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In Emergency Cardiac Care, Time Matters

First in a series about RGHS emergency care.ED

When a patient enters the Rochester General Hospital Emergency Department with symptoms suggesting a cardiac event, that individual is met by two teams working as one coordinated unit, and with a single overarching thought: Time is precious.

The ED and Cardiac teams pay close attention to the minutes between a cardiac patient’s arrival in the ED and their receiving an EKG and, when necessary, angioplasty in the Cardiac Catheterization Lab. Those key response times play dramatic roles in the quality of cardiac care.

gacioch“Studies show us the clear relationship between door-to-balloon times and patient outcomes,” says Gerald Gacioch, MD, Chief of Cardiology for the RGHS Sands-Constellation Heart Institute. “If you can get someone treated within a few hours of the infarction, you have the potential to see zero damage to the heart.”

SCHI’s Cardiologists and the ED clinical team have developed and refined a process over the last decade that ensures fast, high-quality care. Nationwide, the accepted national door-to-balloon standard is 90 minutes; at RGH, anything over 60 minutes is unacceptable. “Here, the EKG is consistently done in under five minutes, which is a huge help,” says Dr. Gacioch. “Our median door-to-balloon time is consistently under 60 minutes – in the mid-40s, actually.”

These successes derive from a collaborative process whose key elements include:

Coordinated Communications. Giving paramedics a dedicated point of contact for cardiac cases helps streamline patient handoffs. “Early notifications are important,” says Bryan Gargano, MD, RGH Associate Chief of Emergency Medicine. The ED and Cardiac teams also share cellphone numbers, and save time by communicating with calls or texts instead of pages.gargano

Carefully Refined Alert Protocols. When an EMS team arrives at the ED with a cardiac case, a doctor and nurse go right to the patient and begin charting immediately. This alert process also gets the cardiologist involved quickly, Dr. Gargano says: “It’s not uncommon for them to meet the EMTs right at the door, and head straight to the Cath Lab from there.”

Synergistic Staffing. The Cath Lab regularly has two cardiologists on call – one to accept handoffs in the ED, and an interventional specialist in the Cath Lab – to trim even more time off the crucial door-to-balloon metric.

Improved Infrastructure. Both the Cath Lab and ED have been renovated in recent years to foster the closest working relationship possible. Besides being physically closer together, a dedicated elevator provides rapid transport to the Cath Lab from the ED; and catheterization kits in each Cath Lab suite are standardized and prepped in advance of a patient’s arrival.

Aggressive Time Management. Even the parking spaces have been adjusted for on-call cardiologists on overnight shifts. “It takes a certain number of minutes to walk from your car to the ED,” Dr. Gacioch says. “The more minutes we can save, the better for the patient.”

The success of this process is well established: RGH is regularly recognized as a state and national leader in cardiac care. Most recently, in early 2013 CareChex, the hospital quality ratings service of The Delta Group, rated RGH #1 among all New York State hospitals in the category of Heart Attack Treatment.

“But we’re still always looking for new ways to improve our times,” Dr. Gargano says. A multidisciplinary workgroup meets monthly to review recent cardiac case data, to seek out and resolve any possible obstacles to optimum patient care.

To get a “second opinion,” in 2012 the teams requested a performance audit from the RGHS department of Clinical Excellence and Performance Improvement. Virtually all of the audit’s recommendations had already been identified by the clinical teams. “They were basically told that they were already operating at ‘Best Practice’ levels,” says Amy Craib, SCHI Vice President.

Those proven results, along with regionally leading outcomes and national recognition, help explain the overwhelming community response regarding the quality of cardiac care at Rochester General Hospital. “If someone thinks they’re having an MI,” says Dr. Gacioch, “this is where they want to be.”