RACE program dashes to success

Rural hospitals join to coordinate care

What happens when you get 122 hospitals to band together and coordinate care for heart attack patients? You save lives, even in small rural hospitals that might not be expected to perform as well as their urban counterparts.

The Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE) program began four years ago in North Carolina under the leadership of Duke cardiologists. The goal was to improve reperfusion time in MI patients, which decades of research shows is key to surviving a heart attack. The original program included several changes to existing protocols. First, there would be a single call that could activate a hospital's catheterization lab at any time of the day or night. Physicians or EMTs could make this call. That meant that EMTs could diagnose heart attacks, something that before was left until a patient got to a hospital. In rural areas, that could take tens of minutes, even hours, for a patient to get to a hospital and see a physician.

Second, cardiologists could be consulted at any time, but their consultation was not required. Again, this speeded up the time spent in an emergency room and allowed the patient to get to the cath lab in a more timely manner.

All the participating hospitals agreed to make use of a single "operations manual" for the program, which was based on existing guidelines and accepted protocols (the 2009 Operations Manual is available at http://www.nccacc.org/RACE/RACEOperationsManualOct.09.pdf).

The initial results were reported in the Journal of the American Medical Association in 20071 and were impressive, with reperfusion times improving for almost all criteria. The number of patients with door-to-reperfusion times under 90 minutes increased from under 57% to 72%; the median time declined from 85 to 72 minutes; for patients transferred from one hospital to another for percutaneous coronary intervention median time dropped from 165 minutes to 128 minutes.

James Jollis, MD, the lead author of the original study, says that the data have held up over the last couple of years. A new study is awaiting publication. Of the 122 hospitals involved, 100 are rural, and somewhere between 20 and 30 are critical access hospitals. Getting stakeholders from that many organizations to agree to a program wasn't as hard as one might think. Jollis says that the key was including everyone in the planning, asking for their input at every step along the way, and recognizing everyone's point of view. For instance, administrators are key to the success, but they might be worried about sending patients away from their facility to receive care elsewhere. "They have a fiscal mandate," Jollis says. "They have to maintain volumes and provide certain services. But everyone wants to provide the best care, and we explained that we are only talking about 2% of chest pain patients."

It helped that there are widely accepted protocols for MI. "The thing you want to do is open the blood vessel; there is consensus about what to do." Jollis says creating a single operations manual that dealt with just the most basic and low-tech elements of care allowed every facility to add onto it as they saw fit. "We provided something that outlined the basic elements," he says.

"If you have a plan like ours in place, there is less paralysis; care always moves forward. The EMTs can diagnose and call into the cath labs, the EDs can decide on treatment without waiting for the cardiologist. The things that are most important to be done are done quickly." That the effort was supported by the local chapter of the American College of Cardiology helped get those cardiologists on board and keep the grumbling at the reduced consultation to a minimum. Eventually, as results came in, even the physicians who were most against RACE came on board and became champions of the program.

Saving 40 minutes of door-to-treatment time for MI patients is "huge," Jollis says. The program wrought other changes, too. For instance, one county that didn't have the right EKG machines in its EMT trucks got them after one of the county supervisors had a family member saved in another county that did have the right ones. "You think you call 911 and it will all be fine, but it can depend on where you are." That's not the case in most of North Carolina now.

The upcoming paper shows little continued improvement in time — Jollis says there is only so fast that you can go. But there is a decline in mortality of 1%, a declining length of stay for patients, and a low overall mortality rate of 2.5%. He also notes that when they stopped measuring for six months, the numbers climbed back up. "We have to keep measuring. I think we are at a good place and it will become embedded in the system. But we have to keep measuring."

For more information on this topic, contact:

  • James Jollis, MD, Professor of Medicine, Duke University, Durham, NC. Telephone: (919) 681-5816.

Reference:

  1. Jollis JD, Roettig ML, Aluko AO et al. Implementation of a Statewide System for Coronary Reperfusion for ST-Segment Elevation Myocardial Infarction. JAMA 2007;298(20):2371-2380.