PPCI - it’s 24/7 or not at all? - BCIS · STEMI A&E & AAU STEMI Patient transferred to Heart...
Transcript of PPCI - it’s 24/7 or not at all? - BCIS · STEMI A&E & AAU STEMI Patient transferred to Heart...
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!