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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

PPCI - it’s 24/7 or not at all?

Dr JIM HALL

CONSULTANT CARDIOLOGIST

JAMES COOK UNIVERSITY HOSPITAL

MIDDLESBROUGH

slide3
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
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
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
PPCI
  • 24/7

– the key issues

  • PROCESS EFFICIENCY
  • INSTITUTIONAL COMPETENCE
  • TRANSPORT TIMES
slide7
PPCI
  • 24/7

– key issue

  • PROCESS EFFICIENCY
slide8

EFFECTIVE PATHWAY FOR STEMI PATIENTS

  • RIGHT PATIENT
  • RIGHT PLACE
  • RIGHT TIME

ST ELEVATION ACUTE MYOCARDIAL INFARCTION STEMI

slide9

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
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

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

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

REMOVING A STEP

- IMPACT ON PPCI D2B TIMES

SpR initiation

CCU nurse initiation

slide14

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

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

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

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

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
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
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

slide21
PPCI
  • 24/7

– key issue

  • INSTITUTIONAL COMPETENCE
institutional experience
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
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
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
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
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
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
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

JCUH database 2005-8 725 PPCIs

  • IABP 10%
  • VENTILATION 3%
  • SHOCK 8%
slide30
PPCI
  • 24/7

– key issue

  • TRANSPORT TIMES
trade offs
TRADE-OFFS
  • DOWNSIDE OF TRANSFER TO 24/7 HEART ATTACK CENTRE
    • INCREASED ISCHAEMIA TIME

mortality increase ~ 1%/hr drive time

m

slide32

EFFECTIVE PATHWAY FOR STEMI PATIENTS

STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR

deLuca et al Circ 2004:109;1223-25

trade offs33
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
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
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

part time ppci 9 5
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
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