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PPCI - it’s 24/7 or not at all? Dr JIM HALL CONSULTANT CARDIOLOGIST JAMES COOK UNIVERSITY HOSPITAL MIDDLESBROUGH.

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Presentation on theme: "PPCI - it’s 24/7 or not at all? Dr JIM HALL CONSULTANT CARDIOLOGIST JAMES COOK UNIVERSITY HOSPITAL MIDDLESBROUGH."— Presentation transcript:

1 PPCI - it’s 24/7 or not at all? Dr JIM HALL CONSULTANT CARDIOLOGIST JAMES COOK UNIVERSITY HOSPITAL MIDDLESBROUGH

2 NO CONFLICT OF INTEREST TO DECLARE

3 PPCI Is it justifiable to have a system that includes treating STEMI patients with PPCI in some units ‘when available’ e.g. 9-5 Mon-Fri and not uniformly in a Heart Attack Centre where PPCI is available ‘all the time’ (24/7) ?  S  n

4 PPCI Is it justifiable to have a system that includes treating STEMI patients with PPCI in some units ‘when available’ e.g. 9-5 Mon-Fri and not uniformly in a Heart Attack Centre where PPCI is available ‘all the time’ (24/7) ?  Systems with part-time PPCI produce inferior patient outcomes

5 PPCI Is it justifiable to have a system that includes treating STEMI patients with PPCI in some units ‘when available’ e.g. 9-5 Mon-Fri and not uniformly in a Heart Attack Centre where PPCI is available ‘all the time’ (24/7) ?  Systems with part-time PPCI produce inferior patient outcomes  Not justifiable in England in 2009

6 PPCI 24/7 – the key issues  PROCESS EFFICIENCY  INSTITUTIONAL COMPETENCE  TRANSPORT TIMES

7 PPCI 24/7 – key issue  PROCESS EFFICIENCY

8 ST ELEVATION ACUTE MYOCARDIAL INFARCTION STEMI EFFECTIVE PATHWAY FOR STEMI PATIENTS RIGHT PATIENT RIGHT PLACE RIGHT TIME

9 EFFECTIVE PATHWAY FOR STEMI PATIENTS RIGHT TIME? AS SOON AS POSSIBLE ISCHAEMIC TIME onset to call call to diagnosis diagnosis to PCI facility = drive timeC2B PCI facility to balloon = D2B

10 EFFECTIVE PATHWAY FOR STEMI PATIENTS SYSTEM DESIGN  Understand the steps in the process  Simplify the system  Set your metrics  Monitor Modernisation Agency: Improving flow www.modern.nhs.ukwww.modern.nhs.uk

11 Pre Hospital Barn door STEMI No significant co-morbidities A&E & AAU Barn door STEMI No significant co-morbidities Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards STEMI / PPCI PATHWAY Wards Barn door STEMI No significant co-morbidities Contact Cardiologist on call and Cath Lab team Contact Cath Lab Co-ordinator and interventionist in Cath Lab

12 Pre Hospital Barn door STEMI No significant co-morbidities A&E & AAU Barn door STEMI No significant co-morbidities Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards STEMI / PPCI PATHWAY Wards Barn door STEMI No significant co-morbidities Contact Cardiologist on call and Cath Lab team Contact Cath Lab Co-ordinator and interventionist in Cath Lab SINGLE POINT OF CONTACT DIRECT TO CATH LAB

13 REMOVING A STEP - IMPACT ON PPCI D2B TIMES CCU nurse initiation SpR initiation

14 Pre Hospital Barn door STEMI No significant co-morbidities A&E & AAU Barn door STEMI No significant co-morbidities Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards STEMI / PPCI PATHWAY 24/7 HAC Wards Barn door STEMI No significant co-morbidities Contact Cardiologist on call and Cath Lab team Contact Cath Lab Co-ordinator and interventionist in Cath Lab

15 Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC + 9-5 DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred to DGH Cath Lab if lab available

16 Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC + 9-5 DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred to DGH Cath Lab if lab available <25% of STEMI

17 Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC + 9-5 DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred to DGH Cath Lab if lab available INEVITABLE CONFUSION AND DELAY

18 Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC + 9-5 DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: 282618 (ambulance) Internal: 54801/53624/52458 Fax ECG: 282615 Patient transferred to DGH Cath Lab if lab available 100% of STEMI INEVITABLE CONFUSION AND DELAY

