Shropshire & Staffordshire Heart and Stroke Network

Operational Policy for

Primary Angioplasty (PPCI)

across

Shropshire and Staffordshire

May 2010

Contents

Section Page No 1. Introduction 3 2. Aims and objectives 3 3. Definitions 4 4. Policy Statement UHNS 5 5. Arrangements 5 6. Responsibilities 7 7. Clinical outcomes and monitoring 14 8. Audit and review 15

References 16 Appendix 1a: Map indicating appropriate PPCI centre – Shropshire

Appendix 1b: Map indicating appropriate PPCI centre – Staffordshire

Appendix 2: PPCI management of STEMI Appendix 3: West Midlands guideline for acute STEMI care Appendix 4: Procedure for patients presenting with STEMI for acute hospitals without PPCI catheter laboratory on site

Appendix 5: Referral for cardiac rehabilitation Appendix 6: Management of acute myocardial infarction (AMI)

Appendix 7: Directions to the PPCI centre at University Hospital of North Staffordshire

Appendix 8: Directions to the PPCI centre at Heart and Lung Centre, New Cross Hospital

Document Version Date Comments Reason Draft Version 0.1 November 2009 For distribution For comments /

amendments Draft Version 0.2 December 2009 For distribution For comments /

amendments Final Version 0.3 March 2010 For distribution

For implementation

Final Draft Version 0.4

April 2010 For distribution For final comments

Final Version 0.6 May 2010 For distribution Operational Policy

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1. Introduction

The Health Oversight and Scrutiny Committees for Shropshire and Staffordshire have jointly approved the introduction of PPCI for the network. The Shropshire and Staffordshire Heart and Stroke Network will establish a network-wide full 24/7 PPCI service by the following timelines:

PCT 24/7 PPCI Northern Staffs/Stoke February 2009 South Staffordshire (exc Burton) 1 November 2009 South Staffordshire (Burton) 1 December 2009 Shropshire, Telford & Wrekin 1 February 2010

The Service Specification for the Management of ST Elevated Myocardial Infarction (STEMI) for the West Midlands specifies that where a Primary Angioplasty (PPCI) centre can be accessed within 90 minutes from time of call then appropriate patients should be transferred to the PPCI centre and Pre Hospital Thrombolysis (PHT) withheld. Where the estimated time of arrival at the PPCI centre is in excess of 90 minutes then PHT should be administered.

2. Aims and objectives

This operational policy aims to establish clear guidelines and responsibilities with regard to the delivery of PPCI across Shropshire and Staffordshire. This policy adheres strictly with the guidelines set out in the “Whole System Service Specification for the Management of STEMI across the West Midlands” document, developed by the West Midlands Cardiac Steering Group. Objectives are: 2.1 To enable the consistent management of patients on first contact with

medical practitioners across Shropshire and Staffordshire. 2.2 To enable collaborative working with paramedic crews, the Heart

Attack Centre’s that serve this network, cardiology wards and local Accident and Emergency departments.

2.3 Repatriation of patients back home and into their appropriate rehabilitation service.

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3. Definitions

Primary Percutaneous Coronary Intervention (PPCI) is a technique for unblocking arteries carrying blood to the heart muscle. A small balloon at the tip of a catheter tube is inserted via an artery in the groin or arm and guided to the blocked artery. It is then inflated and removed, leaving in place a ‘stent’ – a rigid support which squashes the fatty deposit blocking the artery, allowing blood to flow more easily. Primary angioplasty is the use of this technique as the main or first treatment for patients suffering a heart attack.

The key to improving outcomes after a heart attack is to re-establish coronary artery flow as quickly as possible and limit damage to the heart muscle.

Call-to-balloon (device) (CTB) – the time from the patient calling for medical help to the time when an angioplasty balloon is first inflated, or coronary reperfusion is confirmed on angiography

Door-to-balloon (device) (DTB) – the time from the patient arriving in hospital (whether this be a primary angioplasty centre or a non-primary angioplasty centre) to the time when an angioplasty balloon is first inflated, or coronary reperfusion is confirmed on angiography.

