Cardiac waits can kill
Some area hospitals too slow in treating weekend heart attacks
An analysis of data from Portland hospitals reveals people suffering heart attacks are more likely to receive aggressive treatment quickly if brought in on a weekday rather than a weekend.
In fact, three out of five Portland hospitals do not meet national standards for treating heart attacks quickly enough on weekends.
Earlier this month, a large-scale study published in The New England Journal of Medicine found that weekend heart attack sufferers treated at hospitals had higher death rates than people who suffered heart attacks on weekdays. One suggested explanation has to do with the amount of time it takes patients to get treatment.
Reduced hospital staffing on weekends means heart attack treatment teams, called catheter teams, are not all on-site and have to be called in. And that can result in extra minutes before treatment - usually an angioplasty to open blocked arteries - can take place.
When dealing with heart attacks, every minute counts, experts say.
'The shorter the time, the more heart muscle can be saved and the less the disability,' said David Meyerson, director of cardiology consultative services at Johns Hopkins Bayview Medical Center in Baltimore and a spokesman for the American Heart Association.
But on weekends, treatment times in Portland hospitals lengthen.
The most common measurement for heart attack treatment is called 'door to balloon' time, which measures minutes from the moment a heart attack patient arrives at the door of the emergency department until an angioplasty balloon has been inflated to clear the artery.
The American Heart Association and the American College of Cardiology have set a 90-minute goal, and recent studies have shown that death rates rise steadily when an angioplasty takes more than 90 minutes to perform.
Locally, the most dramatic disparity was reported by Legacy Good Samaritan Hospital. The average weekday door-to-balloon time at Good Samaritan is 74 minutes. On weekends, the average is 132 minutes.
Oregon Health and Science University's weekday door-to-balloon time is 53 minutes, with a weekend average of 104 minutes.
At Legacy Emanuel Hospital the weekday average time is 83 minutes, and the weekend average is 116 minutes.
At Providence Portland Medical Center the disparity is smaller. Weekday door-to-balloon time is 66 minutes; on weekends it rises to 80 minutes.
Providence St. Vincent Medical Center averages 67 minutes door-to-balloon during the week and 81 minutes for weekends.
Robert Florek, a cardiologist for Legacy Health Systems, said the differential was mostly due to staffing.
'In almost all hospitals there is not a catheter crew present in the hospital at night or on weekends and holidays,' Florek said. 'So the response time is somewhat longer based on the fact that four to five people have to come in. That's the major difference. It's not practical to keep a crew on 24-hour standby.'
Fewer have angioplasties
Physicians at each of the local hospitals say they have instituted substantial changes in recent years to get weekend heart attack patients up to operating rooms and under treatment faster than before.
Most hospitals now instruct emergency department physicians to call in catheter teams without waiting for a cardiologist consultation. And most hospitals now insist that catheter team members be no farther than 20 minutes away from the hospital while on call.
But the most dramatic change, Florek and others said, has come outside the hospitals. In the last year, nearly all ambulances in Multnomah County have been equipped with portable electrocardiogram equipment.
Ambulance medics now are able to perform tests on-site and relay the data in so the hospital can alert the catheter team while the patient is en route to the hospital. That can save an estimated 15 minutes, according to Joaquin Cigarroa, clinical chief of cardiology at OHSU.
Nevertheless, staffing alone may not explain the higher weekend death rates, experts say. The New England Journal study also found that weekend heart attack patients don't always receive the same treatments as weekday patients.
The study found that 10 percent of people who arrived at hospitals suffering heart attacks on weekdays had angioplasty to open blocked arteries, while only 6.7 percent of weekend patients received an angioplasty.
But area hospitals say that is not the case here. 'If you come into the hospital and the clinical decision based on guidelines is that you merit a catheter, you will get a catheter,' Cigarroa said.
Doctor shortage blamed
Diane Reiner, quality coordinator for the Providence Heart and Vascular Institute, said Providence's internal data does not show a higher death rate among heart attack patients on weekends.
Reiner also said that St. Vincent has such a high volume of heart attack patients that 'oftentimes our staff are working on the weekend. They don't have to come in.'
Still, what is known among medical experts as 'the weekend effect' is not limited to heart attacks, or even weekends. A separate study published three weeks ago in the medical journal found that stroke patients also had higher death rates on the weekend. And patients hospitalized with heart attacks during winter holidays also have higher than normal death rates.
Roy Magnusson, chief medical officer at OHSU, says at least part of the explanation for the weekend effect may have to do with the increasing shortage of doctors, which is making it harder for local hospitals to keep a variety of specialists, including surgeons, on call.
'A lot of specialists in Oregon are getting scarcer and more reluctant to take calls for hospitals,' Magnusson said. 'Their practices are busy and there isn't a lot of compensation for them to do so.'
Though explanations for the weekend effect still elude researchers, Meyerson of the American Heart Association said any data showing longer than 90 minute door-to-balloon times is cause for concern. 'This data should be taken as a wake-up call,' he said.
It's better to be safe than sorry
The greatest risk to people suffering a heart attack, medical experts say, is doing nothing at all. Whether it's a weekday or a weekend, the advice to people who think they might be having a heart attack is to get immediate help, and err on the side of caution.
'Under the worst of circumstances, getting in to a hospital is better, even if it takes a few minutes longer on the weekend,' said David Meyerson, director of cardiology consultative services at Johns Hopkins Bayview Medical Center in Baltimore.
In fact, one possible explanation for the higher weekend death rates revealed in the New England Journal of Medicine study, Meyerson said, is that weekend sufferers of heart attacks might be waiting longer before recognizing symptoms and going to the hospital.
The most common symptoms of a heart attack are chest pain, shortness of breath, lightheadedness and pain reaching into the shoulders, neck and arms. But many heart attacks don't present the classic symptoms. When in doubt, experts say, call 911. And while waiting for the ambulance, take one regular aspirin and chew it, which might help reduce blood clotting.
- Peter Korn