Looking beyond hospitals to save lives

WHO

Heart attack victims need to get the right care, and they need it fast. By looking at the entire chain of survival, Denmark has achieved a sharp decrease in mortality resulting from heart attacks. The approach involved looking at all the steps from the very first contact with the emergency services to the treatments and subsequent rehabilitation.

Twenty years ago Dr Jens Flensted Lassen was involved in starting the process of changing how heart attacks were treated in the country. Now Clinical Director of the Cardiac Catheterization Laboratory at Denmark’s largest hospital, Rigshospitalet, Dr Lassen explains the approach: “The main problem in industrialized countries is not about getting the right treatment but it is about reaching the hospital fast. Giving doctors a head start by making sure they receive as much information as possible before the patient even reaches the hospital doors is also key”.

Balloons or blood thinner?

Sitting in his office, Dr Lassen describes how the drive to improve care for heart attack victims started: “Back in the late 90s we saw that Denmark had a severe excess mortality when it came to cardiovascular diseases compared to similar countries”.

Something had to be done, and the first step was to look at which treatments were given. Since the mid-80s doctors had been able to perform percutaneous coronary interventions (PCI), using a balloon to widen a narrowed blood vessel, instead of thrombolysis to thin the blood.

A scientific project, known as the DANAMI II trial, involving 1200 patients in hospitals all over Denmark was initiated to compare the 2 methods, and the results were very clear. At 30 days after admittance only 8% of patients receiving PCI died or experienced disabling stroke or reinfarction compared with 13.7% of those who had received thrombolysis.

“This study changed everything,” Dr Lassen recalls. “For the first time we had proven that even though it might take time to get to a place that can perform PCI, the treatment is superior to thrombolysis.”

Centralizing and specializing

The results of the survey were presented in March 2002. Dr Lassen produces a newspaper clipping from the 29 November that year, which proudly states that Denmark had conducted state-of-the-art medical research which had changed the way heart attacks were treated across the country overnight.

The finding that it was better to take additional transport time to ensure the right treatment resulted in focusing equipment to deal with heart attacks in 4 hospitals only.

“We are extremely well trained in this. The 7 of us working at Rigshospitalet in this area do more than 1200 acute primary PCIs a year,” he explains. He is quick to emphasize that this shift has been based on cross-sector cooperation through the entire process.

By land or by air – time is of the essence

The next step was to get patients to the hospitals faster. Dr Lassen and his colleagues began looking at how long it took from the phone call to the emergency services to arrival at the hospital door.

Even though Denmark is a relatively small country, and the 4 hospitals offering PCI are located throughout the country, an ambulance ride to one of the hospitals could still take too long.

The solution was to adopt air transport. Helicopters stationed around the country can now take patients from remote locations to the nearest PCI hospital. This means that patients can get to a hospital offering PCI in less than 45 minutes from anywhere in the country.

Diagnosis in the ambulance

But getting to the hospital fast is not enough, as the clinical director explains: “Imagine it’s 4 in the morning and a person comes in with chest pains. First we need to perform an electrocardiogram (ECG) and a clinical evaluation, including taking the patient’s medical history to see if it is a heart attack, then we need to call a switchboard that wakes up 3 nurses and 1 doctor. They have to get to the hospital and prep the operating room, and only then can the patient be treated”.

This problem was at the heart of what ended up being a groundbreaking approach. Every ambulance in Denmark is now equipped with ECG, so that the first examination of a possible heart attack can be done before the patient has reached the hospital.

Special software was developed to allow ambulance staff to send the ECG results to a specialist. Taking out his phone, Dr Lassen shows us an example from the previous night, when he was on call. “At 3:16, I received the results of an ECG, from a man with chest pains. While still in my bed, I looked it over and could tell that it wasn't a heart attack, so he was taken to the local hospital.”

This system means that by the time the ambulance reaches the hospital, the doctors and nurses are already there and have prepped the operating room. Door-to-needle time has been reduced to 10–15 minutes, or as Dr Lassen puts it: “However long it takes to get to the 14th floor with our ancient elevator system”.

An inspirational approach

As a small and relatively wealthy country, Denmark has options when it comes to medical infrastructure which are not shared with all other countries. Regardless of this, Dr Jill Farrington, Coordinator for Noncommunicable Diseases at WHO/Europe, still believes that there is something to learn. “Not all countries have the resources to implement helicopter coverage or even PCI treatment nationwide, but the broad Danish approach still offers inspiration on how to give heart attack victims the best treatment. It is worth noting that something as simple as an ECG machine with a cell-phone connection, can save lives by giving doctors valuable time.”

“Evidence shows that the medical infrastructure can make a difference and saves lives, but it also calls for some tough political decisions, such as quality improvement and restructuring of services, using data to drive this process.”

Dr Farrington emphasizes the positive results yielded from the work across sectors, something which aligns with the crucial role that cross-sector partnerships have to play in achieving the Sustainable Development Goals.

Looking beyond the hospital again

The broad approach, looking beyond the hospital walls and breaking down professional silos has yielded impressive results. In the last 10 years alone, 30 day mortality after admission for heart attacks has dropped significantly, as shown below with data from the Organisation for Economic Co-operation and Development (OECD).

30 day mortality after admission for heart attacks:

2006200720082009201020112012201320142015
12.9%12.4%10.4%11.1%10.0%9.3%9.2%8.6%7.6%7.7%

But according to Dr Lassen, there is still room for improvement. “The next step will be to enable the conduct of a small blood test in the ambulance, where we will be able to tell whether any heart tissue has perished due to lack of oxygen.” Smaller blood clots will often be missed by an ECG, but looking at the condition of the heart tissue with a blood test will tell the doctors in 5 minutes if the patient is suffering from one.

Having looked at door-to-needle time, and first medical contact to measure how fast patients came to the door, it is now also time to focus on the time elapsed from the symptoms arising to when the emergency services are dialled.

Here once again the approach becomes multisectoral. Dr Farrington points out that the Danish Heart Foundation, Denmark’s second largest patient organization, plays a big part in this. “The Danish Heart Foundation is a key player in reducing cardiovascular mortality in Denmark, as they have developed courses for the general public on early recognition of symptoms.”

So treating heart attacks is truly intersectoral when done best, and goes beyond the walls of the hospital.