THE CLINICAL PRESENTATION OF STEMI, NEW OR PRESUMED NEW LBBB MUST BE WITHIN 12 HOURS OF SYMPTOM ONSET (European Heart Journal 2008, European society of cardiology guidelines) (ESC)

Taking into account the ESC guidelines PPCI should be performed in

less than 120 minutes of time of call

The time from call for professional help to arrival at hospital (call to door) will be less than 90 minutes

The time from arrival at the PPCI centre “door to balloon” should be

achieved in less than 30 minutes

The patient should be assessed for pre hospital thrombolysis if geographical or operational issues (as per MINAP) would result in the inability to achieve satisfactory call to balloon time, and where indicated this should be given per the protocol following administration the patient should be transferred directly to a PPCI centre as an emergency. If thrombolysis is contraindicated the patient should still be transferred directly to the PPCI centre.

Time to treatment - Acceptable C.T.B. and D.T.B. times are achievable by direct or indirect admission to the primary angioplasty centre but the ideal is undoubtedly direct admission to the catheter laboratory at the primary angioplasty centre. (NIAP 2008)

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4. Policy Statements UHNS/RWH/HEFT

Primary angioplasty at the University Hospital of North Staffordshire (UHNS), Royal Wolverhampton Hospitals (RWH) and Birmingham Heartlands Hospital (HEFT) will be available for all patients with ST elevation myocardial infarction within the Staffordshire/Shropshire cardiac network area, 24 hours a day, all year round.

5. Arrangements

Following 999 call, paramedic team identify acute ST elevation myocardial infarction according to standard criteria. Oxygen, analgesia and 300 mg of aspirin administered at the scene

The paramedic team notifies the nearest Heart Attack Centre of

incoming patient, determined by the operational maps (appendix 1a and 1b) - UHNS telephone number is 01782 553465 - RWH telephone number is 01902 694339 - HEFT telephone number is 07812 635834

The Heart Attack Centre Co-ordinator alerts the interventional team.

The paramedic team takes the patient directly to the Heart Attack

Centre / or to the catheter laboratory at UHNS / or directly to the Heart and Lung Centre at New Cross Hospital as directed by the Heart Attack Centre co-ordinator.

All West Midlands Ambulance Service (WMAS) ambulance crews will

have directions and instructions to each centre (appendices 7 and 8).

Consent is taken by registrar/consultant, and clopidogrel administered.

Following the PCI, the patient is returned to catheter lab recovery area. A monitored admission bed will be arranged.

On the ward, standard secondary prevention measures will be

implemented and cardiac rehabilitation process initiated. In uncomplicated cases discharge should be scheduled for 3 days after index admission.

The vast majority of patients will be accommodated on the ward and

discharged home from there. Where residual medical or social issues require attention, interim transfer to district hospital may be considered after consultation with the local cardiologist.

Follow-up arrangements will be made with the local cardiologist in the

vast majority of cases.

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For a minority of cases it may be appropriate for patients to return to the HAC for follow up depending on individual clinical circumstances

5.1 Remote Transfers

The Staffordshire/Shropshire/South Cheshire network encompasses a wide geographical area. At its most remote limits the transfer time to UHNS/RWH may be appreciable.

Helicopter transfer should be considered to optimise delivery time of

the remote patient to UHNS/RWH.

If it is envisaged that the transfer time to UHNS/RWH cardiology department will exceed 90 minutes, thrombolysis should be administered at the scene by the paramedic crew, and the patient taken to the nearest Heart Attack Centre.

5.2 Cardiac Rehabilitation

UHNS, RWHT and HEFT will deliver phase I cardiac rehabilitation for all PPCI patients in order to provide early education, support, advice and start the lifestyle changes required.

Patients from Northern Staffordshire (NHS North Stoke and NHS Stoke on Trent PCT’s) will also receive phase II and III.

Out of area PPCI patients will receive phase I cardiac rehabilitation at the Tertiary Centres. Phase I will be delivered by either the Rehabilitation Team (Monday-Friday 9am – 5 pm) or outside of these hours by trained nursing staff on the cardiac ward.

Once the patient is discharged from either the angioplasty centre, the responsibility for the patient’s rehabilitation will transfer back to the local cardiac rehabilitation team.

A detailed discharge letter will be faxed by the ward clerk directly to the relevant Cardiac Rehabilitation Team (this information is located in the British Heart Foundation Register of Cardiac Rehabilitation Programmes in the UK Guide). A standardised form will be used.(See example appendix 5) Information regarding the rehabilitation advice given to the patient is also written in the patient’s medical records. In addition, it will be required to notify the relevant cardiologist at each local DGH on the discharge of a patient from their local health economy on the contact numbers below. A CD of the patient’s procedure should also be sent to the supervising consultant with the discharge summary.

