1 / 38

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.

omer
Download Presentation

PPCI - it’s 24/7 or not at all?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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!

More Related