PPCI - it’s 24/7 or not at all?

Dr JIM HALL CONSULTANT CARDIOLOGIST

JAMES COOK UNIVERSITY HOSPITAL

MIDDLESBROUGH

NO CONFLICT OF INTEREST

TO DECLARE

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

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

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

PPCI

• 24/7

– the key issues

PROCESS EFFICIENCY

INSTITUTIONAL COMPETENCE

TRANSPORT TIMES

PPCI

• 24/7

– key issue

PROCESS EFFICIENCY

ST ELEVATION ACUTE MYOCARDIAL INFARCTION

STEMI

EFFECTIVE PATHWAY FOR STEMI PATIENTS

RIGHT PATIENT

RIGHT PLACE

RIGHT TIME

EFFECTIVE PATHWAY FOR STEMI PATIENTS

RIGHT TIME?

AS SOON AS POSSIBLE

ISCHAEMIC TIME

onset to call

call to diagnosis

diagnosis to PCI facility = drive time C2B

PCI facility to balloon = D2B

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.uk

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

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

REMOVING A STEP

- IMPACT ON PPCI D2B TIMES

CCU nurse initiation SpR initiation

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

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

Contact 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

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

Contact 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

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

Contact 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

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

Contact 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

Effect of Part-time PPCI

• NRMI-4 2000-2002

mixed system v PPCI <34% >88%

PPCI mortality

PPCI DTB

Nallamothu et al Circ 2006;113:222-229

Effect of Part-time PPCI

• NRMI-4 2000-2002

mixed system v PPCI <34% >88%

PPCI mortality 0.64 (0.46 – 0.88)

PPCI DTB 118 99

Nallamothu et al Circ 2006;113:222-229

PPCI

• 24/7

– key issue

INSTITUTIONAL COMPETENCE

INSTITUTIONAL EXPERIENCE

ALKK database 2003

6268 PPCI 67 hospitals

Annual institutional PPCI volume and outcome

mortality

Zhan et al Heart 2008;94:329-335

INSTITUTIONAL EXPERIENCE

ALKK database 2003

6268 PPCI 67 hospitals

Annual institutional PPCI volume and outcome

lowest quartile v highest quartile

<100 >300

mortality

Zhan et al Heart 2008;94:329-335

INSTITUTIONAL EXPERIENCE

ALKK database 2003

6268 PPCI 67 hospitals

Annual institutional PPCI volume and outcome

lowest quartile v highest quartile

<100 >300

mortality 7.7% 4.8%

Zhan et al Heart 2008;94:329-335

INSTITUTIONAL EXPERIENCE

ALKK database 2003

6268 PPCI 67 hospitals

Annual institutional PPCI volume and outcome

lowest quartile v highest quartile

<100 >300

mortality 7.7% 4.8%

more contrast longer flouro

less TIMI 3

Zhan et al Heart 2008;94:329-335

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

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

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

• JCUH database 2005-8 725 PPCIs

• IABP 10%

• VENTILATION 3%

• SHOCK 8%

PPCI

• 24/7

– key issue

TRANSPORT TIMES

TRADE-OFFS

• DOWNSIDE OF TRANSFER TO 24/7 HEART

ATTACK CENTRE

– INCREASED ISCHAEMIA TIME

mortality increase ~ 1%/hr drive time

m

EFFECTIVE PATHWAY FOR STEMI PATIENTS

STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR

deLuca et al Circ 2004:109;1223-25

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

Trade-off: drive time - institutional volume

0

20

40

60

80

100

120

140

160

180

>300 300 250 200 150 <100

High Low

INSITUTIONAL PPCI VOLUME

ISOMORTALITY

BREAK-EVEN LINE

DRIVE TIME

3%

ACCEPTABLE

DRIVE TIMES

Trade-off: drive time - institutional volume

High Low

INSITUTIONAL PPCI VOLUME

ISOMORTALITY

BREAK-EVEN LINE

DRIVE TIME

3%

ACCEPTABLE

DRIVE TIMES

0

20

40

60

80

100

120

140

160

180

>300 300 250 200 150 <100

ACCEPTABLE

DRIVE TIMES

PROCESS DELAY

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 popn)

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 popn)

not applicable to England in 2009

PPCI - it’s 24/7 or not at all!