With an industry goal of a 90-minute door-to-balloon time for a heart attack patient coming through a hospital's Emergency Department, achieving half that time is a cardiologist's dream come true. The patient likely won't even know what a door-to-balloon time is, but suffice it to say a cardiologist's mantra during a patient's heart attack is "time is muscle." The less time it takes to restore blood flow, the less damage is sustained by heart muscle.
Beating standard time between arriving at the Emergency Department and restoring blood flow with angioplasty or surgery can be achieved by combining three things: technology, information and speed. And, of course, you need to be willing to make an investment, too. Jeanes Hospital, on Central Avenue in Northeast Philadelphia, partnered with Philadelphia's Burholme Emergency Medical System to make that investment ten months ago, and it proved its mettle from the very first patient.
This is but one of several ways that Jeanes Hospital has embraced advanced medical and surgical technology to create its own brand of health care reform in Northeast Philadelphia and Montgomery County. Eighty years ago when the hospital first opened its doors, it was the community's go-to for basic care and minor emergencies. Now in one of the most competitive health care arenas in America, the facility is taking bold strides by investing in a much higher standard of care.
Wireless Advantage for Heart Attack Patients
The implementation of communication technology on Burholme's ambulances gives paramedics the opportunity to transmit electrocardiogram (ECG) information wirelessly to Jeanes Hospital, setting in motion a decision-tree that could prompt the hospital to prepare its cardiac catheterization team ahead of time to prepare for the incoming patient, saving critical minutes. From the moment paramedics bring a severe heart attack (known as an ST Elevation Myocardial Infarction, or STEMI for short) patient to the emergency department, to the moment a cardiologist performs a procedure that restores blood flow is known as "door-to-balloon time." The American Heart Association (AHA) recognizes a 90-minute door-to-balloon time as a success. Having assembled the Jeanes cardiac catheterization team while last October's inaugural STEMI patient was still in transit, based on the information transmitted by Burholme EMS from the field, Jeanes teammates expedited the patient to an angioplasty procedure in 58 minutes (the "balloon" being part of the angioplasty tool).
"A patient’s long-term survival after a heart attack is directly proportional to the amount of good heart muscle that remains. Salvaging the heart muscle is directly proportional to how rapidly blood flow can be reestablished in the blocked artery," said Ted Parris, MD, Jeanes Hospital's medical director of cardiac catheterization. "Muscle dies over a six-hour period from the onset of an attack, but if blood flow is restored within 90-to-120 minutes with either a clot-busting drug, angioplasty or a stent, damage is minimized or eliminated." That fact is what prompted the AHA to herald 90 minutes as a benchmark, and it is also what prompted Jeanes and Burholme EMS to bring it down even further.
"That saved time means the world to heart attack patients," said Jeanes Hospital Executive and CEO, Linda Grass. "Bringing together a partnership between Burholme's paramedics, Jeanes emergency department physicians and the cardiac cath team, represents the ideal of what collaborative health care can produce. The marriage of technology on the ambulances to technology at the hospital is a life-saving relationship."
According to Tim Hinchcliff, Managing Director of Burholme EMS, "So few EMS services have engaged in this investment, in an effort to bring down the door-to-balloon time. Yes, it may be costly, but for a STEMI patient in transit, time is no longer money…time is muscle. We are extremely proud of this advancement, and Burholme EMS's newly minted position in Jeanes Hospital's protocol for heart attack patients. Now we just need to get chest pain patients to stop driving themselves to the emergency department," he said. "At the onset of symptoms, if Burholme EMS picks up a STEMI patient and is able to transmit ECG data to Jeanes, so much muscle-saving time is realized, over the patient who drives himself in."
Jeanes Hospital's Chairman Department of Emergency Medicine, Dana Weber, MD, agreed with Hinchcliff’s plea. "Now that we have this outstanding opportunity at our fingertips, we need to let the community know that it is far more favorable to seek ambulance transport than to drive to the emergency department. That pre-hospital work-up allows our EMS colleagues to be the point of entry to our time-saving protocol. Tim and his team can get patients through me and up to our cath lab so much faster."
Concluded Grass, "Everything about this new relationship pays off for the patient."
Customizing Knee Replacements
Jeanes recently became the host hospital for an innovative new tool used by surgeons for knee replacement patients. William Markmann, MD, a private practice orthopedic surgeon who operates at Jeanes, is helping to pioneer the use of the tool in our region. Baby Boomers' need for new knees is a call to action for new technology like Tru-Match, which uses a three-dimensional computerized scan of the patient's leg and creates customized surgical guides that help surgeons achieve consistency in the placement and positioning of the replacement joint.
"While the advent of total knee replacement was truly a revolution in the care of patients with severe knee arthritis, there has been a continued evolution to improve and perfect the procedure," said Dr. Markmann. "Custom fit knee replacement is one more step in that evolution, allowing the surgeon to perform a replacement customized to the patient's anatomy while being less invasive, hopefully allowing quicker recovery, less pain, fewer complications and a longer-lasting result."
Dr. Markmann explained that this technology helps ensure more precise alignment of the knee replacement, and therefore reduces the chances of uneven wear and tear. The technicalities are riveting: specialized software is used with a CT scan to create a 3D model of the knee and the progression of damage. The image is sent to DePuy Orthopaedics in Indiana, where personalized guides are fabricated and delivered to the surgeon. The guides help position and place the knee implant.
Dr. Markmann has launched the use of the customization technique in our region, said manufacturer DePuy Orthopaedics, Inc. In fact, DePuy informed Jeanes Hospital that to-date, he has performed about a tenth of the knee replacements using this technology across the country.
