A MODEL FOR CO-OPERATION

- some inconvenient truths

Mark Signy

Worthing and Brighton

Firstly: Thanks for coming on board…

• Dave Smith and many other ‘DGH’ cardiologists have campaigned for years for primary PCI in the UK : Dave and John Dean did the first proper UK pilot of PPCI in a DGH at Exeter

• This meeting has up to now been a forum for regular debate as to whether we should do PPCI at all in UK…

• Sadly, having decided at last to support it, the powers-that-be appear to be suggesting limiting PPCI to large centres, rather than to where the patients are…

déjà vu?

• Type A/Type B cardiologists

• Limit catheterisation to tertiary centres

• Limit PCI to tertiary centres

• Limit PPCI to ‘heart attack’ centres or large volume centres

• ie mostly tertiary centres…

Why?

• Some publications suggest better PCI outcomes in large volume centres

• Well yes, but several have in fact shown this in centres doing more than about 300 PCIs

(which is well below the minimum number of PCIs per approved centre in the UK) and others have shown no difference at all…

• A low–volume centre in US literature may perform less than 150 cases a year

Are the Tertiary centres simply better?

• Better operators?

• Better outcomes?

• Closer to patients?

Are the tertiary centres simply better?

1999 interventional post at Worthing: approx 20 applications

• some are now ‘tertiary’ interventional cardiologists (including one in Rod Stables’ own unit…)

• Did not being shortlisted or appointed make them better interventionists than if they had been appointed?

• Are they necessarily better interventionists than the appointed candidate? Or vice versa?

Are the tertiary centres simply better?

• Barry Kneale was appointed to the first post he applied for

• Keith Dawkins (for example) wasn’t

• or the second…• Would Barry have been a better

interventionist if he had applied for (and not got) several less competitive posts?

• Do you become a worse interventionist if you move from a tertiary centre to a DGH?

• Are you a worse interventionist until they change your unit from a DGH to a tertiary centre?

• Are you a worse interventionist at the non-surgical centre if you work equally at both types of hospital

Or is the tertiary centres’ outcome data simply better?

• Data presented at this meeting over the last few years (Reading, Eastbourne, Worthing etc) has shown DGH outcomes at least comparable to many tertiary centres…

Are the tertiary centres simply better?

• Robust stats from Brighton back to the very beginning of the unit

• Data from1999 till summer 2007

• Figures supplied by Gaynor Dixon (audit Co-ordinator RSCH)

All Cases

‘TERTIARY’ OPERATOR

• No: 4858

• Mortality: 55(1.13%)

• CABG: 5 (0.1%)

• Q wave MI: 8 (0.16%)

• MACE 68 (1.4%)

‘DGH’ OPERATOR

3363

15 (0.45%)

8 (0.24%)

12 (0.36%)

35 (1%)

Non-elective Cases

TERTIARY OPERATOR

• No: 2948

• Vessels: 1.23

• Stents/vessel: 1.2

• Mortality: 53(1.8%)

• CABG: 3 (0.1%)

• Q wave MI: 6 (0.2%)

• MACE 62(2.1%)

DGH OPERATOR

1308

1.19

1.27

13 (1%)

3 (0.2%)

7 (0.5%)

23(1.7%)

Worthingdata to 31st December 2008

• All ‘DGH’ OPERATORS of course…

• Total cases: 819 – MACE 6 (0.73%)

• Elective: 415– MACE 1 (0.24%)

• Non elective: 404– MACE 5 (1.2%)

Here’s a conundrum: how well do our experts design services?

One tertiary centre for 4.9 million: where would YOU put

it?

In the middle?

THE VISION (apparently…)

• 55 year old male

• Acute MI at 8AM on a busy Monday morning

• Rye (10 miles east of Hastings)

• Ambulance arrives in 10 minutes (if lucky)

• Thrombolysis could be given within 20-30 mins of onset of pain

THE VISION (apparently)

RYE +30 mins pain to thrombolysis

THE VISION (apparently)

RYE +30 mins

HASTINGSPCI lab+60 minsDTN ?30 mins

Possible 90 mins pain to balloon

THE VISION (apparently)

RYE +30 mins

HASTINGSPCI lab+60 minsDTB ?30 mins

EASTBOURNEPCI Lab+105 minsDTB 60 mins

Possible pain to balloon time 165 mins

THE VISION (apparently)

RYE +30 mins

HASTINGSPCI lab+60 minsDTN ?30 mins

EASTBOURNEPCI Lab+105 minsDTN 60 mins

BRIGHTON‘Heart Attack centre’+150 minsDTN 60 mins

Possible DTB time210 mins

THE VISION (apparently)RYE +30 minsto thrombolysis

HASTINGSPCI lab+60 minsDTN ?30 mins

Possible DTB90 mins

BRIGHTON‘Heart Attack centre’+150 minsDTN 60 mins

Possible DTB time210 mins

EXCESS TIME FROM THROMBOLYSIS up to 180 minsEXCESS TIME OVER PCI at HASTINGS up to 120 mins

Where’s the benefit for the patient?Does ANYONE (outside secure accommodation…) really think this is the way forward?

Non surgical centres contribute to the problems though:

• Several centres still doing less than 200 PCIs per year

• Some operators still consistently below 75 PCIs per year

• Some centres neither provide 24hr on-site PCI nor contribute to 24hr on-call for the network/centre

• (ie expect others to pick up their emergency work)

West Sussex/Brighton Model for co-operation

• PCI done at Brighton (approx1200 cases) and Worthing (350-450 cases plus 150-200 taken to Brighton)

• ‘Niche’ intervention all done at Brighton (including rotablation, hole closure percutaneous AVR etc)

• All interventionists now work at both sites• On-call for intervention shared between 7

interventionists (4 Worthing, 3 Brighton - out of hours on Brighton site)

West Sussex/Brighton Model for co-operation

• Primary PCI done at both sites during weekdays

• Out of Hours primary PCI done at Brighton (shared on-call between 7 operators)

• The ambulance service much prefer this to 24 hr long distance transfer

• Thrombolysis not yet completely abandoned…

Model for co-operation• All PCI centres should do 400 cases and all

operators 75 cases annually• All centres must either provide 24 hr PCI or

participate in a central 24hr PCI on-call service

• Non-surgical centre operators should have sessions at the surgical centre, participate in the network PCI audit, and should take/refer ‘niche’ cases and surgery to the centre

Model for co-operation• Primary PCI should be performed as close

to the patients as possible, and as early after onset of symptoms as possible

• STEMI Patients should never, ever, be driven past an open, staffed and appropriate PCI centre simply for the sake of theoretical policy or maintenance of central numbers

Model for co-operation

• Don’t yet throw away high quality established prehospital thrombolysis in the bathwater of weak statistics:

• even in the highly populated south east there are areas where it clearly remains an appropriate therapy

DGH - Signy…

MIXED -Hogan…

TERTIARY-Burrell…

SKI GUIDE…

A MODEL FOR CO-OPERATION