BUILDING SYSTEMS OF CARE, PART 1
By Jason Grady, NRP | JUL 28, 2020
01:05 A woman calls 911 and states her husband awoke with chest pains, difficulty breathing, and not responding appropriately.
01:07 EMS is dispatched to the residence
01:16 EMS arrives on scene to find a 52-year-old male clutching his chest and complaining of pain of 10/10. He vomited x2. Vitals: BP – 88/50, P – 90, R – 20. He is CAOx2
01:21 A 12 lead EKG is performed, and the patient is diagnosed on scene with an anterolateral STEMI
01:31 Enroute to the hospital. Radio report given to the emergency department and the EKG was transmitted. The report states the diagnosis of anterolateral STEMI as well as the vital signs and vasopressors were initiated
01:56 EMS arrived at the ED and transferred the patient to the ED staff with a verbal report and a printout of the EKG. BP – 104/62, P- 90, R – 20
02:01 12 lead EKG performed in the ED and the patient was diagnosed with an anterolateral STEMI
02:05 The 12 lead EKG faxed to the cardiologist and the patient was diagnosed with an anterolateral STEMI
02:07 The cath lab team was activated
02:20 Patient went into VF with sustained ROSC after 15 minutes
02:37 Cath team arrived at the cath lab
02:40 Patient arrived in the cath lab intubated and on multiple pressors. BP – 88/58, P – 104
02:50 Bilateral femoral arterial access obtained
02:55 Percutaneous left ventricular device (pLVAD) placed
02:57 The proximal left anterior descending (LAD) found to be 100% occluded
02:59 A wire and balloon placed in the LAD
03:00 Balloon inflated
03:05 Stent placed
Review of the metrics
Response Time = 9 minutes
On scene to EKG = 5 minutes
Scene Time = 15 minutes
Transport Time = 25 minutes
Door to EKG = 5 minutes
EKG to Cath Lab = 44 minutes
Cath lab to balloon = 20 minutes
Door to Balloon = 64 minutes
First Medical contact to Balloon = 104 minutes
A review of the segments of patient care shows that at each stage the diagnosis and treatment were rapid and appropriate, and each individual team could consider their contribution a “win” because their metrics are within the guidelines.
The Relay Race
When a relay team is put together, the goal is not to run each leg the fastest; the goal is to win the entire race. To do this, each runner must be at the top of their game and contribute to their maximum potential. However, the speed and efficiency of each runner is not what makes a relay race team successful. The winning team is the team making the best transitions between each runner. The team that has the most successful transitions is the team that will win. The healthcare industry has worked hard and has done a great job educating, training, and recruiting high functioning physicians and staff. Prehospital care has improved over the decades with better education, clinical experience, and increased scope of practice but yet, while mortality has decreased, it is nowhere near where it could be. In cases such as cardiac arrest, mortality has remained low and essentially unchanged.
Door to Balloon Time: Is it the right metric or just make us feel good?
At the beginning phases of standardizing STEMI care, measuring Door to Balloon (D2B) Time quickly became an important metric (2). Hospitals began to focus and fixate on this metric because it was the standard by which they were held. The data clearly show that the reduction of D2B has a benefit in mortality, especially when the benchmark went from 120 minutes to 90 minutes. Unfortunately, this came with unintended consequences. Only measuring D2B is tantamount to measuring only the last leg of a relay race. It does not take into consideration the beginning of the race- the other “legs” or transitions of patient care.
This is the only metric that determines whether we “win” or not. We certainly can come up with creative ways to show good D2B times. One example is that EMS can drive around the parking lot for as long as needed to allow the cath lab to get ready. As soon as they are, EMS can enter the “door” and then the clock starts. In a football or basketball game, no one would ever claim victory because they scored more points in the fourth quarter when they lost the first three quarters and ultimately the game. If this were the case, then the Atlanta Falcons won Superbowl LI 28-3. If we would never do this in sports, why would we do it when people’s lives are on the line? As in any team effort, we win as a team and we lose as a team. There is nothing in the middle. It truly is as significant as winning the battle but losing the war.
CASE STUDY Outcome
03:45 Patient transported to the CCU
06:00 Patient began to decompensate
12:30 PEA arrest
13:00 Patient pronounced dead
All's Fair in Love, War, and Systems of Care
In sports, cheating is closely monitored and, if caught, the consequences can be severe and potentially career-ending. In a System of Care, "cheating" should not only be accepted but encouraged. How many relay races could be won if only three runners had to compete in a four-person race or if they could run across the field instead of circling the track? “Cutting corners” saves precious time and can make definitive care not only faster, but safer and more effective. However, even when stages can be bypassed, transitions are still the most crucial part of patient care. They must be planned, practiced, and well-executed if there is hope for the best possible outcome for our patients.
