Christopher B. Granger, MD

When it comes to surviving a heart attack, every minute counts. That’s why Duke cardiologists pioneered the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project.  

The goal of RACE is to provide the fastest, most beneficial care to the greatest number of heart attack patients eligible for potentially lifesaving reperfusion (artery-opening) therapy.

Reperfusion therapies include clot-dissolving drugs, blood thinners, and angioplasty -- a surgical procedure that uses slender catheters carrying balloons and stents to prop open blocked vessels.

Just a few years after its launch, RACE has proved so successful that it was named by the American Heart Association as one of the top research advances of the year. It is now being adopted not only throughout North Carolina but across the nation in a project called Mission: Lifeline lead by the American Heart Association.

Better, Faster Care

The RACE project is based on a simple observation -- fragmentation of the health care system results in failure to provide lifesaving care in a consistent and timely manner.

RACE has recruited hospitals and emergency medical services across North Carolina to work together to remove the obstacles that prevent patients from receiving reperfusion therapy in a timely manner and to provide better care.

“The beauty of the RACE program is that it doesn't require novel treatments that could cost millions of new dollars. It's simply doing better and faster what we already know how to do," says Christopher Granger, MD, Duke cardiologist and a co-director of the project.

The quality improvements at the core of the program include new training for paramedics, physicians, nurses, and other providers, collaboration between hospitals and emergency response teams throughout the state, and establishing smarter processes for responding to heart attack patients.

Moving Care Forward

Duke implemented these RACE protocols by training paramedics to do the work of the emergency room physicians, and training ER physicians to do the work of cardiologists. Teaching paramedics to diagnose a heart attack in the field allows ER physicians and cardiologists to immediately administer reperfusion therapy when the patient arrives.

"Cardiologists had to give up some of the control we were used to having," says James Jollis, MD, a Duke cardiologist and lead author of the study. "It was a hard habit to break. But once we saw the results, we knew we could trust the process."

This process of “moving care forward” helps to dramatically shorten the time between the patient’s arrival at the hospital and the time when the patient receives angioplasty.

Working Together, Working Smarter

Collaboration between hospitals and EMS services throughout North Carolina is vital to the RACE project’s success. North Carolina is the only state in the nation that has all primary angioplasty centers working together to improve care, and this makes for a powerful team.

As an example of improving the system, several years ago, Duke designated one phone line for emergency departments or paramedics to call when they identify a heart attack patient in Duke’s referral network. A call on this phone activates the catheterization laboratory at Duke to ensure the patient is rapidly treated.

Making small but smart changes has helped Duke speed the process of getting patients from “first door to balloon.” These changes include obtaining ECGs in the patient’s home or work place, allowing paramedics to diagnose the heart attack and immediately activate the cath lab, receiving patients on the feeder hospital’s stretchers, collecting performance information in a standard way, and encouraging swift feedback to guide continued improvement.     

RACE has evolved so that it is not only a Duke project; rather, it is owned by health care providers of North Carolina who have dedicated an enormous amount of time and energy to improve care for all heart attack patients.

Results

Duke has seen impressive results since implementing the RACE protocols. The time from “door to balloon” for patients who arrive at Duke University Hospital has decreased by 42 to 60 minutes, depending on whether the patient came directly to Duke or was transferred there.

Between 80 and 100 percent of heart attack patients at Duke receive reperfusion treatment within 90 minutes of their arrival. These significant time improvements result in hundreds of lives being saved every year.

Duke’s commitment to providing quality care for all patients led to the creation of the RACE project. The dramatic improvements measured in communities that participate in the RACE project provide a model for how hospitals and EMS systems throughout the nation can respond to heart attack patients.