NO CONFLICT OF INTEREST TO DECLARE

J.M. McLENACHAN, LEEDS

PRIMARY PCI FOR STEMI

Is a 24 / 7 service sustainable?

Jim McLenachan, Leeds

26th January, 2006

2.jpg

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

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%)

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

MEDIAN DOOR TO BALLOON TIMES

0

20

40

60

80

100

120

APR MAY JUN JUL AUG SEPT OCT NOV

MINUTES

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%

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%

West Yorkshire Cardiac Network

Harrogate

York

PontefractDewsbury

Halifax

Huddersfield

Airedale

BradfordLeeds

Pinderfields

EXPECTED ANNUAL NO. OF PPCI PATIENTS(population of 3.1 million)

8 am – 8 pm 570

8 pm - midnight 90

midnight – 8 am 190

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

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

ESC GUIDELINES FOR STEMI2005

PCI

STEMI THROMBOLYSIS

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

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