional needed hands for groin prep and transport. The prep team is comprised of cardiovascular and intensive care nurses. Their pagers are programmed to go off simultaneously when the cath lab team is activated. The STEMI prep team immediately reports to the ED. The STEMI prep team meets the patient at the ED door and transports them directly to the CCL. The STEMI prep team then assists the CCL team by completing the prep in the CCL. To illustrate how this process works from start to finish, the following steps take place sequentially once the STEMI prep team is activated: 1. The CVU charge RN secures a transport monitor and the STEMI team tool kit. 2. The ICU and CVU charge RNs report directly to the ED. 3. If the patient’s condition warrants assessment in the ED, the STEMI prep team will assist the ED RN caring for the patient with the following: • Obtain Informed Consent. • Ensure patient is on O2, 2 liters/min. minimum. • Remove the patient’s clothing and undergarments. • Place 18 or 20g IV, preferably in the left arm. • Prime 500cc normal saline on tubing with an extension tubing attached. • If not contraindicated, ensure the patient has received the following medications: ASA, clopidogrel, beta blocker. • Place radio-translucent ECG patches from the STEMI team tool kit (Right side: RA & RL both on shoulder area. Left side on LA on left shoulder). • Clip both sides of groin - remove loose hair using 2-inch tape. • Locate and assess lower extremity pulses and mark with marker. • Obtain handoff communication from ED staff. • Transport the patient to the CCL. • Provide hand-off communication to CCL RN. Results In the year since the Heart First program was launched, our D2B time was decreased 50 percent. Subsequent to our aggressive Heart First campaign, Blessing Hospital has treated approximately 18 percent more patients for chest pain and cardiac symptoms, and our CCL volume is proportionately reflective. Additionally, area county EMS reports an approximate 15 percent increase in their chest pain call volumes. Dr. Richard Saalborn, medical director of Blessing’s ED, reports, “The continued overall concerted effort to educate the community has made a difference. We are starting to appreciate a decrease in the number of patients driving themselves to the ED when having chest pain.” In addition to community education, Dr. Saalborn emphasized the benefit of having standardized protocols is a key element in the success for the Heart First program. Even more inspiring is the fact that the STEMI prep team has allowed us to cut our ED dwell/prep time in half. Our D2B time has also benefited: we are currently at 59 minutes and counting down. STEMI Star Communication Board As part of our Heart First data collection, we developed a STEMI star communication board. This was one of the most valued communication tools developed to display our case-by-case D2B times. This rapid turnaround feedback is displayed for the entire team. On the communication board, we include the date of each STEMI, before and after angiogram (de- identified), arrival method of patient, and EMS team, ED team, and CCL team members and D2B time. Diagnostic Enhancement According to the AHA/ACCF/ HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram, “ECG is considered the single most important initial clinical test for diagnosing myocardial ischemia and infarction.”2 The correct, rapid interpretation of the ECG is the basis for therapeutic interventions. Our clinicians soon realized the 12-lead ECG has limited sensitivity to detect post-MI injury patterns. Blessing Hospital has adopted the use of 16-lead ECG as a standard in the ED for assessing patients who present to the ED with high probability of coronary artery disease. Blessing Hospital uses this “balanced lead” configuration by adding an additional four leads: two right-sided leads and two posterior leads. Our Philips model TC 70 ECG machine (Bothell, WA) labels our 16 leads automatically. Utilizing the 16-lead approach, we are able to confirm the reciprocal patterns noted with posterior MI injury, thus ensuring accuracy. We are also better able to diagnose a potentially missed circumflex (LCX) occlusion, as some of these patients will only have ST changes noted in the posterior leads. The 16-lead approach gives our clinicians the additional information to increase sensitivity and specificity over the basic 12-lead ECG. Community Awareness Continues We continue to stress signs and symptoms of heart attack and stroke at all community outreach events. We provide every patient treated at the Blessing Heart & Vascular Center with a “thank you” card. Included in the thank you card is a comprehensive review of these symptoms, advising our customers to immediately call 911 should they occur. The message continues to be “Every Second Counts!” Community AED Donation In August 2009, we provided 23 automatic external defibrillators (AED)s to organizations throughout the Blessing region as a Heart First initiative to increase awareness of sudden cardiac arrest (SCA) and the need for early intervention. Blessing Hospital partnered with St. Jude Medical and Cardiac Science to provide these at no cost to our community. Timing of the donation was perfect, due to the recent changes in Illinois state law requiring an increase in availability of AEDs within communities. Our area schools, local municipal airport, community center, community swimming pool, parks and recreation department, local YMCA, multiple community services organizations, Quincy Mall, and FastCare Clinic benefited as recipients of these life-saving devices. Ongoing Community Screening Events Blessing Heart and Vascular Center offers multiple screening events to the community throughout the year. The intent of our community screenings is to not only identify cardiovascular disease early, but to also raise awareness for prevention of this deadly disease. Our goal is to decrease major adverse cardiovascular events in our community. We offer, at little or no cost, EKGs, cardiac ultrasound screenings, cholesterol, glucose, blood pressures, ankle brachial indices (ABI), abdominal aortic aneurysm (AAA) ultrasound screenings, and CAD risk analysis, resulting in more than 12,000 outreach encounters each year. Providing these screenings is a direct reflection of the Blessing Hospital’s mission, “To provide high quality accessible health care showing compassion and respect to those we serve.” Screenings: the Sooner, the Better The non-invasive cardiology team recently kicked-off our first annual free Marfan/Hypertrophic Cardiomyopathy (HCM) screening for area youth, ages 13 to 18, wishing to participate in high school athletics. This potentially life-saving cardiac ultrasound screen for our young athletes takes only one minute to perform. HCM is the most common cause of sudden death in American athletes, with several of these sudden death events reported every year. Our Blessing cardiologists generously donated their time to provide this important gift back for the youth of our community. Our cardiologists provide immediate interpretation during the cardiac ultrasound exam, giving our parents assurance in addition to their child’s required sports physical. We have screened over 350 young athletes to date, with future plans to take our services mobile to surrounding communities. Remember: When seconds count, please think Heart First! Author Sheree Schroeder can be contacted at shereeschroeder@gmail.com

1. ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non–ST-Elevation Myocardial Infarction). Available at http://content.onlinejacc.org/ cgi/content/full/j.jacc.2008.10.012. Accessed August 17, 2009.

2. ` Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Available online at http://circ.ahajournals.org/cgi/content/extract/119/10/e262. Accessed August 17, 2009.

3. The American College of Cardiology and Partners Launch National Alliance To Reduce Door-to-Balloon (D2B) Times. November 13, 2006. Available at: http://www.acc.org/media/releases/highlights/2006/nov06/d2b.htm. Accessed August 17, 2009.

4. American College of Cardiology (ACC). Quality@ACC. 2008. Available at http:// www.acc.org/qualityandscience/quality/quality.htm. Accessed August 17, 2009.