The fax numbers to be used by UHNS/RWH for cardiac rehabilitation teams are:-

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Leighton 01270 612471 Princess Royal, Telford 01952 271601 Royal Shrewsbury 01743 261169 Stafford 01785 230110 Burton 01283 593027

The cardiac rehabilitation team at UHNS can be contacted on 01782 553225 or 01782 552149 in order to discuss individual patients as required. The cardiac rehabilitation team at RWHT can be contacted on 01902 694226 and the fax number is 01902 694360 The fax numbers used for direct referral to Shropshire and Staffordshire Network cardiologists are:

Princess Royal Telford (FAO cardiology secretaries)

01952 242218

Royal Shrewsbury 01743 261374 Mid Staffs 01785 230677 Queens Hospital Burton (Dr Why) 01283 593027 Queens Hospital Burton (others) 01283 593029

6. Responsibilities

6.1 Primary care

Protocols should be in place in primary care for primary care staff and patients that include:-

i) Pre event

The importance of calling 999 when cardiac chest pain is suspected

ii) Post event

To ensure maintenance of the administration of statins, beta

blockers, ACE inhibitors, aspirin and clopidogrel. The use of CHD registers and 12 month follow up Assessment of lifestyle change 12 month post event

6.2 Ambulance service management

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a) In general terms, all procedures should be within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and NHS Confederation “Ambulance Network”.

b) 999 chest pain calls will receive either a category A response within

8 minutes or a category B response within 19 minutes dependant on the code generated from the AMPDS. An emergency response may only be by:

An emergency ambulance; or

A rapid response vehicle equipped with a defibrillator to provide

treatment at the scene; or

An approved first responder equipped with a defibrillator, who is dispatched by and accountable to the ambulance service; or when a healthcare professional is at the location of the incident; equipped with a defibrillator and deemed clinically appropriate to respond by the trust. A first responder is not a substitute for an ambulance response therefore an ambulance response will always be dispatched to all calls attended by an approved first responder.

An ambulance able to transport the patient will arrive at the

scene within 19 minutes or less of the request for transport

Ideally for all suspected chest pain cases a two man vehicle will be despatched, with one person being a paramedic who has been assessed as being competent in the assessment and management of people with suspected STEMI.

In all cases the nearest response will be sent. This may be a

solo response which would be backed up by a two man vehicle, with one being a paramedic who has been assessed as being competent in the assessment and management of people with suspected STEMI. However, if a rapid response vehicle is despatched, then all such vehicles must be equipped with a 12 lead ECG machine and the paramedic able to record and interpret the ECG to identify STEMI or bundle branch block, if necessary with decision support via telemetry.

Assessment and care will proceed according to standard

JRCALC guidelines: resuscitation, morphine, oxygen, nitrates and aspirin as indicated.

b) The first ECG should be recorded within 10 minutes of arrival at the

patient by an individual equipped and trained to do so. c) In order for the ambulance clinician to determine whether STEMI or

LBBB (left bundle branch block) is present in patients with symptoms of cardiac related chest pain, they will record a 12 lead

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d) Patients with ECG evidence of left bundle branch block (LBBB) or

posterior myocardial infarction may be at particularly high risk of death and should be discussed with the telemedicine desk or receiving hospital. Those with LBBB on ECG and a good history will be considered as eligible for PPCI.

e) The diagnosis of STEMI by ambulance staff will be based on the

presence of at least 1mm ST elevation in two continuous limb leads OR at least 2mm ST elevation in two contiguous chest leads

f) Patients with ECG evidence of presumed new left bundle branch

block (LBBB) or posterior MI may be at particularly high risk of death and should be discussed with the receiving hospital. Those with LBBB on ECG and a good history will be considered as eligible for PPCI

g) All patients being considered for PPCI will be given aspirin unless

contra-indicated, and cannulated in the left arm if possible. Difficulty in gaining intravenous access should not be allowed to cause delay in transport to hospital.

h) Patients who do not have STEMI, LBBB or suspected posterior MI

should be taken to the nearest Emergency Department.

