Tag Archives: heart attack

Root Cause Analysis

Shoveling snow really can trigger heart attacks

By Kim Smiley

You may have heard that shoveling snow can trigger a heart attack and studies have found that there is truth behind that concern.  Before you pick up a shovel this winter, there are a few things you should know.

Shoveling can be much more strenuous than many people realize – even more strenuous than running at full speed on a treadmill.  Snow shoveling also tends to be a goal-oriented task.  People want to clear the driveway before they stop and they may push their bodies beyond the point where they would if they were exercising for fitness.

Cold temperatures can increase the risk of heart problems occurring.  When a body gets cold, the arteries constrict and blood pressure can increase, which in turn increases the risk of heart issues.  High blood pressure and a sudden increase in physical activity can be a dangerous combination.  Additionally, it may take longer than normal for emergency help to arrive if it is needed because of snow and ice on the roadways which makes the situation potentially even more dangerous.

If you are young and fit, snow shoveling can be a great workout (and maybe you could help out your elderly neighbors if possible…), but if you are at risk of heart problems, you may want to put some thought into how you attack the problem of clearing your driveway and/or sidewalks.  First off, you should know if you are potentially at high risk.  Studies have found that people over 55 are four times more likely to experience heart-related issues while shoveling and men are twice as likely as women. People with known heart problems, diabetes or high blood pressure are also potentially high-risk.  Anybody who is sedentary is also at a higher risk of heart issues than somebody who exercises regularly.

So what should you do if you are concerned about the risk of heart problems and shoveling?  If possible, you may want to avoid shoveling if there is somebody else who can do it.  If you are determined to shovel yourself, make sure you drink lots of water and dress warmly.  Try to push the snow if possible, rather than shoveling it.  It is also generally better to shovel lots of lighter loads rather than fewer, heavy loads.  If possible, you may want to shovel several times throughout the storm to spread the work out over time. Take frequent breaks and stop immediately if you feel tired, lightheaded, short of breath or your chest hurts. Stay safe this winter!

To see a Cause Map, a visual root cause analysis, of this issue, click on “Download PDF” above.  A Cause Map visually lays out all the causes that contribute to an issue so that it can be better understood.  This example Cause Map also includes evidence and potential solutions.

Root Cause

How One Hospital Improved Heart Attack Care

By ThinkReliability Staff

The heart is responsible for pumping blood through the body, but it also requires blood flow to continue functioning. When the blood supply to the heart is cut off, it’s known as a heart attack and it can be deadly. According to the Centers for Disease Control and Prevention (CDC), about 15% of people who have a heart attack will die from it. Time is of the essence when treating heart attacks. Again according to the CDC, “The more time that passes without treatment to restore blood flow, the greater the damage to the heart.”

Treatment to restore blood flow is generally a balloon (which pushes aside the blockage) and a stent (which holds the artery open). In the United States, this is performed in a hospital. Although hospitals can’t control the amount of time it takes to get a heart attack victim TO the hospital, they can control the time from when a patient enters the hospital until treatment is begun. This is known as the door to balloon (or D2B) time.

A national campaign to improve the speed of heart attack treatment was launched. At that time, the typical heart attack process went like this: a patient suffered a heart attack and (hopefully) 911 was called. An ambulance picked up the patient and delivered them to a hospital. Once the patient arrived at the hospital, an electrocardiogram (EKG) was taken and transmitted to a cardiologist, who determined whether or not the patient was suffering from a heart attack. If it was a heart attack, an interventional cardiologist and other members of the heart attack team were called and made their way to the hospital. The patient was taken through a consent and surgical prep process, and then then balloon and stent were installed. At this time, the national goal was for half of patients to receive a stent and balloon within 90 minutes of arrival at a hospital.

One of the hospitals to take up the challenge was Our Lady of Lourdes Medical Center in New Jersey. In 2007, heart attack treatment was on par or better than other hospitals, with half of patients treated within 93 minutes. (In many locations it took more than 2 hours.) By 2011, treatment time was down to 71 minutes. The head of the cardiovascular disease program challenged the staff to continue to decrease the time and staff members set up a “D2B task force”. This task force looked at each step in the process for potential improvements. Some individual steps were shortened. The forms required for consent were reduced as much as possible. The time spent individually calling in all the members of the cardiac care team was reduced by having a single call ring to all their pagers. Those on the team that were on call were limited to being 30 minutes away from the hospital.

Other steps, instead of being performed one after the other, were performed simultaneously. Instead of waiting for the patient to arrive at the hospital for an EKG, it is taken in the ambulance and transmitted to the emergency room. Each step required for surgical prep is performed as much as possible simultaneously by a team. Additionally, one surgical room is reserved for heart attack patients and is kept stocked with necessary supplies.

Now the median D2B time is 50 minutes. This was demonstrated on March 29, when a patient arrived at the medical center at 1:54 AM and whose D2B time was 55 minutes. This was unusually long for the center. What caused the difference? Because the patient was a 49-year-old woman with ambiguous symptoms, the emergency room doctor waited until the patient arrived at the hospital for another EKG to verify the heart attack before the heart attack team was called.

From 2003 to 2013 the death rate from coronary heart disease has fallen 38%. Some of this drop is attributed to better control of cholesterol and blood pressure, but some is surely due to quicker treatment at most US hospitals.

The “before” and “after” process map that shows the flow of heart attack treatment at Our Lady of Lourdes Medical Center can be diagrammed visually to show how the process flows. To view the process map, the problem outline and timeline of the treatment of the heart attack patient on March 29, 2015, please click on “Download PDF” above. Or click here to read more.

Root Cause Analysis

Serious Side Effects From Low Dose Aspirin

By Kim Smiley

A recent study determined that the risks associated with regular use of low dose aspirin may outweigh the benefits for many patients. The researchers determined that regular aspirin users were 10 percent less likely to have a heart event and 20 percent less likely to have a nonfatal heart attack.  These statistics sound good except that regular aspirin users are also around 30 percent more likely to have serious gastrointestinal (GI) bleeding.  The overall risk of death was the same for both patients who regularly used aspirin and those who did not.

This study looked at nine randomized studies of aspirin use and included more than 100,000 patients.  The study only included patients who had not had a heart attack or stroke and involved giving participants either an aspirin or a placebo to see the benefits of regular doses of aspirin.

These findings have the potential to affect many people since nearly a third of middle-age Americans take a low dose aspirin regularly.  Benefits from aspirin seem to outweigh the risks for people who have a history of heart attacks, but this study calls into question the benefits for patients who are hoping to prevent their first heart attack or stroke.

This issue can be analyzed by building a Cause Map, an intuitive, visual form of root cause analysis.  In this example, the safety goal is the main goal that would be considered because of the higher risk of GI bleeding.  The higher risk of bleeding is caused by the fact that patients are taking aspirin regularly and that GI bleeding is a known side effect of aspirin.  People take aspirin because it has been shown to reduce the likelihood of blood clots.  Reducing blood clots will in turn reduce the risk of heart attacks and stroke since blood clots have the potential to block flow to the brain or heart.

The conclusion that the study draws is that there is no one size fits all solution to the question of whether patients should regularly take low dose aspirin.  The risks and potential benefits need to be determined on a case by case basis by the patient’s physician.  For an individual with a strong family history of heart disease, the benefits may very well outweigh the risk of GI bleeding, but for others the use of aspirin may not be worth the risk.

To view a high level Cause Map of this issue, click on “Download PDF” above.