By Duke Medicine News and Communications

A major Duke-based initiative designed to speed up heart attack care in North Carolina is launching a second phase of development that could involve all 21 primary cardiac interventional facilities throughout the state and dozens of additional referral hospitals.

The effort builds on the success of the RACE program (RACE stands for Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments), founded by cardiologists at DukeUniversityMedicalCenter and hailed as a model for the nation.

Over the past two years, RACE members -- including thousands of emergency services personnel, physicians, nurses, and administrators in 68 hospitals across North Carolina -- have demonstrated that through better cooperation and collaboration, emergency medical teams can dramatically slash the time between occurrence of a heart attack and initial treatment.

RACE success was also based on the philosophy of "moving care forward" -- training and equipping personnel on the front lines to handle some of the diagnostic and treatment procedures traditionally performed in hospital emergency rooms.

"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, a cardiologist at Duke and a co-director of the project. "Now, with our next step, which we are calling 'RACE-ER'(RACE- Emergency Response), we are recruiting every hospital and emergency medical service in the state to join us."

The first phase of the RACE project involved 10 centers equipped to perform angioplasty, or artery-opening therapy, and 65 hospital emergency departments. RACE-ER hopes to include 21 angioplasty sites and a total of 100 North Carolina hospitals when it is fully implemented.

Mayme Lou Roettig, a nurse and executive director of RACE, says the second phase will grow within the existing regions previously established under phase one: Coastal Plains, Triangle, Triad, Charlotte-Metro, and Western N.C. Integrated treatment teams at some sites are already collecting performance data on current delivery systems. The results will create a baseline from which future performance will be evaluated.

Roettig says there is no one-size-fits-all solution to faster care. "Each site has a unique set of resources and personnel, and we feel confident they are all capable of designing a workable response plan. Our job is to provide training, feedback and coordination where needed." Implementation of redesigned delivery systems is not expected until 2009.

Studies have shown that when it comes to surviving a heart attack, every minute counts.

Guidelines endorsed by the American College of Cardiology and the American Heart Association state that patients suffering from heart attacks from blocked arteries should receive clot-busting medical therapy within 30 minutes or angioplasty within 90 minutes. Despite the proven value of such treatments, James Jollis, MD, co-director of the RACE program, says that up to a third of patients who could benefit from them are not receiving the treatments, and an even larger number are not getting them in a timely fashion.

RACE-ER, like RACE, will focus on patients with one kind of heart attack (known as a STEMI) that can be successfully treated with speedy, artery-opening care, although project leaders say a seamless, streamlined emergency response system is likely to improve care for patients with both types of heart attacks.

Roettig, who is also the national director of the American Heart Association's Mission Lifeline program, says the goal of RACE-ER is to match or exceed the performance improvement in the first phase of the program. RACE leaders reported that members had:

• Reduced median time from door to treatment for hospitals offering angioplasty from 85 to 74 minutes. (22 percent)

• Reduced median time from door to infusion of clot-busting therapy from 35 to 29 minutes. (17 percent)

• Reduced median time from door-in to door-out at transfer hospitals from 120 to 71 minutes. (41 percent)

• Reduced median time from arriving at a feeder hospital to beginning treatment at a receiving hospital from 149 minutes to 106 minutes. (29 percent)