Case Study Debrief
When each stage of this patient moving through the system of care is reviewed, the efficiency and treatment is appropriate. EMS, ED, and Cardiology, if graded individuality, all get an “A” on appropriate diagnosis, treatment, and efficiency. However, within the system, the patient lost his life. It is well noted that cardiogenic shock is the most common cause of death in STEMI patients, and carries a mortality rate of 50-80% (3). This could be due to the fact that many patients are treated with a similar model described in the aforementioned case study. The question should be, "Is this the best way to treat a patient in a system of care?" The three specific areas to critique are transitions, communication, and “cutting corners”.
EMS assessed the patient, performed an EKG, and diagnosed the patient with an anterolateral STEMI. The information was relayed and a copy of the EKG was left with the ED however the ED performed another assessment and EKG and diagnosed the patient with an anterolateral STEMI. The EKG was sent to the cardiologist and the patient was diagnosed with an anterolateral STEMI and the cath team was activated. The transitions were essentially nonexistent, each stage performing their own assessment and EKG, and all arrived at the same diagnosis.
Maybe you remember the game from your childhood commonly referred to as the “Telephone Game?” You know, the one where one person whispered something to the person, then that person whispered the same thing to the person next to them, and so on. This continued down the line until the last person received the information the first person started, or at least that was the intent. What really happened was the information became “twisted” a little each time by every person. Each person thought they heard something (which was not correct) and passed on incorrect information or interpretations. In our case study, from the first medical contact by EMS until the definitive treatment by an interventional/cath lab cardiology team, there can be as many as four or five people to go through in order to get the correct information to all who need it in order to treat this patient. Because it was not possible for EMS to communicate directly with cardiology, the stages in between are set up and the patient must be reassessed and re-diagnosed multiple times before treatment can be determined.
At first glance, “cutting corners” can be interpreted as unethical and potentially detrimental to patient care. To be clear, "cutting corners" means cutting out superfluous steps that serve no true purpose but cause a delay in treatment. In our case study, the patient was seen by a paramedic, nurse, ED physician, and interventional cardiologist. Two 12 lead ECGs were performed with everyone having the same diagnosis. Because of this, care was delayed within the system. We must ask ourselves, “is the best we could have done for our patient?”
Many Moving Parts
Systems of care can be difficult across their spectrum simply because of all the moving parts. Complicating this further is the fact that these many parts are made up of multiple agencies, groups, individuals, and (the most damaging of all) egos. The ED does not trust EMS, and cardiologists do not trust the ED. We have all heard these excuses as to why a system of care cannot be as efficient as possible. Because these various groups are unfamiliar with each other, and often ignorant of their education, scope of practice, capabilities, and competency, the path of least resistance becomes to “just handle the diagnosis and decisions myself.” While this may keep people from having to come in as much in the middle of the night, it is not what is best for the patients for whom we have dedicated our lives to protecting.
These many moving parts are made up of individual stakeholders, and it is important to point out that these are not all clinical; we should approach it as such. Each stage of the system is not only made up of individual providers but also administrators who are tasked with supporting protocols, technology, scope, and trust. Buy-in is created when each stakeholder understands what it takes to treat and care for patients appropriately within a system and support it with all means that are necessary and reasonable. The only way this can be done is by the open and transparent sharing of data across the system for each patient contact. Bi-directional trust is essential to success and trust starts with humility. When egos are put aside and we understand that we win as a team and we lose as a team, finger-pointing stops and we figure out together the best care for patients. Anything less is counterproductive and harmful.
1 OHCA survival rates
Benjamin EM, et al. Heart Disease and Stroke Statistics—2019 Update. A Report from the American Heart Association. Circulation. 2019;139:00. DOI:10.1161/CIR.000000000000659
2 ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr; American College of Cardiology; American Heart Association; Canadian Cardiovascular Society.
J Am Coll Cardiol. 2005 Apr 19;45(8):1376.
3 Hochman JS, Boland J, Sleeper LA, et al. Current spectrum of cardiogenic shock and effect of early revascularisation on mortality. Results of an international registry. SHOCK registry investigators. Circulation. 1995;91:873–81. [PubMed] [Google Scholar]