“The Doctor said another 5 minutes and I would have been dead”

A regional approach to saving heart muscle

Vanessa ThorntonClinical Head Emergency Care

Background• Time to PCI is an internationally measured

indicator of care for patients with ST Elevation Myocardial Infarction (STEMI).

• Earlier the heart is perfused the better the outcome for heart function.

• The internationally agreed is Time to PCI < than 90mins.

• Since 2010 we have transferred patients to ACH for PCI after 1530 until 0730.

Analysis in 2011PCI performed at

Middlemore Hospital

Auckland City Hospital

<90 minutes

>90 minutes

Auckland City Hospital

Analysis After Hours Patients Left MMH EC within 45 minutes (13/30)

Late Presentation MI

Delay to book ambulance

Failure to view initial ECG

Evolving MIserial ECG’s

No interventionalist available at MMH / waiting

cardiology decision

Delay CCU RN/ICU Dr

Unstable

Treating another condition

AnalysisDoor to ballon time (after hours STEMI Patients) January 2011 to date

0:00

1:30

3:00

4:30

6:00

7:30

9:00

10:30

12:00

1

Do

or

to b

allo

on

tim

e

Mean door to balloon time 2:2016 out of 82 (20%) < 90 minutes

The Patients Voice

08:00-15:30 CN CCU arrange

PCI

Pt Tx to PCI

Chest Pain in the community

GP Ambulance R40

ECG Arrive MMH TC1 or

2

ECG 10 mins

S/B 10 mins

Ref Cardio *3167

Self present to MMH ED

15:30 – 08:00 Cardio discuss

ACH

ACH accepts pt

Cardio informs MMH SMO

EC organise ambulance

Cardio organise CCU escort

Ambulance dispatched

Ambulance arrives

Pt transferred to ambulance

Depart to ACH

Arrive at ACH

CHANGE CONCEPT = SIMPLIFY PROCESS AFTER HOURS

Ref to Medicine

Improving Time to Nurse Seen by

R40 likely STEMI on ECG or STEMI likely at triage

ECG within 10 mins

Notify EM SMO *3703 & monitor registrar

15:30 – 08:00 & weekendsRequest ambulance to wait and ph 9037060 / 0800262266 stating

“Patient still on stretcher of vehicle ‘xx’ and vehicle ‘xx’ is doing the transfer to Auckland Hospital”

(NB St John may request the patient is transferred in a PTS ambulance If one is already on site or if the crew are at

the end of their shift).or

If delay expected or ‘walk in’ patient, book ambulance ph 9037060 / 0800262266 stating “Urgent priority 1 ambulance…patient transfer to Auckland City Hospital cath lab

with escort”.

Transfer to ACH cath lab with CCU RN escort & notify ACH CCU 0212406774 or 3757040.

ICU will assist with unstable patients.

After Hours

On arrival, keep patient on ambulancetrolley & perform ECG

WithinHours

STEMI?

08:00 – 15:30 Mon – Fri?

NoRefer NSTEAC/

chest pain pathway. Transfer patient

onto EC bed & let ambulance go.

Ambulance arrival

Follow blueWalk in arrival

Follow green

Yes

STEMI

CHEST PAIN

Call

*3167 (within hours this connects directly with CCU

CN, after hours this connects with the operator – ask for the on call cardiologist)

STEMI?

NoRefer NSTEAC/

chest pain pathway.

Transfer patient to EC bed &

perform ECG

08:00-15:30 hrs Monday – Friday

Call CCU CN on *3167

Fax ECG to CCU 8176

Transfer patient ASAP to MMH cath lab

Ref STEMI pathway

Show ECG to RMO / SMO

Ambulance DelaysTime from calling for ambulance to depature from

Middlemore Emergency Care

00:00

00:10

00:20

00:30

00:40

00:50

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

Patient number

Tim

e(h

ou

rs:m

inu

tes

)

Result of Holding Original AmbulanceAfter:70% Patients receive PCI within 90 minutesMean time to PCI 83 minutes

Door to ballon time (after hours STEMI Patients) January 2011 to date

0:00

1:30

3:00

4:30

6:00

7:30

9:00

10:30

12:00

1

Do

or

to b

allo

on

tim

e

Door to ballon time (after hours STEMI Patients) January 2011 to date

0:00

1:30

3:00

4:30

6:00

7:30

9:00

10:30

12:00

1

Do

or

to b

allo

on

tim

e

Other activities• The project aligned itself to the Regional

Cardiac Network.• Continue to measure all the times involved

for the individual patients presenting with a STEMI.

• We audited St Johns from March to June, measuring confidence level of crew in identifying STEMI.

Next Improvement

Challenges – timing?

• St John are in the process of phasing out their old defibrillators.

• Also upgrading their entire national computer system.

• They had other priorities and projects, for example Christchurch.

• Delay to get complete regional transmission.

In Progress

• All the stakeholders are totally committed.• This was always a phased approach• Relocating all MRX defibrillators to

Counties Manukau area.• Training St Johns ambulance and

Emergency Staff.• Upgrading 19 ambulances with

transmission capabilities.

Conclusion• Currently 70% of patients now receive

PCI < 90mins “after hours”• This is up from 20%.• Holding ambulance in EC and improving

time to ECG review has improved after hours care.

• ECG transmission by ambulance to MMH Emergency is the future improvement.