STEMI Initiative Cuts Response Time by 72%

A quality program at UNC Hospitals empowers non-physician clinicians to activate response teams for cardiology inpatients using triage protocols used by first responders.

UNC Hospitals physicians say initial results midway through an inpatient STEMI (ST elevation myocardial infarction) identification and treatment pilot project show response times have been cut by 72%.

George A. Stouffer, MD, chief of cardiology at UNC Hospitals, says the in-house initiative at the Chapel Hill-based health system began after clinicians noted a high mortality rate among non-cardiac inpatients suffering from STEMI.

"We initially did a study looking at our patients here at UNC. We did a subsequent study using a California database and found it was a problem in hospitals there and presumably nationwide," says Stouffer, who published a research letter on his study this month in JAMA Cardiology.

"We put in place a quality improvement program at UNC to see if we could improve the times, and that was one of the reasons that patients were dying at a high rate—the delayed recognition and treatment," Stouffer says.

Nationwide, Stouffer estimates that there are approximately 11,000 cases of STEMI each year among hospital inpatients, and about 4,300 deaths in this group. He says STEMI is difficult to detect, especially for inpatients, because they often don't present with the "classic heart attack symptoms."

Rapid Identification
The initiative borrows techniques from emergency first-responders, which includes a quick diagnosis with an EKG and alerting the cardiac catheterization lab. It empowers nurses and other non-physician clinicians to initiate a rapid response team if STEMI is suspected.

"For someone in the hospital, say they've had a knee replacement or some other surgery or they're in with pneumonia, they present differently," he says. "Often, they get short of breath, but they often don't have typical symptoms and they are not able to convey that as easily to the doctors."

"The most common symptom is the patient is short of breath. Also the blood pressure falls, the patient gets confused, the heart rate monitor goes up or down," he says.

Empowered Nurses Are Key
All of these symptoms may have been noticed, "but the thinking was not necessarily that they are having a STEMI. We have done education at UNC so that that thought does go into the mind of the nurse so they can activate this cardiac response team. Within five minutes we will know, based on the EKG, whether that is the cause or not."

So far, the project has reduced response times from 483 minutes to 136 minutes. The pilot project has expanded to include 17 hospitals across the nation, and Stouffer says he hopes to have definitive data to support the efficacy of the program within three years.

Stouffer says the initiative was fairly simple to implement at UNC in large part because it relies on enlightenment and empowerment.

"A lot of this depends upon nurses in the hospitals, and nurses in non-cardiac services have watched their patients struggle for hours before a diagnosis was made," he says. "They were very interested in expediting this."