“The Doctor said another 5 minutes and I would have been dead” A regional approach to saving heart muscle Vanessa Thornton Clinical Head Emergency Care

Background Time to PCI is an internationally measured indicator of care for patients with ST Elevation Myocardial Infarction (STEMI). Earlier the heart is perfused the better the outcome for heart function. The internationally agreed is Time to PCI < than 90mins. Since 2010 we have transferred patients to ACH for PCI after 1530 until 0730.

Analysis in 2011 PCI performed at Middlemore Hospital Auckland City Hospital <90 minutes >90 minutes

Auckland City Hospital Analysis After Hours Patients Left MMH EC within 45 minutes (13/30) Late Presentation MI Delay to book ambulance Failure to view initial ECG Evolving MI serial ECG’s No interventionalist available at MMH / waiting cardiology decision Delay CCU RN/ICU Dr Unstable Treating another condition

Analysis Mean door to balloon time 2:20 16 out of 82 (20%) < 90 minutes

The Patients Voice

08:00-15:30 CN CCU arrange PCI Pt Tx to PCI Chest Pain in the community GPAmbulanceR4 0 ECGArrive MMH TC 1 or 2 ECG 10 mins S/B 10 mins Ref Cardio *3167 Self present to MMH ED 15:30 – 08:00 Cardio discuss ACH ACH accepts pt Cardio informs MMH SMO EC organise ambulance Cardio organise CCU escort Ambulance dispatched Ambulance arrives Pt transferred to ambulance Depart to ACH Arrive at ACH CHANGE CONCEPT = SIMPLIFY PROCESS AFTER HOURS Ref to Medicine

Improving Time to Nurse Seen by R40 likely STEMI on ECG or STEMI likely at triage ECG within 10 mins Notify EM SMO *3703 & monitor registrar 15:30 – 08:00 & weekends Request ambulance to wait and ph / stating “Patient still on stretcher of vehicle ‘xx’ and vehicle ‘xx’ is doing the transfer to Auckland Hospital” (NB St John may request the patient is transferred in a PTS ambulance If one is already on site or if the crew are at the end of their shift). or If delay expected or ‘walk in’ patient, book ambulance ph / stating “Urgent priority 1 ambulance…patient transfer to Auckland City Hospital cath lab with escort”. Transfer to ACH cath lab with CCU RN escort & notify ACH CCU or ICU will assist with unstable patients. After Hours On arrival, keep patient on ambulance trolley & perform ECG Within Hours STEMI? 08:00 – 15:30 Mon – Fri? No Refer NSTEAC/ chest pain pathway. Transfer patient onto EC bed & let ambulance go. Ambulance arrival Follow blue Walk in arrival Follow green Yes STEMI CHEST PAIN Call *3167 (within hours this connects directly with CCU CN, after hours this connects with the operator – ask for the on call cardiologist) STEMI? No Refer NSTEAC/ chest pain pathway. Transfer patient to EC bed & perform ECG 08:00-15:30 hrs Monday – Friday Call CCU CN on *3167 Fax ECG to CCU 8176 Transfer patient ASAP to MMH cath lab Ref STEMI pathwaySTEMI pathway Show ECG to RMO / SMO

Ambulance Delays

Result of Holding Original Ambulance After: 70% Patients receive PCI within 90 minutes Mean time to PCI 83 minutes

Other activities The project aligned itself to the Regional Cardiac Network. Continue to measure all the times involved for the individual patients presenting with a STEMI. We audited St Johns from March to June, measuring confidence level of crew in identifying STEMI.

Next Improvement

Challenges – timing? St John are in the process of phasing out their old defibrillators. Also upgrading their entire national computer system. They had other priorities and projects, for example Christchurch. Delay to get complete regional transmission.

In Progress All the stakeholders are totally committed. This was always a phased approach Relocating all MRX defibrillators to Counties Manukau area. Training St Johns ambulance and Emergency Staff. Upgrading 19 ambulances with transmission capabilities.

Conclusion Currently 70% of patients now receive PCI < 90mins “after hours” This is up from 20%. Holding ambulance in EC and improving time to ECG review has improved after hours care. ECG transmission by ambulance to MMH Emergency is the future improvement.