Team work makes the difference Story by Kelly Miller   -   Photos by Bob Pluckebaum

Through the efforts of everyone at the MVRMC---the emergency room physicians, cardiologists, nurses and paramedics---the average "door-to-needle time" is 18 minutes. Nationwide, only 40% of patients receive thrombolytics within the desired 30 minute door-to-needle time. At the crux, is the knowledge that lower times result in less morbidity.

Dr. Kevin Kraal gives credit to the nurses and paramedics whose cooperation and communication has improved care for both MI and trauma care patients. Kraal has been an emergency room physician with the Medical Center for over nine years. He also serves as EMS Medical Director. Kraal credits the lowering of their door-to-needle time over the last 5 years---from 52 minutes to 18 minutes---to a "bottom up" driven approach. "No one told us to lower our time," says Kraal. "We just did it."
 

Left: Emergency physician Dr. Kevin Kraal and nurse Regina Harrington meet paramedics Blaine Patterson (left) and Stan Flint (center) at the Magic Valley Regional Medical Center's emergency department entrance.  Right: Paramedic Blaine Patterson reads a printout from an ECG. Information interpreted in the field from the 12 lead ECG is relayed to the MVRMC emergency physician.

Magic Valley Regional Medical Center is big enough to provide everything Kraal needs, but not so big that "we have this machinery" stopping innovative advancement from the grass roots.

"We had a systems approach," explains Kraal. "We really looked at how a patient goes through the system." From cardiologists to nurses to paramedics---a team of involved health care providers assisted the Emergency Department in finding places to initiate change. Now, when time is critical, highly-trained paramedics follow Cardiac Alert protocol, performing 12 lead ECGs in a pre-hospital setting. The emergency department staff is fully prepared and waiting at the door. Now, emergency physicians read ECGs through the training of the local cardiologists and determine when to give the appropriate medications. The patient receives lifesaving drugs in substantially less time.

As a result of this massive ground swell of effort, not only was the door-to-needle time lowered by 34 minutes, but MVRMC also had the second fastest time in the country a year ago for similar hospitals, according to the Institute of Health Care Improvement. Kraal is often requested to speak to other medical providers in the country about the efforts and success of the team approach to cardiac emergency care. More people nationally know about the MVRMC door-to-needle time than in Idaho. Kraal believes that "people working in the Emergency Department feel like they own it, and that is important for change."

The MVRMC Emergency Department services approximately 3,256 square miles---more than 17,000 patients a year. The Emergency Department has 7 rooms, 5 emergency department physicians, 15 paramedics, 10 EMTs and 25 nursing FTEs. To keep on top of the game, the Magic Valley Emergency Department voluntary compares itself through the National Trauma Registry of the American College of Surgeons---submitting monthly data through an RN on stabilization and patient care. Through the input and comparison, the department is able to make changes that are significant to patients care.

One key to the success of the Emergency Department is that the paramedics are employees of the MVRMC. The paramedics agree. "With hospital-based emergency medical services, we are able to keep up on new trends and have access to better equipment," acknowledges paramedic Blaine Patterson. As employees and part of the team, the paramedics are invested in the program and have opportunities to institute change in the procedures. Kraal oversees the Emergency Medical Service and credits much of the success of the emergency room to the initiative of the paramedics and emergency medical technicians. "They are very smart people, they love their work and want to help people," says Kraal.
 

Left: Paramedic Blaine Patterson has been with MVRMC for three and a half years, and is the Retovase(tm) study chairman.  Right: A MVRMC paramedic uses 12 lead ECG technology in the field.

 
Pre-hospital Thrombolytic Study

Not resting on their laurels, the paramedics under the direction of Kraal have instituted a pre-hospital thrombolytic study. "For many cardiac patients, there wasn't much we could do," explains paramedics Patterson and Stan Flint. "We wanted to make a bigger difference in the care of cardiac patients." Over 50 percent of the transports are more than 15 minutes away from the hospital---critical time is lost due to the rural terrain surrounding Twin Falls.

Many studies have been performed, and have consistently illustrated the benefits of rapid thrombolytic therapy in acute myocardial infarction (AMI). In June 1991, the National Heart, Lung and Blood Institute launched the National Heart Attack Alert Program to promote the rapid identification and treatment of AMI, with the goal of reducing AMI morbidity and mortality, including AMI-related sudden death. The identified delay of thrombolytic therapy is the fundamental barrier in providing optimal MI care. Studies attribute that delay to three different areas: the patient seeking the care, the EMS system, and the delay in the emergency department.

At MVRMC, Emergency Department staff have lowered the door-to-needle time to levels far below national averages through intensive training and team work. Nevertheless, the "door-to-needle time" can be irrelevant when transport distances in a rural area combined with patient delay in seeking attention results in thrombolytic therapy being administered after the optimum time of 90 minutes at the onset of chest pain.

Twin Falls County is large, often resulting in transports of up to 40 minutes or more. In addition, MVRMC also provides Advance Life Support (ALS) rendezvous with ambulances from Shoshone and Jackpot, Nevada. Though these patients are have for a lengthy transport times, they ultimately benefit because of the ALS treatment they receive throughout their post-rendezvous travel.

MVRMC began addressing the issue of lengthy transports through the purchase of pre-hospital 12 lead ECG equipment and the development of "Cardiac Alert" protocols. In 1998, the Magic Valley Paramedics performed 12 lead ECGs on 98 pre-hospital patients with cardiac signs and symptoms. Of those, 14 acute myocardial infarctions were identified by paramedics in the pre-hospital setting.
 

Left: Paramedic Stan Flint "administers" the placebo Ratavase(tm) as  part of the MVRMC field study.  Right: Emergency physician Kevin Kraal, MD, has been with MVRMC for over nine years, and serves as EMS Medical Director.

The MVRMC Emergency Department is currently evaluating the administration of thrombolytic therapy, specifically Retavase^TM, by paramedics in a pre-hospital setting. Two advantages of Retavase^TM for pre-hospital use are that it is not weight dependent and it has a two-dose regimen. If bleeding or other complications occur with the first dose, the second can be withheld in order to minimize the complications. Both the RAPID 2 and the INJECT have shown relatively low incidence of associated CVA, bleeding or anaphylactic reactions using Retavase^TM.

In 1999, at the initiative of the paramedics, the Centocor^® Corporation began supplying the MVRMC placebo Retavase^TM kits containing saline instead of the thrombolytic. When the paramedic determines according to protocol that rapid thrombolytic therapy is necessary, the paramedic removes the locking pin and administers the saline into the sharps container.

Through the study, the Magic Valley Emergency Department will collect data on the time elapsed between onset of symptoms and the 911 call, arrival time of ALS personnel, scene time, time of transport to destination facility, time for initial 12 lead ECG and interpretation, time of placebo administration, any subsequent 12 leads, and time of arrival at destination. The emergency medical team will also track the accuracy of differential diagnosis and patient outcomes.

The objective of the study is to ascertain if transport times allow the time necessary to complete the protocol, to determine if enough time is saved to impact the high morbidity and mortality, and if paramedics can make the differential diagnosis with a high degree of accuracy and properly administer the thrombolytics in the pre-hospital setting. The team estimates that the study will require 1 1/2 years to collect adequate data to determine the effectiveness and costs of administering thrombolytics in the field in a rural setting.

As study chairman, Patterson is proud of the team's efforts. "This is a national class program in a little place." Good things do come in small packages. ---TP