Acute Heart Attack Care Faces Prolonged Challenges Post COVID-19

Door-to-balloon (D2B) time, ideally set at 90 minutes or less, is a crucial benchmark in heart attack care as it correlates with better outcomes for patients. However, the pandemic introduced new challenges, such as the necessity for COVID-19 screening, associated isolation protocols, and intensive cleaning in cardiac catheterization labs.

According to new research presented at the American College of Cardiology (ACC) Quality Summit 2023, these factors contributed to increased D2B times, and the latest research indicates that many health care facilities are still grappling with these challenges, causing D2B times to lag.

Delays in restoring blood flow to the heart muscle, known as reperfusion, are linked to higher mortality and morbidity rates in patients who have had a heart attack. Although certain delays are inevitable due to various factors, including diagnosis uncertainties and long transport times, achieving the D2B goal remains paramount. According to an ACC press release, recent studies have emphasized that reducing D2B times further improves outcomes and decreases mortality.

The current study focused on Hackensack Meridian Health Ocean University Medical Center (OUMC) in New Jersey. In April 2022, OUMC reported a rising D2B time of 73 minutes for the first quarter, well above their prepandemic average of around 60 minutes.

According to Sara Belajonas, MSN, MBA, CCRN, APN-C, chest pain coordinator at OUMC and author of the study, some new national standards that were created in response to the pandemic actually added minutes to D2B time.

“Although the incidence of COVID myocarditis increased during the pandemic and led to false activations, the total number of STEMI [ST elevation myocardial infarction] activations actually decreased,” said Belajonas. “I believe this created a scenario that our STEMI process was not utilized as often, therefore creating the need for reeducation and the refocusing on the importance of time.”

Globally, heart attack hospitalizations decreased by 28% during the pandemic, not necessarily reflecting a lower incidence of heart attacks but likely due to patients avoiding medical treatment. According to Belajonas, noting these trends can help prepare for the future.

“Utilizing past research and trends, we already know symptomatic patients are not getting the emergency care they need,” she said. “All health care workers should do their part in educating the public on the importance of early heart attack care.”

The study's review of heart attack care processes identified prolonged stays in the emergency department (ED) for various reasons affecting patient throughput. Issues such as national nursing and emergency medical services (EMS) personnel shortages, exacerbated by burnout, were identified as major impediments to achieving timely care, with Belajonas emphasizing that OUMC is not alone in this struggle.

“Post COVID rebuilding has been a challenge,” she said. “Health care, as a whole, is changed.”

It was also discovered that not all STEMIs transported by advanced life support units underwent preactivation, which involves notifying the cardiac catheterization lab at the receiving hospital before the patient arrives. This proactive step enables patients to bypass the standard protocol of going to the ED initially, allowing them to be directed straight to the cardiac catheterization lab and thereby saving crucial minutes.

OUMC has since implemented various strategies to reduce D2B times, including reeducation, involvement of additional staff, regular drills, collaboration with EMS, and adherence to ACC recommendations. By the end of 2022, OUMC had reduced its D2B time from 73 to 72 minutes, and by August 2023, had successfully achieved its goal of 60 minutes, demonstrating continued improvement in acute heart attack care.

Reference

Challenges in acute heart attack care continue post COVID-19. News release. American College of Cardiology. October 4, 2023. Accessed October 8, 2023. https://www.acc.org/About-ACC/Press-Releases/2023/10/04/12/54/Challenges-in-Acute-Heart-Attack-Care-Continue-Post-COVID19