National infarct angioplasty project : review of cardiac ...

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NHS Heart Improvement Programme National Infarct Angioplasty Project – review of cardiac networks December 2007 NIAP Cardiac Network Survey - September 2007 The NHS Heart Improvement Programme received a request from the Department of Health to gain a snapshot of reperfusion activity in all of the cardiac networks to provide additional information to support the findings of the National Infarct Angioplasty Audit. Phase 1 was a survey (appendix A) of the 31 cardiac networks requesting information on the geographical coverage of the network; pre-hospital thrombolysis services; arrangements for ambulance transfers; hospital based reperfusion services; and future plans for changes to reperfusion services. All 31 networks responded. Phase 2 focussed on the 04 December meeting with cardiac networks to discuss the findings of the survey and discuss in more detail the barriers to change of implementing a PPCI service and learning and sharing experiences from networks across the country. Phase one key findings Service provision This question is to gain a picture of where primary PCI is operational. It must be noted this may only be in one centre in a network. Of the 31 cardiac networks in England, 65% provide a pre- hospital thrombolysis (PHT) service, whilst 13% of networks (those in London) do not provide any PHT services due to close proximity to PPCI centres and HIP NIAP Analysis report – V1 1

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Transcript of National infarct angioplasty project : review of cardiac ...

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NHS Heart Improvement Programme

National Infarct Angioplasty Project – review of cardiac networks

December 2007

NIAP Cardiac Network Survey - September 2007

The NHS Heart Improvement Programme received a request from the Department of Health to gain a snapshot of reperfusion activity in all of the cardiac networks to provide additional information to support the findings of the National Infarct Angioplasty Audit.

Phase 1 was a survey (appendix A) of the 31 cardiac networks requesting information on the geographical coverage of the network; pre-hospital thrombolysis services; arrangements for ambulance transfers; hospital based reperfusion services; and future plans for changes to reperfusion services.

All 31 networks responded.

Phase 2 focussed on the 04 December meeting with cardiac networks to discuss the findings of the survey and discuss in more detail the barriers to change of implementing a PPCI service and learning and sharing experiences from networks across the country.

Phase one key findings

Service provision

This question is to gain a picture of where primary PCI is operational. It must be noted this may only be in one centre in a network.

Of the 31 cardiac networks in England, 65% provide a pre-hospital thrombolysis (PHT) service, whilst 13% of networks (those in London) do not provide any PHT services due to close proximity to PPCI centres and ambulance journey times being within target limits for the service.

74% of networks offer PPCI in at least one centre, whilst 26% do not provide any PPCI services at all. Of the 31 networks, 61% offer a mixture of both PHT and PPCI services to STEMI patients.

This response does not include in-hospital thrombolysis.

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Proportion of networks doing PHT; PPCI and a mixture of both

65%

74%

61%

13%

26%

Just PPCI13%

Part Service23%

Just PHT26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PHT pPCI Mixture

Service

Per

cent

age

of N

etw

orks

Yes No Part Service Just PPCI Just PHT

PHT and PPCI provision

Networks highlighted in blue only provide PHT Networks highlighted in green only provide PPCI (London) All other networks provide a mixture of both

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It must be noted that some networks are very close to providing a PPCI only service e.g., Greater Manchester and Cheshire (12) do not use PHT in Greater Manchester but there are a couple of areas in Cheshire.

Ambulance Transfers

Cardiac networks were asked to identify the breakdown of arrangements for transfer of STEMI patients to PPCI centres.

For those networks that provide PPCI, including those that offer a mixture of PHT & PPCI, 43% of networks transfer all STEMI patients directly to a PPCI centre. For those networks that offer both a PPCI and PHT service, 16% of patients are accessed at a non-PPCI centre before being transferred to a PPCI centre.

Transfer arrangements across networkType of PPCI service

offered across networkn Not transferred for

PPCITransferred from

DGHsTransferred direct

from sceneOnly PPCI 4 0 0% 2 50% 2 50%

PPCI and PHT 19

8 42% 3 16% 8 42%

Overall 23

8 35% 5 22% 10 43%

All networks were asked to identify what proportion of ambulance crews have 12-lead ECG recording; have paramedics trained to interpret the ECG; and can use telelink of any kind. All ambulance crews in all networks use 12 lead ECG recording.