* For all patients with STEMI the PPCI centre will be alerted * WMAS will have a system which will identify to the clinician the most rapidly accessible PPCI centre for the transfer of appropriate patients, including patients who receive pre-hospital thrombolysis Confirmation in the form of a patient signature must be obtained and recorded on the patient report form (PRF) if the patient declines transportation to their most rapidly accessible PPCI centre WMAS will hold a plan for accessing other PPCI centres where, due to a capacity issue, the most rapidly accessible PPCI centre is unable to accept referrals Documentation will be completed on the WMAS patient report form, cardiac proforma and/or E-PRF that identifies: Accurate Call, On Scene, Transfer time, Door and Hospital Arrival times Onset of symptoms Time of first 12 lead ECG recording ECG findings/interpretation

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Administration of medicines: times, drug dosages and route and batch number

Confirmation that an alert message has been sent to the receiving centre WMAS should plan for the transfer of all patients suspected of having STEMI to the most rapidly accessible PPCI centre, including patients who receive pre-hospital thrombolysis or following hospital thrombolysis where the responding vehicle is not carrying thrombolysis. Dedicated maps which indicate the nearest PPCI centre will be carried on very vehicle for the use of identification (appendices 1a and 1b). If the attending ambulance staff estimate that a call to door time of 90 minutes or less can be achieved, then the most rapidly accessible PPCI centre should be alerted. The patient should be assessed for pre hospital thrombolysis if geographical or operational issues would result in the inability to achieve satisfactory call to balloon time, and where indicated this should be given per the protocol following administration the patient should be transferred directly to the nearest PPCI centre as an emergency. If thrombolysis is contraindicated the patient should still be transferred directly to the PPCI centre. Action in the event of patient deterioration If during transit to a PPCI centre there is a clinical deterioration e.g. ventricular fibrillation, then following resuscitation, the journey should continue as planned to the nearest PPCI centre if the patient is stabilised. If clinical deterioration continues, e.g. need for sustained resuscitation and ventilation, consider ambulance divert to the nearest A&E department WMAS will ensure paramedics are aware that there is no upper age limit on consideration for PPCI West Midlands Ambulance Service draft protocol for direct admission from scene to the Cardiac Catheter Laboratory for confirmed acute MI patients is in appendix 2. NB: If carrying out an “Emergency Transfer” from another hospital to a cardiac catheter laboratory place an alert call to the catheter lab on leaving the hospital – Patients should be monitored until they reach the catheter lab and have resuscitation equipment including a defibrillator with them in case of cardiac arrest when transferring to and from the ambulance. 6.3 Self presenters at A&E (Non PCI)

6.3.1 Patients who self present to A&E of a hospital that does not provide PPCI will be transferred to a designated PPCI centre as an emergency.

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6.3.2 The patient should be assessed for hospital lysis if geographical or operational issues would result in the inability to achieve satisfactory call to balloon time, and then transferred to a PPCI centre (appendix 4).

6.3.3 A&E departments will request the “Emergency Transfer” of

patients to the nearest designated PPCI centre irrespective of whether or not thrombolysis has been administered. – see WMAS guidelines for acute STEMI care (appendix 4)

6.3.4 A flowchart has been developed for easy use/referral for staff at

A&E, and relevant hospital departments and wards, GP surgeries etc (appendix 6).

6.4 Joint working hyper-acute management

6.4.1 Each DGH should have an agreed procedure for in-patients who

present with the symptoms of a STEMI. A protocol should be agreed for clinical decisions to be made to transfer these patients to the nearest PPCI centre if clinically appropriate. The “Emergency Transfer policy (appendix 6) should then be operated.

6.4.2 Local protocols should be in place enabling direct access to

catheter laboratories on arrival at a PPCI centre, avoiding the assessment of patients in A&E, with the identification and agreement of a designated handover/ transfer of care methodology and location.

6.4.3 The department will telephone the direct designated WMAS

phone number to request an “Emergency Transfer” of the patient to the nearest designated PPCI centre - see WMAS guidelines for acute STEMI care (appendix 4)

6.4.4 Acute units will have an agreed communication cascade, that

initiates the call in of all staff in the shortest time possible, ideally implemented through switchboard to maximise notice

6.4.5 The STEMI coordinator/bleep holder will alert the on call team

advising to prepare catheter lab, identifying the responsible person to receive the patient.

6.5 Adjunctive medications for PCI

6.5.1 Clear protocols will be agreed and in place to support the

assessment, recording (including dose and time) and administration of any medicines given prior to admission to the cardiac catheter laboratory.