DePuy has indicated that they are being very conservative in their commercial release of this technology, so they can allow close monitoring of the early surgical outcomes. Having recently topped only 100 cases, the results have been very favorable across the industry thus far. Dr. Markmann confirmed positive outcomes for his cases at Jeanes Hospital.
"Being at the forefront of this kind of advanced technology is another way for Jeanes Hospital to serve our community," said Grass. "Partnering with progressive members of our medical staff, like Dr. Markmann, gives us the opportunity to lead the region in new opportunities. That's why patients choose Jeanes - to get sophisticated care with a personal touch."
Stroke: Preventing and Treating
The blockage had narrowed the patient's right carotid artery for years, but she didn't expect the mini-stroke it caused last year. She certainly didn’t expect to lose vision in her right eye. One more thing that the 69-year-old patient from Northeast Philadelphia likely didn't expect was to be able to have a high-end vascular procedure to fix her carotid artery only a few blocks from home, and be discharged early the next day.
Historically, that kind of condition is repaired by surgically bypassing the blockage with a shunt. This time, however, it was repaired by way of a minimally invasive catheter, and a protection device to prevent the arterial plaque debris from traveling to her brain. In its own way, the procedure is a means to preventing stroke, which can help close the loop for the at-risk population in the Jeanes community.
"Thirty percent of strokes are caused by carotid blocks," said Krishnasamy Soundararajan, MD, the vascular surgeon who performs the carotid stent procedure at Jeanes. "Our first patient had a mini-stroke which led to the procedure, but in other cases this is a way to prevent strokes from happening in the first place. Just as important is the device used to filter the plaque and prevent it from causing potentially dangerous outcomes for out patients."
Dr. Soundararajan also indicated that the vascular department at Jeanes is now offering aortic endographs too, and a "gadget for treating hypertension." He noted with the benefit of experiencing life at large, academic medical institutions, "Recent expansions at Jeanes are providing our patients with tertiary-level care, with the advantages of a well-established community hospital." By tertiary-level, the doctor was referring to the highly complex medical and surgical procedures that are typically the specialty of larger institutions. Dr. Soundararajan has performed six carotid stent procedures at Jeanes in the last year.
"The past two years have been big for the stroke care program at Jeanes," said Grass. "These achievements tell a great story about the quality of stroke care here, and our bond with neighboring emergency medical squads has tightened as a result. They look at our accreditation as a 'primary stroke center' as a sign that we have developed quality and safety standards that are recognized as best practice."
According to neurologist Dr. Marcia Halpern, Jeanes Hospital's stroke care medical director, "Accreditation from the American Stroke Association signifies that the stroke services provided at Jeanes have the critical elements necessary to achieve long-term success in improving clinical outcomes. It also reflects the demonstrated ability of the stroke team to meet or exceed performance measures."
Opportunity Everywhere
More recently, clinicians at Jeanes used their newly expanded cardiac cath lab for a stent procedure of a different style. The repair of an abdominal aortic aneurysm (AAA) in the hospital’s cardiac cath lab may seem like an orange in a bushel of apples, but the match was actually quite logical. The placement of a stent in the aneurysm helps to restore blood flow, reducing the chance of rupture. Traditional surgery for a case like this is far riskier, and requires a lengthy post-op inpatient stay. Repairing the AAA in the cath lab was minimally invasive with a fast recovery time.
Recent expansion of the hospital's cardiac catheterization program attracted the attention of more cardiologists in Philadelphia and Montgomery County, because caths and electrophysiology procedures are a vital component in the continuum of heart care. "Expanding diagnostics in cardiac care is leading to a more robust open heart surgery program," explained Chief Nursing Officer, Denise Frasca. "It's proven that the more cases you perform, the more apt you are to provide good outcomes for each patient."
Also expanding at Jeanes during the past 24 months are bariatric weight loss surgery and spine care, explained Grass. "We've had such a tremendous response to bariatric surgery at Jeanes, from our community and from our physician referral base, that we've made it a priority service here. Three bariatric surgeons performing both laparoscopic banding and gastric bypass procedures at a hospital of our size is a significant statement of achievement," she said.
The same can be said for the new spine care center, which offers patients a complete range of services for the diagnosis and treatment of spinal disorders. The Temple Spine Center at Jeanes opened for business in September of 2008.
"Our philosophy reflects a comprehensive approach to spine care," said F. Todd Wetzel, MD, Surgical Director of the new center. "Many spine problems can be managed successfully without surgery, so we provide a wide variety of non-surgical or pre-surgical options like pain management and physical medicine." For patients who do require surgery, the Center provides a full range of surgical services, including spinal fusion, artificial disc replacement, and innovative procedures such as microdiscectomy and X-Stop surgery to alleviate sciatica.
"Three years ago, it became clear that Jeanes was ready to scale to the next generation of complexity in its services," said Grass. "With empowering support from our medical staff, and experience at the Temple University Health System to help us develop, we've been able to maintain our community hospital presence while growing programs like joint replacement and open heart surgery."
Jeanes Hospital's Chief Medical Officer, Andrea McCoy, MD, said, "To provide these kinds of services while being recognized regularly for our patient safety, medication safety, and service excellence programs, illustrates the high level of skill here." Last year, the Joint Commission on Accreditation of Healthcare Organizations recognized Jeanes' protocol for insulin patients, and the hospital's infection control program, as being among the best in the country. Dr. McCoy said the Joint Commission also recognized the hospital's emergency preparedness plan as being in the top five percent of programs they’ve scrutinized nationwide.