For those networks only providing a PHT service, 89% of crews are trained to interpret the ECG, and 44% have full access to telelink facilities. For those networks only providing a PPCI service, 87% of crews are able to interpret the ECG and 30% have full access to telelink facilities. Some areas do not use telelink as they use the scoop and run system.

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Proportion of ambulance crews that have 12-lead ECG recording; have paramedics trained to interpret ECGs; and have telelink capabilities - By service category

100%89%

44%

100%

87%

30%

100%

84%

37%

11%

33%

13%

30%

16%

37%

22%

39%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 le

ad E

CG

Para

medic

s

inte

rpre

t

Tele

link

12 le

ad E

CG

Para

medic

s

inte

rpre

t

Tele

link

12 le

ad E

CG

Para

medic

s

inte

rpre

t

Tele

link

PHT . pPCI . Mixture

Service category

Perc

en

tag

e o

f serv

ice c

ate

go

ry

None

Some

All

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Of those networks providing PHT, 63% use JRCALC defined criteria for its use; with 26% using other or local guidelines. 11% of respondents did not indicate what criteria they use.

Hospital based reperfusion services

For their patch, networks were asked to identify what proportion of hospitals provide PPCI in at least one centre and state the arrangements for receiving STEMI patients. 48% of networks transfer STEMI patients to PPCI centres; 26% receive STEMI patients and do not provide PPCI; and 26% of networks have PPCI centres that receive STEMI patients directly.

Number / proportion of networks that provide PPCI in at least one hospitaln = 31 networks

826%

826%

1548%

PPCI Not provided Only PCI centres Transfer to PCI Centres available

Combined:

Per hospital and network perspectives: proportion of PPCI offered - only at PCI centres; transfer to PCI centre available;

or PPCI not available at all

15%

26%

21%

48%

64%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hospitals Networks

Pro

po

rtio

n

PPCI not provided

Transfer to PCI Centres

PCI centres only

Network level applies where at least one hospital fits the category

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For those networks that have at least one centre providing PPCI, they were asked to identify the different times that PPCI is offered to STEMI patients. 13 networks offer a 24/7 PPCI service; 7 networks offer the service ‘in-hours only’; none of the 31 networks offer a PPCI service ‘in hours’ and at weekends. Five networks stated that they offer ‘other’ PPCI arrangements:- this includes provision of an ‘ad-hoc’ service (if the patient is in the right place at the right time) and some 8am to 8pm PPCI services.

Breakdown of times PPCI offered, at network and hospital level

19

13

0 0

13

7

5 5

0

2

4

6

8

10

12

14

16

18

20

Hospitals Networks

Nu

mb

er o

f n

etw

ork

s / s

ites

"twenty four-seven"

"In-hours" and weekends

"In-hours" only

Other arrangements

Note: On a network level, two networks offer PPCI across multiple hospitals but at different times. For example, the PCI centre may offer PPCI 24/7 but a referring DGH may only offer the service ‘in-hours’.

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Times PPCI provided

Networks highlighted pink have at least one hospital providing PPCI “24–7”

Networks highlighted turquoise have at least one hospital providing PPCI “in-hours”

Networks highlighted in dark blue have other arrangements or did not state when their service operated.

Networks not shaded as above do not offer PPCI

Most hospitals commenced with working in-hours and extended to 24 when they developed the expertise and addressed staffing issues. The limiting factor to providing a 24 hour service is personnel and balancing the out of hours rota with providing a full service.

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Planned changes to current reperfusion services

Networks were asked to state any planned changes to either the PHT or PPCI services offered within the next two years. Those networks that stated they had ‘no changed planned’ to their PHT service either provide a full PPCI service already, or do not have any plans to change their current PHT service.

For those networks providing PPCI, work is planned to extend the hours of PPCI service provision.

Planned changes to PHT NetworksNo Changes planned 10Integrate PPCI with PHT service 8Increase number PHT by protocol, support 8Revise protocol - other reasons 6No PHT 3Stream study 1

Planned changes to PPCI services NetworksIn-hours expand area 9In-hours whole network 7No plans 524/7 whole network 3NSTEMIs 324/7 PCI centres 224/7 in limited area 2In-hours PCI centres 2Stream study 2Infrastructure at PCI centre 1

Finally, networks were asked to identify any barriers that they feel may need to be overcome in order to develop reperfusion services across their patch. It was agreed to follow this up further at a meeting with cardiac networks, and this formed the basis for discussions at the 04 December meeting (further discussion below).

