Emergency Physician Activation of Catheterization Labs
Khot UN, Johnson ML, Ramsey C, et al
Circulation. 2007;116:67-76
Physicians already know that the American College of Cardiology, American Heart Association, and emergency medicine organizations all endorse the concept that patients with ST elevation myocardial infarctions (STEMIs) should be treated with immediate reperfusion therapy, and that percutaneous coronary intervention (PCI) is preferable to thrombolytics when it can be obtained "expeditiously." Specifically, the recommended door-to-balloon (inflation) time should be less than 90 minutes for these patients. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other organizations now use the 90-minute rule as a "quality-of-care indicator" for individual hospitals. Nevertheless, the literature indicates that in the United States only a minority of patients receive PCI within 90 minutes. Many hospitals are therefore looking for ways of reducing their door-to-balloon times. One way in which those times have been improved at many hospitals is through emergency physician (EP) activation of the catheterization laboratory. In other words, it is the EP rather than the cardiologist who calls in the cath lab team. Within the last few months, EPs have been hearing and reading about multiple studies supporting this concept, and the literature is not limited to emergency medicine journals. This current Viewpoint draws its subject for discussion from the cardiology literature and looks at a recent article on EP activation of the catheterization lab that was published in Circulation. As will be seen, it seems clear that the cardiology community is slowly lending support for this concept as well.
A prospective study by Khot and colleagues in Indianapolis hospitals initially followed a protocol whereby if the EP diagnosed a STEMI, a cardiologist was consulted. The cardiologists in the hospital at the time of the call would then evaluate the patient and contact the cath lab team to assemble. After the new protocol was established, the EP diagnosing a STEMI would activate the cath lab team independent of a cardiologist's evaluation. The patient would then be taken immediately to the cath lab by emergency department (ED) personnel as soon as the lab was ready, and a cardiologist would see the patient at that time.
The researchers evaluated 60 consecutive STEMI patients undergoing emergency PCI before implementation of the ED physician-activated cath vs 86 consecutive STEMI patients undergoing emergency catheterization after implementation of the new protocol. There were no differences in patient characteristics before and after the new protocol was instituted. Median door-to-balloon time decreased overall (113.5 vs 75.5 minutes). Decreased times were also noted when the researchers looked at PCI during specific hours, ie, regular hours (83.5 vs 64.5 minutes), off-hours (123.5 vs 77.5 minutes), and with transfer from an outside affiliated ED (147 vs 85 minutes). Treatment within 90 minutes increased from 28% to 71%. These reductions in treatment time are even more remarkable considering that the cardiologists in the study, even prior to initiation of the new protocol, were always taking in-house calls which, again, eliminates any delay that would have arisen from having them respond from home. Mean infarct size, hospital length of stay, and total hospital costs per admission all decreased significantly as well. Although the cardiologists had the option to overrule the decision to perform catheterization when they evaluated the patient in the lab, this rarely occurred.
This type of protocol is gaining favor at other hospitals in the United States and emphasizes the necessity for EPs to continuously hone their ECG skills. As EPs establish themselves as experts and the positive impact on door-to-balloon times is made evident, the catheterization teams will increasingly rely on them to make the call.
Abstract
Khot UN, Johnson ML, Ramsey C, et al
Circulation. 2007;116:67-76
Physicians already know that the American College of Cardiology, American Heart Association, and emergency medicine organizations all endorse the concept that patients with ST elevation myocardial infarctions (STEMIs) should be treated with immediate reperfusion therapy, and that percutaneous coronary intervention (PCI) is preferable to thrombolytics when it can be obtained "expeditiously." Specifically, the recommended door-to-balloon (inflation) time should be less than 90 minutes for these patients. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other organizations now use the 90-minute rule as a "quality-of-care indicator" for individual hospitals. Nevertheless, the literature indicates that in the United States only a minority of patients receive PCI within 90 minutes. Many hospitals are therefore looking for ways of reducing their door-to-balloon times. One way in which those times have been improved at many hospitals is through emergency physician (EP) activation of the catheterization laboratory. In other words, it is the EP rather than the cardiologist who calls in the cath lab team. Within the last few months, EPs have been hearing and reading about multiple studies supporting this concept, and the literature is not limited to emergency medicine journals. This current Viewpoint draws its subject for discussion from the cardiology literature and looks at a recent article on EP activation of the catheterization lab that was published in Circulation. As will be seen, it seems clear that the cardiology community is slowly lending support for this concept as well.
A prospective study by Khot and colleagues in Indianapolis hospitals initially followed a protocol whereby if the EP diagnosed a STEMI, a cardiologist was consulted. The cardiologists in the hospital at the time of the call would then evaluate the patient and contact the cath lab team to assemble. After the new protocol was established, the EP diagnosing a STEMI would activate the cath lab team independent of a cardiologist's evaluation. The patient would then be taken immediately to the cath lab by emergency department (ED) personnel as soon as the lab was ready, and a cardiologist would see the patient at that time.
The researchers evaluated 60 consecutive STEMI patients undergoing emergency PCI before implementation of the ED physician-activated cath vs 86 consecutive STEMI patients undergoing emergency catheterization after implementation of the new protocol. There were no differences in patient characteristics before and after the new protocol was instituted. Median door-to-balloon time decreased overall (113.5 vs 75.5 minutes). Decreased times were also noted when the researchers looked at PCI during specific hours, ie, regular hours (83.5 vs 64.5 minutes), off-hours (123.5 vs 77.5 minutes), and with transfer from an outside affiliated ED (147 vs 85 minutes). Treatment within 90 minutes increased from 28% to 71%. These reductions in treatment time are even more remarkable considering that the cardiologists in the study, even prior to initiation of the new protocol, were always taking in-house calls which, again, eliminates any delay that would have arisen from having them respond from home. Mean infarct size, hospital length of stay, and total hospital costs per admission all decreased significantly as well. Although the cardiologists had the option to overrule the decision to perform catheterization when they evaluated the patient in the lab, this rarely occurred.
This type of protocol is gaining favor at other hospitals in the United States and emphasizes the necessity for EPs to continuously hone their ECG skills. As EPs establish themselves as experts and the positive impact on door-to-balloon times is made evident, the catheterization teams will increasingly rely on them to make the call.
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