1. PPCI – National Update NCBC Workshop Jim McLenachan, National Clinical Lead for PPCI, NHS Improvement, England. London, 24 th November, 2010 1NCBC Annual Workshop November 2010 - CONFIDENTIAL

2. National Cardiothoracic Benchmarking Collaborative (NCBC) Annual Workshop 2010 Breakout Group PPCI – National Update Dr Jim McLenachan National Clinical Lead for PPCI, NHS Improvement, England. 2 NCBC Annual Workshop November 2010 - CONFIDENTIAL

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4. Falling STEMI mortality (Source MINAP report 2010) % 4 NCBC Annual Workshop November 2010 - CONFIDENTIAL

5. NATIONAL MINAP DATA 5 NCBC Annual Workshop November 2010 - CONFIDENTIAL

6. NORTH CENTRAL LONDON MINAP DATA 6 NCBC Annual Workshop November 2010 - CONFIDENTIAL

7. NCBC 2010 ESSEX MINAP DATA 7 NCBC Annual Workshop November 2010 - CONFIDENTIAL

8. NCBC 2010 MANCHESTER AND CHESHIRE MINAP DATA 8 NCBC Annual Workshop November 2010 - CONFIDENTIAL

9. NCBC 2010 - Primary PCI Number of PPCI Cases Undertaken, 2008/9 & 2009/10 Median 2009/10 9 NCBC Annual Workshop November 2010 - CONFIDENTIAL

10. NCBC Trusts - PPCI Cases per million population, 2009/10 (Rate adjusted for weeks of operation by service operated) Median 10 NCBC Annual Workshop November 2010 - CONFIDENTIAL

11. The switch from lysis to PPCI... NCBC Annual Workshop November 2010 - CONFIDENTIAL

12. Primary PCI for Essex Dr Paul Kelly Lead Cardiologist, Essex CTC 12 NCBC Annual Workshop November 2010 - CONFIDENTIAL

13. NCBC - 2010 Predicted Numbers - Essex Total STEMI for Essex = 823 (thrombolysis) From pre hospital setting = 655 From A+E depts = 132 From DGH wards = 36 (source MINAP & Discharge diagnosis 07/08) 13 NCBC Annual Workshop November 2010 - CONFIDENTIAL

14. NCBC 2010 Logistics Essex CTC located at Basildon (60 miles max) 8 Interventional Cardiologists Increased cath lab staff numbers East of England Ambulance Service Provision of on call rooms Change of post on call duties 14 NCBC Annual Workshop November 2010 - CONFIDENTIAL

15. NCBC 2010 Essex Protocols & Pathways Operational Policy for CTC Operational Policy for A+E Depts Operational Policy for DGH Wards Policy and agreement for DGH admission post PPCI Patient pathways from pre hospital to cardiac rehab 15 NCBC Annual Workshop November 2010 - CONFIDENTIAL

16. Essex - Operational Policy for CTC Paramedic decision to activate pathway Inclusion criteria – ECG driven Exclusion criteria – relatively few 16 NCBC Annual Workshop November 2010 - CONFIDENTIAL

17. Time Line for PPCI Total call to balloon = 165 mins Call to paramedics leaving scene = 45 mins (call to scene, assess and mobilise patient) Transfer to CTC = max 90 mins Door to balloon = 30 mins 17 NCBC Annual Workshop November 2010 - CONFIDENTIAL

18. Following Procedure Transfer to HDU ward in CTC 24 - 48 day stay post PCI and transfer to DGH ? Some patients discharged home from CTC Cardiac Rehabilitation Assessment 18 NCBC Annual Workshop November 2010 - CONFIDENTIAL

19. Potential Problems Delays in pathway – concerns for CTB > 165m Excess demand (compared to predictions) Bed Capacity on Roding Ward/ ITU DGH capacity to accept patients post PPCI 19 NCBC Annual Workshop November 2010 - CONFIDENTIAL

20. Timetable for Implementation Big bang, pan Essex start date 1st September 2009 Communication for all involved in process Information for patients 20 NCBC Annual Workshop November 2010 - CONFIDENTIAL

21. Potential for Growth in Primary PCI Activity in NCBC Trusts Thrombolysis Too late for reperfusion Clinically ineligible for reperfusion 21 NCBC Annual Workshop November 2010 - CONFIDENTIAL

22. NCBC 2010 STEMI – Reperfusion % by Method - NCBC Trust Networks - 2009 Potential for growth (2) Essex increased pPCI coverage since 2009 22 NCBC Annual Workshop November 2010 - CONFIDENTIAL

