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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. NO CONFLICT OF INTEREST TO DECLARE. PPCI.

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PPCI - it’s 24/7 or not at all?

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  1. PPCI - it’s 24/7 or not at all? Dr JIM HALL CONSULTANT CARDIOLOGIST JAMES COOK UNIVERSITY HOSPITAL MIDDLESBROUGH

  2. NO CONFLICT OF INTEREST TO DECLARE

  3. 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

  4. 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

  5. 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

  6. PPCI • 24/7 – the key issues • PROCESS EFFICIENCY • INSTITUTIONAL COMPETENCE • TRANSPORT TIMES

  7. PPCI • 24/7 – key issue • PROCESS EFFICIENCY

  8. EFFECTIVE PATHWAY FOR STEMI PATIENTS • RIGHT PATIENT • RIGHT PLACE • RIGHT TIME ST ELEVATION ACUTE MYOCARDIAL INFARCTION STEMI

  9. 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

  10. 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

  11. 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

  12. 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

  13. REMOVING A STEP - IMPACT ON PPCI D2B TIMES SpR initiation CCU nurse initiation

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. PPCI • 24/7 – key issue • INSTITUTIONAL COMPETENCE

  22. INSTITUTIONAL EXPERIENCE ALKK database 2003 6268 PPCI 67 hospitals Annual institutional PPCI volume and outcome mortality Zhan et al Heart 2008;94:329-335

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. JCUH database 2005-8 725 PPCIs • IABP 10% • VENTILATION 3% • SHOCK 8%

  30. PPCI • 24/7 – key issue • TRANSPORT TIMES

  31. TRADE-OFFS • DOWNSIDE OF TRANSFER TO 24/7 HEART ATTACK CENTRE • INCREASED ISCHAEMIA TIME mortality increase ~ 1%/hr drive time m

  32. EFFECTIVE PATHWAY FOR STEMI PATIENTS STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR deLuca et al Circ 2004:109;1223-25

  33. 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

  34. Trade-off: drive time - institutional volume DRIVE TIME 3% ISOMORTALITY BREAK-EVEN LINE ACCEPTABLE DRIVE TIMES High Low INSITUTIONAL PPCI VOLUME

  35. 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

  36. 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)

  37. 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

  38. PPCI - it’s 24/7 or not at all!

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