There have been many advances in the understanding of heart attacks (myocardial infarctions) over the past several decades. These advances are responsible for treatment protocols that have increased the survival rate to over 90 percent for patients having a heart attack.
According to some researchers, the use of medications to break up blood clots and angioplasty in the early stages of a heart attack account for more than half the reduction of heart attack deaths over the past 30 years.
Hospitals have also made great strides in reducing the so-called “door-to-balloon (D2B) time.” (D2B refers to the time between a patient presenting in the ER and when they receive medical intervention). This includes procedures such as an angioplasty, where a small balloon is inserted and inflated to open a blocked artery. As a point of reference, American College of Cardiology/American Heart Association guidelines recommend a D2B interval of no more than 90 minutes. The vast majority of hospitals meet this target and some hospitals have even reduced this time to well under 60 minutes, which has become the current “gold standard.”
Which Hospital a Patient Goes to Can Impact Heart Attack Mortality and Survival Rates
This increased survival rate is clearly good news for the almost 800,000 patients who have heart attacks each year. The not-so-good news for health care providers and the communities they serve is that heart attack treatment and survival rates for patients can vary greatly from hospital-to-hospital.
One hospital in Pennsylvania, for example, has a heart attack death rate of 11.6 percent while another in Virginia reports a rate of almost 20 percent. The difference from provider to provider can be so great that one study based on an analysis of Medicare records suggests that going to the right hospital can add a year or more to a patient’s life.
An important metric is post-heart attack survival rate, which varies from hospital to hospital. This measurement is important since it goes beyond the initial acute period, usually when the patient is hospitalized, to include what happens during their remaining life span. In this case, researchers found that patients treated at “high performing” hospitals tended to have an overall increased life expectancy compared to those at hospitals where a greater number of heart attack patients die during the first month of care. While additional research needs to be done, one critical factor in improved survival rates beyond the initial 30-days seems to be how closely providers follow current guidelines for treating a heart attack.
And When Patients Arrive at the ER Can Also Make a Difference
Many people probably know that heart attacks during certain times of the day tend to be more serious and life-threatening than at others. But what many do not know is that the time of day when a patient having a heart attack arrives at the Emergency Room (ER) can also have an impact on treatment outcome and survival rates.
According to a survey of healthcare professionals, patients tend to receive the best care in the ER between 6:00 AM and noon. Another study from the American Heart Association shows that heart attack patients who arrive in off hours (nighttime, weekend, holidays) have a 13 percent increased risk of dying compared to patients who arrive during regular hours.
More research is required to confirm the exact reasons for these differences in treatment outcomes. But there is some evidence that during normal business hours the D2B interval was about 56 minutes while during other times it was around 70 minutes. In terms of patient numbers, about 89 percent of patients arriving during normal business hours had an angioplasty within 90 minutes and that percentage dropped to 79 percent during off hours. These numbers are well within the 90-minute ACC/AHA guidelines but given that D2B intervals can impact the amount of cardiac tissue damage that occurs during an acute heart attack, these times are important.
Several factors may account for these differences at different times of the day. One researcher posited that, from a human resources perspective, ER staff most likely are more alert and engaged at the beginning of the morning shift than they would be at the end of their shift or in the middle of the night when they may be fatigued. There may also be more staff during the day than in the evening and this could also impact treatment response times. Last, but not least, one study also pointed out that the costs of maintaining fully-staffed, round-the-clock catheterization labs would be, (as are other 24-7 services), cost prohibitive for most hospitals.
What Providers can Do
Further decreases of D2B times may produce some increase in survival rates. But more importantly, providers need to consider other actions they can take to improve the probability of a patient not only surviving the acute phase of the heart attack but also well beyond the initial 30-day treatment window. These include the following:
- Community Education and Prevention – Many people still question whether they are really experiencing a heart attack. As a result, they may waste precious time wondering whether or not to call 911. Providers can do more to educate their communities on not only how to recognize a heart attack but also what they should do in those most important first minutes. They can also review and enhance their current programs to help prevent heart attacks. These programs have been shown to benefit hospitals, patients and the community-at-large.
- Discharge Instructions and Follow-up – What happens after a patient leaves the hospital is just as important as the care provided during the acute and initial treatment while the patient is under the provider’s direct care. It is critical that the patient, family and other caregivers understand the discharge plan. Patients need to have ample time to ask relevant questions and be encouraged to reach out if they have any questions in between follow-up visits.
- Internal Reviews – As part of their ongoing review processes, providers should examine and identify ways to improve response time, communications and coordination among first responders and hospital staff, and aftercare programs. As one hospital found out, these could result in something as simple as locking down elevators so they are immediately available when a patient who is en route via a first responder to the ER.
Finally, healthcare providers should routinely visit the U.S. Centers for Medicare and Medicaid Services (CMS) comparison of death rates for heart attacks and heart failure which shows how individual providers compare to the national average for these and other metrics. This information can be used as part of internal reviews to identify areas where hospitals could improve quality of care. This comparison can be found at https://www.medicare.gov/hospitalcompare/search.html.