23. How do we improve the quality of the service? 23 NCBC Annual Workshop November 2010 - CONFIDENTIAL

24. Why does Newcastle have short door to balloon times? Richard Edwards Primary PCI lead Freeman Hospital Newcastle 24 NCBC Annual Workshop November 2010 - CONFIDENTIAL

25. NCBC 2010 - Primary PCI Median Door to Balloon Time (Minutes), by average number of PPCIs per week, 2009/10 Average number of PPCI per week Median NCBC Annual Workshop November 2010 - CONFIDENTIAL

26. Is it because… As a larger volume centre we have developed more routine processes & therefore have quicker DTB time? Do we just cover a larger geography & have more warning to activate the team? Both…. 26 NCBC Annual Workshop November 2010 - CONFIDENTIAL

27. Primary PCI Median Door to Balloon Time (Minutes), 2008/9 & 2009/10 Median 2009/10 27 NCBC Annual Workshop November 2010 - CONFIDENTIAL

28. NCBC 2010 - Primary PCI % Change in Median Door to Balloon Time (Minutes), 2008/9 & 2009/10 (Trusts with data for both years) Longest Median Door to Balloon TimesShortest Median Door to Balloon Times Improvements in % reduction in Median DTB Times irrespective of whether Trusts had longer or Shorter DTB time in 2008/9 N Staffs increased Its catchment area 28 NCBC Annual Workshop November 2010 - CONFIDENTIAL

29. NCBC 2010 - Primary PCI Median Call to Balloon Time (Minutes), 2008/9 & 2009/10 Median 2009/10 NCBC Annual Workshop November 2010 - CONFIDENTIAL

30. Half an hour to Freeman March 31 st 2008 Roll out Newcastle May 1 st 2008 Roll out South of Tyne July 1 st 2008 Roll out North of Tyne 30NCBC Annual Workshop November 2010 - CONFIDENTIAL

31. Is it because… As a larger volume centre we have developed more routine processes & therefore have quicker DTB time? Do we just cover a larger geography & have more warning to activate the team? Both…. 31 NCBC Annual Workshop November 2010 - CONFIDENTIAL

32. NCBC 2010 - Primary PCI Number of PPCI Cases Undertaken, 2008/9 & 2009/10 Median 2009/10 32 NCBC Annual Workshop November 2010 - CONFIDENTIAL

33. routine processes… Ergonomics –CCU has its own ambulance admission point –Cath lab and CCU on ground floor (50yds apart) –Pt taken straight to cath lab (Not to CCU, NOT to A&E) –Interventionists live < 3miles from Freeman Communication –Paramedics and CCU gatekeepers and telecommunicate –Cardiologist not part of routing decision making minimise bureaucracy 33 NCBC Annual Workshop November 2010 - CONFIDENTIAL

34. routine processes… Process –history and examination take place whilst patient transferred to cath lab –out of hours patient waits in CCU for team to arrive –verbal consent taken –culprit vessel treated first Economy of scale –Redeployed staff in an emergency –Always make an empty lab 34 NCBC Annual Workshop November 2010 - CONFIDENTIAL

35. routine processes… Motivated team –Published D to B times motivate staff to improve –Low staff turnover –Some staff voluntarily stay overnight –Staff much more willing to work generically in an emergency 35 NCBC Annual Workshop November 2010 - CONFIDENTIAL

36. Is it because… As a larger volume centre we have developed more routine processes & therefore have quicker DTB time? Do we just cover a larger geography & have more warning to activate the team? Both…. Saves 26 minutes Saves 7 minutes 36 NCBC Annual Workshop November 2010 - CONFIDENTIAL

37. Critical Mass – Volumes and Quality Do larger volume centres develop more routine processes & therefore have quicker DTB times? Do they just cover a larger geography & have more warning to activate the team? With the right streamlined processes, can all Trusts get to a median DTB of below 25 minutes? 37 NCBC Annual Workshop November 2010 - CONFIDENTIAL

38. NCBC 2010 - Primary PCI Median Call to Door & Door to Balloon Time (Minutes), by average number of PPCIs per week, 2009/10 Median CTB 38 NCBC Annual Workshop November 2010 - CONFIDENTIAL

39. NCBC 2010 - Primary PCI Median Door to Balloon Time (Minutes), by average number of PPCIs per week, 2009/10 Average number of PPCI per week Median 39 NCBC Annual Workshop November 2010 - CONFIDENTIAL

40. Summary Population coverage Performance Size vs outcome 40 NCBC Annual Workshop November 2010 - CONFIDENTIAL