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6.6 Acute trusts In order to be considered to become a designated/accredited PPCI centre, acute trusts needs to be able to demonstrate their adherence to the following standards:-

a) Designated centres will be required to identify one alert contact number which can be used to alert the whole angioplasty team.

b) The target door to balloon (device) time 30 minutes

Required numbers of procedures/operators.

i. The PPCI centre will fulfil national guidance (BCS/BCIS) for a PCI centre with regard to numbers performed and operators/institutional volume.

ii. There will be an appropriate number of operators, in line with

nationally agreed legislation, for a 24 hour/7 day service. In addition there will be an appropriate number of other essential staff including nurses, radiographers and cardiac technicians to run a service 24 hours a day, 7 days a week.

Facilities

i. To retain accreditation as a PPCI centre, the preferred model should be 2 fixed cardiac catheter laboratories available on site at all times. New centres should adhere to this guidance, but existing centres with only 1 cardiac catheter laboratory should undertake a risk assessment with their commissioners and move towards having 2 fixed laboratories on site.

ii. In other respects facilities should be in accordance with BCIS

guidance. Repatriation of patients

i. Patients will remain in the PPCI centre, being discharged to their normal place of residence. Patients will only be repatriated to a non designated PPCI if it is in the best interest of the patient, and/or if an extended stay is predicted.

Patients treated by thrombolysis

i. Patients who have thrombolysis will be required to have a 90 minute

ECG and assessment for re-perfusion ii. Patients will be assessed for rescue angioplasty

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iii. All patients will be considered for early angiography unless there are exceptional circumstances.

Pre and post procedural guidelines

i. Protocols should be in place for pre and post procedural care in all

acute units General/discharge information

i. A follow up appointment will be made 6-8 weeks post discharge at the patient’s local hospital.

ii. Prior to discharge patients will receive phase I rehab advice from

the cardiac rehabilitation team

iii. Patients will be referred to their local rehab team and will receive a named local contact for this local team

iv. The patient will be given verbal information, supported by written

instructions to inform of:-

a. the risk of late vascular and other complications b. instructions on any changes in medication c. advice on driving or other restrictions d. arrangements for return to work and clinic follow up

v. All patients must be given a copy of their ECG on discharge.

vi. Follow up by the cardiac rehabilitation teams will be in line with

West Midlands Cardiac Rehabilitation Standards. Discharge medication

i. Patients will be discharged on Clopidogrel with the recommendation

to the General Practitioner that this is continued for 12 months (unless otherwise specified)

Follow up

i. The PPCI centre will be responsible for making appropriate follow

up and prompt discharge summary to the patients local centre (cardiologists and rehabilitation teams). Please refer to table of contact numbers for cardiac rehabilitation teams and cardiologists in section 5.2.

ii. A standardised form will be used on discharge to inform relevant

rehab teams and respective Cardiologists (appendix 5).

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iii. Protocols and pathways will be in place that will enable patient follow up in their local DGH, or in line with local policy

iv. Assessment of LV function will be performed at 1 month post

discharge at the patient’s local hospital.

7. Clinical outcomes and monitoring 7.1 Clinical indicators

i. Reduction in mortality rate ii. Reduction in readmission rate iii. Reduction in average length of stay iv. Reduction in excess bed days

7.2 Key indicators to be used to monitor the service Ambulance Service

i. % of ambulances responding to Category A calls within 8 minutes or less

ii. % of ambulances able to transport patients within 19 minutes or less of the request for transport (Category A)

iii. Number of ECGs performed iv. Proportion of completion of Patient Record Forms (PRF) v. % of patients with call to door times within 30, 60 and 90 minutes of

call for help vi. Number of STEMI patients transferred directly to PCI centre vii. Patients with a ‘missed’ diagnosis or presenting later than 12 hours viii. % of patients receiving pre-hospital thrombolysis ix. % of patients given aspirin x. Onset of symptoms xi. Call, In attendance, transport time, Door time

Secondary Care

i. % of patients meeting door to balloon/call to balloon targets ii. Number of PCIs performed iii. % of patients given hospital lysis iv. % of patients given clopidogrel v. % of patients with more than 60 minutes wait for PPCI and given

thrombolysis vi. % of implanted stents vii. % of failed angioplasties viii. % of emergency referrals to surgery ix. Evidence of access to information about heart disease and lifestyle x. % of patients with a care plan including a discharge plan xi. Complaints relating to the service xii. Number of patients offered a programme of phase 1, 2 and 3

rehabilitation xiii. Number of patients accessing phase 3 rehabilitation

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xiv.Number of patients with LV dysfunction

