By Mary Jo Feldstein, St. Louis Post-Dispatch, February 13, 2008

The table sat some of the area''s best minds in emergency and cardiac medicine. Their mandate, as it is at each meeting, was to analyze every patient who entered Barnes-Jewish Hospital in the previous few months in the midst of a heart attack.

For heart attack patients, minutes count. The most effective form of treatment is angioplasty.

In this procedure, a balloon is threaded up to the blocked artery in the heart. Then the balloon is inflated, opening the blood vessel and allowing blood to flow. The faster the clot is opened, the less damage to the heart muscle.

Minutes count for hospitals as well.

Some government quality measures focus on whether hospitals can complete this procedure within 90 minutes of a patient''s arrival.

Because this data is publicly released, performance has an impact on reputation. Eventually, insurers and government payors are expected to pay less to facilities that don''t perform well on quality measures.

When the quality measures were first released, Barnes didn''t perform as well as expected. To remedy this, it began to systematically analyze each step of the process.

Last year, the Centers for Medicare and Medicaid Services, the same government agency that once blemished Barnes'' reputation in cardiac care, ranked it among the 17 best hospitals in the nation for treating heart attacks.

Many of the ideas behind this transformation originated from an evolving working group, gathering regularly in a small, nondescript meeting room.

At first, the group included a representative from almost every step in a heart attack patient''s care. The idea was to create a team approach. Fewer than 10 people meet regularly now. As issues were solved, members were no longer needed.

Some changes were clinical. Preparing the room for the procedure and calling in staff was taking too long, especially during the middle of the night. Now, a physician in the emergency room calls in the cardiologist and staff and while they are driving in, the room is readied.

It has led to more false alarms, but it also has sped up the process. For now, the compromise will be better guidelines for when to call in the team and ongoing discussion.

Other changes were physical, such as making doorways wider.

Every step was aimed at making the process as easy and standardized as possible.

Dr. Douglas Char, an emergency medicine physician, said it hasn''t always been a smooth process.

"There were knock-down, drag-out discussions," Char said.

Barnes'' most recent results exceed its own targets. Ninety percent of heart attack patients in need of a balloon inflation between December 2006 and November of last year received one within 90 minutes.

"We''ve hit our goals and we''ve been able to sustain them for over a year," said Dr. Richard Bach, cardiologist on the committee. "But we also know we have to look at every single patient."

When the team analyzes a case, the 90-minute window is broken into several smaller windows, each with its own goal. Not every case lends itself to a standardized process.

Of the patients being analyzed at this meeting, the first poses the most difficulty. He''s a 43-year-old man complaining of chest pain and shortness of breath. He also has schizophrenia and wants to speak with his family before he''s treated.

Waiting for him to do so leaves the team with only a half hour to complete the balloon inflation. It''s completed on-time, but it''s close.

The table wants more clarification about why there was a delay during the patient''s initial moments in the emergency room.

Staff says the patient''s mental illness required a slower, calmer pace, but it wasn''t documented.

Jennifer Williams, a clinical nurse specialist, promises to follow up and report at the next meeting.

Finding answers shouldn''t be difficult.

Williams'' nurses frequently call to find out how patients fared and whether time targets were met, rather than wait for patient case review or the meeting.

"They''re very invested," Williams said. "They want to know immediately, ''How did we do?''