Barriers to development NetworksWorkforce issues 22Ambulance issues 15Evidence to support PPCI cost effectiveness, funding issues 12Geography 10Who gets paid and for what – tariff unbundling 7Working across organisational boundaries 7Trained paramedics 5No current barriers to overcome, full PPCI service in place 3Capacity of PCI centres 3Clinical evidence of benefit of PPCI 2Development of NSTEMI plans 1

Phase 2 – meeting with cardiac networks

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The meeting on 04 December focused on further exploring the survey responses. Invited to the meeting were cardiac network representatives, members of the NIAP steering group, ambulance service representatives, network clinical leads and NIAP pilot site clinical leads.

Discussions at the meeting centred on the current situation regarding reperfusion, future plans, barriers to providing a PPCI service, and any potential solutions to overcoming these barriers. The main themes of the discussions focussed around:

Capacity in terms of ambulance availability and cath lab access Human resource issues Commissioning Rural areas with long travelling distances to PPCI centres Clinical Governance

Capacity Ambulance availability Catheter lab access Impact on elective work

The availability of ambulances to provide extra journeys and services across network boundaries was highlighted as an issue across the country. In order to provide a full PPCI 24/7 service, an increase in crews and ambulances is needed, as well as increased communication between ambulance services’ to look at closer working relationships and tackling the cross boundary issues.

An ambulance services strategy was proposed as a potential solution to this issue, along with networks doing further work to look at the cross boundary issues and joint working between networks and ambulance services in order to agree a collective approach to providing a PPCI service.

Concerns were raised surrounding the capacity of catheter labs to provide PPCI services, particularly out of hours and 24/7. Also, what are the implications for staff, wards and services at DGH, with increased activity in tertiary centres? Some networks stated that they do not believe that they have enough cardiologists to provide a full 24/7 PPCI service.

A potential solution to this could be to look at moving services to DGH settings from tertiary centres, to alleviate costing/capacity issues of moving services out of the DGH with the introduction of PPCI.

Human resources Availability of staff Hours of work – problems in providing 24/7 Cardiology rotas ‘density’ of cardiologists in rural areas Impact of primary PPCI on DGH CCU

The human resource aspects of providing PPCI are a particular concern for all networks. Providing an out of hours or 24/7 service requires a full rota of medical and non-medical staff with different skills. The availability of staff to provide this service based on their current ways of working may not be HIP NIAP Analysis report – V1 8

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possible, and depending on the location of the catheter labs, may not be achievable. Some areas do not have enough interventional cardiologists to include on a OOH/24/7 PPCI rota, and, depending on where the PPCI service is located, they may not be based at the interventional centre at all times.

When asked to identify barriers to change, in relation to workforce issues, one network stated that “(the) need to cover labs overnight adds significant change to workforce practice”.

Another network saw “consultant and other clinical staff working hours and the unwillingness of Trusts in the Network to enable an out-of-hours rota which could mean the supplying Trust losing consultant time the following day” as a workforce barrier to change.

A potential solution to the human resource issues are to look at ways of working differently, including the introduction of generic catheter lab staff; multi-skillng of professional roles and extending the ‘routine’ working day. Shared rotas and increased joint working between centres may help to reduce the pressure on the human implications of providing a PPCI service.

Concerns were raised about the potential deskilling of cardiology staff in DGHs. Consideration should be given to changes to cardiac care units to accommodate acute coronary syndrome to ensure current skill levels are maintained. A further potential solution may be to look at the integration of DGH interventionalists onto PPCI rotas at tertiary centres.

Commissioning Evidence base and cost effectiveness

Some commissioners are sceptical about the value of PPCI and its’ cost effectiveness compared to providing thrombolysis for STEMI patients. The impact of providing a PPCI service, whether OOH or 24/7, has massive commissioning implications for staffing levels, capacity levels and ambulance services. There is also a concern surrounding the potential commissioning costs for cardiac rehabilitation unbundling of the tariff.

