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NO CONFLICT OF INTEREST TO DECLARE
J.M. McLENACHAN, LEEDS
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PRIMARY PCI FOR STEMI
Is a 24 / 7 service sustainable?
Jim McLenachan, Leeds
26th January, 2006
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2.jpg
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PRIMARY PCI SERVICE AT LEEDSHOW IT WORKS
Commenced 7/3/05 24 / 7 service (after much discussion) Initial phase covering Leeds only (population 800,000) Plan to roll out to rest of West Yorks over 2 years
(total population 3.1 million) Interventionist on-call 1 in 6 2 full-time PPCI nurses and 1 PPCI support officer Referrals via cath lab scheduler 8 – 4 Mon to Fri and via
SpR out of hours
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PRIMARY PCI SERVICE AT LEEDSTARGETS
DOOR TO BALLOON TIME < 120 MINUTES
CALL TO BALLOON TIME < 90 MINUTES
DOOR TO REFERRAL TIME < 20 MINUTES
HOSPITAL DISCHARGE AT 3 DAYS (achieved in 75%)
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TOTAL NUMBERS OF PPCI PATIENTS(data for first 10 months)
TOTAL NUMBER OF PATIENTS 203
MEDIAN NUMBER OF PATIENTS PER MONTH 20
MEAN NUMBER OF PATIENTS PER MONTH 18
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MEDIAN DOOR TO BALLOON TIMES
0
20
40
60
80
100
120
APR MAY JUN JUL AUG SEPT OCT NOV
MINUTES
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HOSPITAL MORTALITY
0123456789
10
PRIMARY PCI THROMBOLYSIS THROMBOLYSIS
MO
RT
AL
ITY
%
7/3/05 – 12/1/06 7/9/04 – 6/3/05 28/4/03 – 28/10/03
6.2%
9.1% 9.9%
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PPCI AT LEEDSDAY OF THE WEEK AND TIME OF THE DAY
(first 137 patients)
0
5
10
15
20
25
M T W T F S S
01020
304050
607080
90
8am -8pm
8pm-12mn
12mn-8am
63% 16% 21%
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West Yorkshire Cardiac Network
Harrogate
York
PontefractDewsbury
Halifax
Huddersfield
Airedale
BradfordLeeds
Pinderfields
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EXPECTED ANNUAL NO. OF PPCI PATIENTS(population of 3.1 million)
8 am – 8 pm 570
8 pm - midnight 90
midnight – 8 am 190
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EXTERNAL CHALLENGES
Convincing healthcare commissioners De-skilling of A and E staff De-skilling of CCU staff in non-PCI centres Uncertainty / anxiety among thrombolysis nurses Ambulance issues :
pre-hospital thrombolysis
longer transfer times
“displaced” ambulances
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INTERNAL CHALLENGES
WORKING TIME FOR CATH LAB STAFF:
finish before midnight - normal hours next day finish after midnight - 11 hours off
WORKING TIME FOR CONSULTANTS:
SPA session on morning after on-call
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ESC GUIDELINES FOR STEMI2005
PCI
STEMI THROMBOLYSIS
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ESC GUIDELINES FOR STEMI2005
Considerthrombolysis
PCI
Contra-indicationto thrombolysis
or shock
ECG resolution
thrombolyse
No ECGresolution
STEMI
< 3 hours since onset
3-12 hours since onset
salvagePCI PCI
within24 hours
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IS A 24 / 7 PCI SERVICE SUSTAINABLE?Yes, but…………
Simple guidelines and routes of communication needed
Requires flexibility
??Easier in a large centre where the frequency of on-call is less but the expectation of being called out-of-hours is higher