Siouxland Providers Work Together to Better Serve Critical Patients
With the first signs of Spring beginning to burst outside on a lazy day last April, Jo Rettinghaus couldn’t get herself to leave the house. After spending much of the day laying around trying to shake what was ailing her, she finally decided to go to bed.
It wasn’t long before Jo was back out of bed, dealing with a sensation that “felt like an elephant” was sitting on her chest. At around 11:30 p.m., Jo asked her daughter Shannon to call 911.
Had Shannon waited much longer to place that call, Jo may not have survived what turned out to be a significant heart attack. In technical language it was classified as a ST-Elevation Myocardial Infarction (STEMI).
Luckily for Jo, Shannon’s call to 911 initiated a protocol fostering the cooperation of rural providers and the cardiac catheterization team at UnityPoint Health – St. Luke’s in Sioux City.
Building a Coalition
In effectively managing a STEMI, time is of the essence. The standard of care, for the type of incident Jo was experiencing, calls for getting the patient to the cath lab as soon as possible so a stent can be deployed restore blood flow through the blocked artery.
The STEMI protocol in place in Siouxland was developed through a broad coalition that sought to implement guidelines offered up by the American Heart Association in its Mission: Lifeline® initiative. In short, it is designed to advance the system of care for patients with acute, high-risk time sensitive life and/or quality of life-threatening disease states.
Edward Zajac, MD, FACC
, of UnityPoint Health Cardiology Services and Cardiovascular Associates
and a member of the cardiac team at St. Luke’s, was a member of the founding team for the STEMI protocol. He says that since the beginning, the mission has been to deliver life-saving care, regardless of where in Siouxland a patient experiences a heart attack.
“This [protocol] is extremely important, especially in rural Iowa,” Dr. Zajac says. “We were aware that those who had a myocardial infarction (heart attack) in an urban area were treated differently than those in smaller towns or rural areas.”
The difference boiled down to access to advanced therapies like cardiac catheterization. Those services are available in a city the size of Sioux City, but not in the dozens of small towns throughout Siouxland. Getting timely care for heart attack patients in these rural areas has required the buy-in of providers throughout the region, and a commitment to working together in the best interest of the patient.
“It was a very major accomplishment to get a large number of physicians involved in this effort who could develop consensus on how to move forward,” Dr. Zajac says of the early taskforce work that went into developing the protocol.
The STEMI protocol is set in motion as soon as the 911 call is placed. EMS teams throughout the region have extensive education and training on gathering the data necessary to help the cardiologist on duty at St. Luke’s or the local emergency department physician assess the patient’s condition. This ensures a timely recommendation can be made on whether the patient should be cared for locally or immediately transported to St. Luke’s.
In Jo’s case, it was evident early on that she needed the type of advanced care that only St. Luke’s could provide. The EMS team gathered an electrocardiogram, transmitted it to St. Luke’s, and was directed almost immediately to transport Jo to Correctionville for transport via helicopter for an emergency cardiac catheterization.
Jo says it was all a blur.
“I kept going in and out of consciousness,” she says. “I do remember them putting the pads on my chest, landing in Sioux City and looking up to see the blades of the helicopter go around. I also remember hearing the doctor say that they were taking me right to the cath lab.”
Dr. Zajac says that the work of the EMS team makes it possible to meet patients like Jo at the helicopter or in the ambulance and move them without hesitation to the cath lab.
“The EMS service is so much more than a transport service,” he says. “A lot of the primary management of a heart attack takes place in the living room of the patient. The EMS team has the equipment required to transmit an electrocardiogram right to us. This allows them to get insight from the physician and begin treatment in the home.”
Additionally, it gives the cardiac care team a heads up on what to expect when a critical patient arrives.
“When they arrive, we know a lot about them already,” Dr. Zajac says. “We are ready to deliver care and that saves time. When you save time, you save muscle. When you save muscle, you save lives.”
Time is what the entire protocol is built around.
There are a number of milestones that the team is focused on hitting to ensure the required care can be delivered as soon as possible. To help keep the entire network of care providers on the same page, St. Luke’s offers regular education and training to rural providers including physicians, nurses and EMS staff.
“I work with a lot of the EMS squads in offering continuing education,” says Kevin Handke, NRP, FP-C, CCP, CMTE, St. Luke’s STEMI Coordinator. “We are working to get the electrocardiogram in ten minutes or less. That early notification allows the cath lab team to get in place. Just that one step will save anywhere from five to 15 minutes. And even when we are talking about saving five minutes, that can save significant muscle from being damaged.”
While Jo was unaware of the high level of cooperation that went into getting her from her home to the cath lab in right around 45 minutes – typically, a drive from Ida Grove to Sioux City takes more than an hour—she is thankful for the care provided by so many.
“I didn’t wake up until later in the morning after all this happened the night before, but when I did, I felt 100-percent better,” Jo says. “I was in the hospital for three days afterward and the care was excellent. I also appreciated how they kept my daughter Shannon informed of everything throughout. From the night it happened until I was discharged. They made sure that she was aware of everything that was happening.”
Dr. Zajac says the STEMI team is constantly reviewing data to get a better understanding of what is working and needs to be expanded, and what can be improved. At its core, the cooperative effort is aimed at better serving the region.
“We see patients from about a 100-mile radius of Sioux City,” he says. “In order to serve those patients, we rely on a robust outreach program. What we are able to do, with a lot of teamwork, is to help our smaller providers reach a level of sophistication they haven’t been at before. That takes a lot of education and a lot of training, but we have been active in participating in that.”
As data continues to point to the success of the effort, Dr. Zajac says he is pleased.
“We are following these patients and their data,” he says. “When it goes well we are trying to replicate it.
“When we first started this,” Dr. Zajac continues, “I was skeptical, and I wasn’t certain it would be a success. But it’s happened. I’ve seen it happen.”
As has Jo.
“I had a great care team, all of them,” she says. “They were very professional, very skilled and they saved my life.”