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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.

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Ppci it s 24 7 or not at all l.jpg

PPCI - it’s 24/7 or not at all?

Dr JIM HALL

CONSULTANT CARDIOLOGIST

JAMES COOK UNIVERSITY HOSPITAL

MIDDLESBROUGH



Slide3 l.jpg
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


Slide4 l.jpg
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


Slide5 l.jpg
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


Slide6 l.jpg
PPCI

  • 24/7

    – the key issues

  • PROCESS EFFICIENCY

  • INSTITUTIONAL COMPETENCE

  • TRANSPORT TIMES


Slide7 l.jpg
PPCI

  • 24/7

    – key issue

  • PROCESS EFFICIENCY


Slide8 l.jpg

EFFECTIVE PATHWAY FOR STEMI PATIENTS

  • RIGHT PATIENT

  • RIGHT PLACE

  • RIGHT TIME

ST ELEVATION ACUTE MYOCARDIAL INFARCTION STEMI


Slide9 l.jpg

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 l.jpg
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


Slide11 l.jpg

Pre Hospital

Barn door STEMI

No significant co-morbidities

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact Cath Lab

Co-ordinator and interventionist in Cath Lab

Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards

Contact Cardiologist on call and

Cath Lab team

STEMI / PPCI PATHWAY

Wards

Barn door STEMI

No significant co-morbidities

A&E & AAU

Barn door STEMI

No significant co-morbidities


Slide12 l.jpg

Pre Hospital

Barn door STEMI

No significant co-morbidities

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact Cath Lab

Co-ordinator and interventionist in Cath Lab

Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards

Contact Cardiologist on call and

Cath Lab team

STEMI / PPCI PATHWAY

Wards

Barn door STEMI

No significant co-morbidities

A&E & AAU

Barn door STEMI

No significant co-morbidities

SINGLE POINT OF CONTACT

DIRECT TO CATH LAB


Slide13 l.jpg

REMOVING A STEP

- IMPACT ON PPCI D2B TIMES

SpR initiation

CCU nurse initiation


Slide14 l.jpg

Pre Hospital

Barn door STEMI

No significant co-morbidities

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact Cath Lab

Co-ordinator and interventionist in Cath Lab

Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards

Contact Cardiologist on call and

Cath Lab team

STEMI / PPCI PATHWAY

24/7 HAC

Wards

Barn door STEMI

No significant co-morbidities

A&E & AAU

Barn door STEMI

No significant co-morbidities


Slide15 l.jpg

Pre Hospital

STEMI

Contact Cardiologist on Call

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab

9 am – 5pm /

Mon – Fri

Patient transferred to Heart Attack Centre Cath Lab

Patient transferred to DGH Cath Lab if lab available

Switchboard contacts on call

Cath Lab team

STEMI / PPCI PATHWAY

24/7 HAC + 9-5 DGH

Wards

STEMI

A&E & AAU

STEMI

5pm – 9am /

Weekends


Slide16 l.jpg

Pre Hospital

STEMI

Contact Cardiologist on Call

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab

9 am – 5pm /

Mon – Fri

Patient transferred to Heart Attack Centre Cath Lab

Patient transferred to DGH Cath Lab if lab available

Switchboard contacts on call

Cath Lab team

STEMI / PPCI PATHWAY

24/7 HAC + 9-5 DGH

Wards

STEMI

A&E & AAU

STEMI

5pm – 9am /

Weekends

<25% of STEMI


Slide17 l.jpg

Pre Hospital

STEMI

Contact Cardiologist on Call

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab

9 am – 5pm /

Mon – Fri

Patient transferred to Heart Attack Centre Cath Lab

Patient transferred to DGH Cath Lab if lab available

Switchboard contacts on call

Cath Lab team

STEMI / PPCI PATHWAY

24/7 HAC + 9-5 DGH

Wards

STEMI

A&E & AAU

STEMI

5pm – 9am /

Weekends

INEVITABLE CONFUSION AND DELAY


Slide18 l.jpg

Pre Hospital

STEMI

Contact Cardiologist on Call

Contact CCU Co-ordinator

External: 282618 (ambulance)

Internal: 54801/53624/52458

Fax ECG: 282615

Contact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab

9 am – 5pm /

Mon – Fri

Patient transferred to Heart Attack Centre Cath Lab

Patient transferred to DGH Cath Lab if lab available

Switchboard contacts on call

Cath Lab team

STEMI / PPCI PATHWAY

24/7 HAC + 9-5 DGH

Wards

STEMI

A&E & AAU

STEMI

5pm – 9am /

Weekends

INEVITABLE CONFUSION AND DELAY

100% of STEMI


Effect of part time ppci l.jpg
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 ppci20 l.jpg
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


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PPCI

  • 24/7

    – key issue

  • INSTITUTIONAL COMPETENCE


Institutional experience l.jpg
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 experience23 l.jpg
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 experience24 l.jpg
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 experience25 l.jpg
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 experience26 l.jpg
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 experience27 l.jpg
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 experience28 l.jpg
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


Slide29 l.jpg


Slide30 l.jpg
PPCI

  • 24/7

    – key issue

  • TRANSPORT TIMES


Trade offs l.jpg
TRADE-OFFS

  • DOWNSIDE OF TRANSFER TO 24/7 HEART ATTACK CENTRE

    • INCREASED ISCHAEMIA TIME

      mortality increase ~ 1%/hr drive time

      m


Slide32 l.jpg

EFFECTIVE PATHWAY FOR STEMI PATIENTS

STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR

deLuca et al Circ 2004:109;1223-25


Trade offs33 l.jpg
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 l.jpg
Trade-off: drive time - institutional volume

DRIVE TIME

3%

ISOMORTALITY

BREAK-EVEN LINE

ACCEPTABLE

DRIVE TIMES

High Low

INSITUTIONAL PPCI VOLUME


Trade off drive time institutional volume35 l.jpg
Trade-off: drive time - institutional volume

DRIVE TIME

3%

ISOMORTALITY

BREAK-EVEN LINE

PROCESS DELAY

ACCEPTABLE

DRIVE TIMES

ACCEPTABLE

DRIVE TIMES

High Low

INSITUTIONAL PPCI VOLUME


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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 9 537 l.jpg
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