8. Audit and review

a) MINAP and BCIS data will be collected, submitted and reported.

b) A trust or hospital should provide the appropriate audit and information technology infrastructure to a cardiology department to allow clinicians to collect accurate data and to ensure that it is analysed and made available to commissioning groups and other interested parties. This includes the appropriate personnel to ensure accurate data collection and validation. It should have a system of clinical governance to oversee the results of the treatments provided.

c) A cardiology department should appoint a key clinician to lead on

an audit process for interventional cardiology, ensure that there is an appropriate method to collect and analyse data, and ensure that the trust has provided appropriate support staff to make this process work. Departmental data collection systems must be compatible with the national dataset.

d) Every interventional cardiologist should conform to the department’s

audit process, collect data on his or her patients, and share the results of the treatment with the trust’s clinical governance programme

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References A Whole System Service Specification for the Management of STEMI across the West Midlands (January 2010), West Midlands Cardiology and Cardiac Surgery Steering Group British Cardiovascular Intervention Society www.bcis.org.uk British Cardiovascular Society www.bcs.com European society of cardiology guidelines (2008), European Heart Journal National Infarct Angioplasty Project (NIAP) (2008) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083061 A thank you is extended to all that have contributed; either with the document, involvement in the process or both – this has ensured that this service has been fully implemented across Shropshire and Staffordshire

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Appendix 1a

Map indicating appropriate PPCI centre Shropshire

Key

University Hospital North Staffs Royal Wolverhampton Hospitals

This map will be carried on every operational vehicle to assist clinicians with the conveyance decisions.

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Appendix 1b

Staffordshire

Key

Royal Wolverhampton Hospitals University Hospitals North Staffs

Heart of England This map will be carried on every operational vehicle to assist clinicians with the conveyance decisions.

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Appendix 2

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Appendix 3

Appendix 4

Procedure for patients presenting with ST Elevation Myocardial Infarction (STEMI) for Acute Hospitals without Primary Percutaneous Coronary Intervention Catheter

Laboratory on site

Introduction West Midlands Ambulance Service NHS Trust is committed to transferring patients that need PPCI for STEMI as quickly as possible. To ensure that there is no delay in response the Trust has produced this guidance to ensure that there is no miscommunication when an emergency transfer is required. Procedure Upon identifying a patient with STEMI the following should occur whilst the initial treatment for the patient is being commenced: Contact the Ambulance Emergency Operations Centre for your area on one of the following:

Staffordshire = 01785 220370

Birmingham, Black Country, Hereford, Worcester or Shropshire =

01384 215520

Coventry and Warwickshire = 01926 885050

On the operator answering inform them that: “I require a Paramedic crew to undertake an “Emergency Transfer” from (state the

unit/ward you require the ambulance to come to) to the nearest PPCI Centre” The operator will then take you through a list of questions. These questions will not delay the response of a vehicle. If there is a significant delay expected due to operational demands you will be informed of the delay by the Emergency Operations Centre.

WMAS PPCIP – 1/12/2009 MW Version 1

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Appendix 5 Referral for Cardiac Rehabilitation Referring Hospital

Patient Telephone Number Hospital No/NHS No Consultant

Patients Name

Sex Ward Next of Kin & Relationship Tel No.

Ethnic Origin Language Interpreter Yes/No

Address……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………….Postcode……………………………………… Date of Birth Occupation

HGV YES / NO

Date of Admission Date of Discharge

GP Surgery Details

1st Diagnosis …………………………………………………………….. IHT: Yes No Date:…………………………………… Relevant PMH………………………………………………………………………………………………………………………………………………

Diagnosis Primary PCI CABG Elective PCI AVR / MVR Other & PCI (includes NSTEMI, ACS, Angina etc)

Procedure details……………………………………………………. …………………………………………………………………………. …………………………………………………………………………. Date of Procedure……………………………………………

Angiogram Yes No Date of Procedure……………………………

Result…………………………………………………………. ……………………………………………………………….. ……………………………………………………………….. ……………………………………………………………….. ……………………………………………………………….. If Normal Coronary Arteries, the patient’s diagnosis is: ………………………………………………………………………………… Patient informed Yes No

LV Function LV Dysfunction: Yes No Info not available If yes: Mild Moderate Severe ECHO: Yes No Copy…………Y / N

Postoperative Complications Infection Heart Failure Bleeding Cardiac Arrest Haematoma Pacemaker Other ……………………………………………………………………….