19 Effect of Part-time PPCI NRMI-4 2000-2002 mixed system v PPCI 88% PPCI mortality PPCI DTB Nallamothu et al Circ 2006;113:222-229

20 Effect of Part-time PPCI NRMI-4 2000-2002 mixed system v PPCI 88% PPCI mortality 0.64 (0.46 – 0.88) PPCI DTB 118 99 Nallamothu et al Circ 2006;113:222-229

21 PPCI 24/7 – key issue  INSTITUTIONAL COMPETENCE

22 INSTITUTIONAL EXPERIENCE ALKK database 2003 6268 PPCI 67 hospitals Annual institutional PPCI volume and outcome mortality Zhan et al Heart 2008;94:329-335

23 INSTITUTIONAL EXPERIENCE ALKK database 2003 6268 PPCI 67 hospitals Annual institutional PPCI volume and outcome lowest quartile v highest quartile 300 mortality Zhan et al Heart 2008;94:329-335

24 INSTITUTIONAL EXPERIENCE ALKK database 2003 6268 PPCI 67 hospitals Annual institutional PPCI volume and outcome lowest quartile v highest quartile 300 mortality 7.7% 4.8% Zhan et al Heart 2008;94:329-335

25 INSTITUTIONAL EXPERIENCE ALKK database 2003 6268 PPCI 67 hospitals Annual institutional PPCI volume and outcome lowest quartile v highest quartile 300 mortality 7.7% 4.8% more contrast longer flouro less TIMI 3 Zhan et al Heart 2008;94:329-335

26 INSTITUTIONAL EXPERIENCE NRMI database 1994 - 1998 IABP for cardiogenic shock lowest tercile v highest tercile IABP/yr mortality Chen et al Circ 2003;108:951-7

27 INSTITUTIONAL EXPERIENCE NRMI database 1994 - 1998 IABP for cardiogenic shock lowest tercile v highest tercile IABP/yr 3.4 37.4 mortality Chen et al Circ 2003;108:951-7

28 INSTITUTIONAL EXPERIENCE NRMI database 1994 - 1998 IABP for cardiogenic shock lowest tercile v highest tercile IABP/yr 3.4 37.4 mortality 65 50 p<0.001 Chen et al Circ 2003;108:951-7

29 JCUH database 2005-8 725 PPCIs IABP10% VENTILATION3% SHOCK 8%

30 PPCI 24/7 – key issue  TRANSPORT TIMES

31 TRADE-OFFS DOWNSIDE OF TRANSFER TO 24/7 HEART ATTACK CENTRE –INCREASED ISCHAEMIA TIME mortality increase ~ 1%/hr drive time m

32 EFFECTIVE PATHWAY FOR STEMI PATIENTS STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR deLuca et al Circ 2004:109;1223-25

33 TRADE-OFFS DOWNSIDE OF TRANSFER TO HEART ATTACK CENTRE –INCREASED ISCHAEMIA/DRIVE TIME mortality increase ~ 1%/hr drive time DOWNSIDE OF LOCAL DELIVERY –DECREASED INSTITUTIONAL VOLUME mortality increase ~ 3% LOW v HIGH

34 Trade-off: drive time - institutional volume High Low INSITUTIONAL PPCI VOLUME ISOMORTALITY BREAK-EVEN LINE DRIVE TIME 3% ACCEPTABLE DRIVE TIMES

35 Trade-off: drive time - institutional volume High Low INSITUTIONAL PPCI VOLUME ISOMORTALITY BREAK-EVEN LINE DRIVE TIME 3% ACCEPTABLE DRIVE TIMES ACCEPTABLE DRIVE TIMES PROCESS DELAY

36 Part time PPCI (9-5) Justifiable if >3 hour drive time to HAC or > 1 hour drive time to HAC + zero process delay + 9 - 5 volume ~200/yr (requires >1M pop n )

37 Part time PPCI (9-5) Justifiable if >3 hour drive time to HAC or > 1 hour drive time to HAC + zero process delay + 9 - 5 volume ~200/yr (requires >1M pop n ) not applicable to England in 2009

38 PPCI - it’s 24/7 or not at all!

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