For Missouri heart attack patients, the nearest hospital isn't always the best
The Missouri Department of Health and Senior Services has designated nine hospitals in St. Louis County as priority heart attack centers to ensure that the most at-risk patients receive help as fast as possible.
On May 15, the department announced 23 hospitals throughout the state as the most comprehensive centers for the most serious heart attacks. The list of so-called STEMI centers is part of a decade-long effort by the state to create a process called the Time-Critical Diagnosis System.
State lawmakers voted to establish the system in 2008, and it’s already in place for other time-sensitive health issues such as trauma and strokes. Starting this month, it also directs how emergency responders care for a certain serious heart attack called an ST-elevation myocardial infarction, in which a whole artery is plugged.
The system coordinates the responses of ambulances, paramedics and hospitals based on how serious a patient’s symptoms are. Traditionally, emergency responders only took distance into account when choosing where to take someone, said Michael Lim, a cardiologist at Saint Louis University Hospital.
“Before this law, EMS was mandated to go to the closest hospital, and you couldn’t bypass, you couldn’t drive five more miles, even if you knew it was a better place for that patient,” Lim said.
Under the Time-Critical Diagnosis System, emergency personnel would instead transport patients to the nearest qualified hospital. The most serious patients will go to the ones best-equipped to treat serious heart attacks.
The point is “to get the patient with a critical diagnosis from a time standpoint to a place where they can get everything done at that location,” Lim said.
According to Lim, the highest-level STEMI centers have around-the-clock lab capabilities and a high volume of heart attacks. Lower levels serve as entry points into the system and can stabilize more serious patients if needed.
Getting a STEMI designation is voluntary, and hospitals need to apply to receive it. According to the state health department, all the 53 hospitals in the state that submitted received the designation they applied for.
What ultimately makes the system successful is the expertise and quick thinking of emergency medical responders, said Ryan Barker, vice president of policy for the Missouri Foundation for Health.
"It's about the EMS working with the patient in the field as an individual," said Barker, whose nonprofit perfected the plan before sending it to state legislators.
“Sometimes, if the nearest hospital … can provide the appropriate level of care for what’s going on with that individual, that’s where they’ll take a patient,” he said. “A lot is driven by what’s going on in the field with that individual and making the decision of what hospital to go to.”
The Time-Critical Diagnosis system was designed by Bill Jermyn, a former state emergency services director. He knew that when it came to surviving a heart attack or stroke, every minute became crucial.
“He came to us and was talking about the ‘golden hour’,” Barker said. “After a heart attack or stroke, receiving the right care in the right place during that first hour is just so important. It saves heart tissue, it saves brain tissue. There so much riding on it.”
While the bill that would approve the Time-Critical Diagnosis system was working its way through the legislature, Jermyn died of a heart attack while mowing his lawn. Days later, state lawmakers voted unanimously to implement his idea across the state.
Although state health officials couldn’t produce detailed data for how well the time-critical diagnosis protocol improved health outcomes, an unnamed HSS spokesperson said in an email that there have been notable positive outcomes.
“For example, patients with stroke symptoms are recognized much sooner and transported to appropriate facilities, allowing them to be treated properly in a timely manner. As a result of timely treatment, the amount of time in a rehabilitation facility or nursing home is reduced,” the spokesperson wrote.
This story has been updated with comments from Ryan Barker, vice president of policy for the Missouri Foundation.
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