Mobility Level – Please state mobility level at time of discharge ……………………………………………………………………………………………………………………………………………………………….. Are any aids required Yes No if yes, what?.................................................................................................. Is there any help at home Yes No if yes, who?................................................................................................... Other Comments…………………………………………………………………………………………………………………………………………

Cardiac Medications on Discharge Drug Name Dose Frequency Comments

Aspirin

Clopidogrel

B/Blocker

ACE/A2

Statin

GTN Spray

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Page 2 PATIENT’S NAME………………………………………………………………………………………

Risk Factors

Other Comments: Risk Factors Smoking Yes / No / Ex High BP Yes / No Diabetes (type 1 / 2) Yes / No High Cholesterol Yes / No Stress Yes / No Inactivity Yes / No Family History Yes / No Alcohol Units/Wk………….HGT……… WGT……… BMI……..

Education Session Yes / No* One to one / Group* Date Given:

Local Information pack given Yes No Date Given:

* delete as appropriate

Follow-Up To be arranged by:

Echo Yes No

Local Hospital New Cross Hospital UHNS

ETT Yes No

Local Hospital New Cross Hospital UHNS

PMIC Yes No

Local Hospital New Cross Hospital UHNS

Cardiac Rehabilitation – Phase III NXH, Wolverhampton Heart Care, Walsall Action Heart, Dudley

Kidderminster

Worcester Sandwell PRH Telford RSH Shrewsbury

QH Burton

Mid Staffs UHNS Other (please state)

Please FAX this form to the Rehabilitation Team

Cardiac Rehab referred to: Name of person completing referral Signature Date & Time

To be completed by Local Rehabilitation Teams:

Telephone Assessment Yes / No Date:………………………………………….

Visit Arranged Yes / No Date:………………………………………….

Referral to Phase III Yes / No Date:………………………………………….

Appendix 6

DGH INTERNALGUIDELINE FOR THE MANAGEMENT OF STEMI

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Patient self presents to A&E

Continue chest pain/ NSTEMI assessment

pathway in DGH

Exit STEMI pathway

ECG shows ST elevation/ LBBB

Call Ambulance Emergency Operations Centre on: Staffordshire = 01785 220 370 Shropshire/Black Country = 01384 215 520 Ask for “EMERGENCY TRANSFER” to nearest PPCI centre Alert Heart Attack Centre UHNS: 01782 552 225 Alert Heart & Lung Centre RWH: 01902 694 339 Alert Ward 6 HEFT: 07812 635834

PRIMARY PCI

Day 3 Discharge to local DGH Rehab teams

On Arrival of Patient at A&E or Patient on Ward or Department

1. Immediate triage and

diagnosis 2. Oxygen 3. GTN as necessary 4. 300mg Aspirin 5. Opiate analgesia 6. *Clopidogrel 600 mg

Immediate 12 lead ECG * If ECG supports STEMI

In Patients

*Patient Exceptions 1. G.C.S <12 2. Requires

ventilation

Post Infarct (unless contraindicated)

1. Statins 2. Beta blockade 3. ACE inhibition 4. Aspirin 5. Clopidogrel min 12

mths 6. Assess LV function 7. Assessment of residual

ischaemia (as appropriate)

Is ”call to door” time likely to be >90 Minutes?

No

Yes No

Yes If not contra-indicated: Thrombolyse

*Patient Experiencing Symptoms Compatible with MI (chest pain, collapse, shortness of breath, diaphoresis)

Transfer to HAC for consideration of rescue

or early PCI

Appendix 7

Directions to the PPCI Centres at University Hospital North Staffordshire and Heart and Lung Centre New Cross

Heart Attack Centre City General Newcastle Road Stoke-on-Trent ST4 6QG

Telephone: 01782 553465

HAC

Version 1 Access to PPCI HAC and H&L

Heart and Lung Centre New Cross Hospital Wednesfield Road Wolverhampton WV10 0QP Direct Telephone Number: 01902 694339

On arrival at the heart and lung centre the crew park outside the heart and lung entrance. Locate the access buttons next to the automatic door and press cardiology button (blue light access). Staff will answer and open the door via ward access button.

Heart and Lung Centre

Take lift to 2nd floor where you will be met by the coordinator at the lift and taken to cardiology ward.

Version 1 Access to PPCI HAC and H&L

Appendix 8