The provision of a reperfusion commissioning guide with key recommendations may help to engage commissioners and aid their understanding of providing a PPCI service, along with a clear clinical reperfusion strategy implemented across the network. Some networks discussed the possibility of introducing a ‘repatriation’ tariff as a potential solution to the threat to DGH incomes of a PPCI service provided at a tertiary centre.

Geography Rural areas with long travelling distances Use of helicopters

Providing a PPCI service across a large geographical patch, particularly in rural areas, is an issue for most cardiac networks. Journey times for ambulances to the nearest tertiary centre, and delays in reperfusion due to geographical spread are highlighted as key concerns to implementing a full PPCI service. HIP NIAP Analysis report – V1 9

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Equity issues surrounding the provision of a PPCI service for those STEMI patients who live a great distance from a tertiary centre should not be overlooked.

Some networks are discussing the use of PPCI and PHT hybrid approaches as a potential solution to development of their reperfusion strategy. Whilst the use of helicopters to transfer patients to tertiary centres is being considered in those areas where long journey times cannot be avoided.

Clinical Governance Evidence base Cross boundary working Need for single protocol when have mixed provision

Many networks stated that clinical providers require evidence of the clinical benefits of PPCI before they further investigate the provision of a full service. The NIAP report and its’ findings will be able to provide clarity around this issue.

It is clear that, if the evidence base clearly suggests better patient outcomes for PPCI, that there is a need for clear protocols for the provision of PPCI and any PPCI and PHT hybrid approaches to reperfusion. Such protocols should also cover issues relating to transferring patients across network/geographical boundaries and the governance issues relating to this.

This requires development of clear communication channels between all providers to ensure that the governance arrangements are clear and understood and adhered to by all involved.

Rhiannon Pepper & Sheelagh MachinJanuary 2008

APPENDIX A

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National Infarct Angioplasty Project Cardiac network survey of reperfusion strategies

Name of network:

Name of person completing form:

Contact details:

Network coverage

1. What geographical area does your network cover?

2. What is the catchment population?

3. How many consultant interventional cardiologists work in your network area?Name of hospital Number

Pre-hospital thrombolysis

3a Is pre-hospital thrombolysis provided within your network? (please tick box)Yes, for the whole networkYes, for part of the networkNo

3b Do you have any defined criteria for the use of pre-hospital thrombolysis? (please tick box)YesIf yes, please state what they are:

No

Ambulance transfers

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4a Are there any arrangements for ambulances to transfer STEMI patients to PPCI centres? (please tick box)

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No, taken to nearest acute hospitalYes, bypass local hospital to transfer to PPCI centreYes, assessed at non-PPCI centre then STEMIs transferred to PPCI centreIf patients bypass local hospitals, what are the criteria for bypass?

4b Do frontline ambulances in the service have 12-lead ECG recording?(please tick box)All Some

Are paramedics trained to interpret the ECG? (please tick box)All SomeNone

Can they send the ECG to the hospital or ambulance centre by telelink of any kind? (please tick box)AllSomeNone

Hospital based reperfusion services

5 Within your network, how many hospitals:a Receive patients with STEMI?b Provide thrombolysis for patients with STEMI?c Provide PPCI for patients with STEMI?d Have transfer arrangements to PPCI centre for the majority

of STEMIs (bypass or direct transfer from A&E)? e Have transfer arrangements to PPCI centre for occasional

STEMIs (on an ad-hoc basis)?f Have transfer only for ‘rescue PCI’?

6 For centres providing PPCI (5c above) how many:a Provide a PPCI service -

In-hours only?In-hours and weekday nights?24/7?Other? Please describe

b Have arrangements in place with feeder hospitals to receive:The majority of STEMIs (bypass or direct transfer from A&E)Occasional STEMIs on an ad-hoc basis

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Future plans for changes to reperfusion services

7 Are there any plans to alter the reperfusion services offered within your network over the next 2 years?If so, please describe:

a Any changes to pre-hospital thrombolysis

b Any changes to primary angioplasty services

Barriers to change

8 Please describe any barriers that you feel may need to be overcome in order to develop reperfusion services as you would like (i.e., financial, workforce numbers, working practices, physical, services boundaries)

Please return your completed survey to [email protected] by 25 September 2007.

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