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PPCI - it’s 24/7 or not at all?
Dr JIM HALLCONSULTANT CARDIOLOGIST
JAMES COOK UNIVERSITY HOSPITAL
MIDDLESBROUGH
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NO CONFLICT OF INTEREST TO DECLARE
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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
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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
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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
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PPCI
• 24/7 – the key issues
PROCESS EFFICIENCY
INSTITUTIONAL COMPETENCE
TRANSPORT TIMES
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PPCI
• 24/7
– key issue
PROCESS EFFICIENCY
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ST ELEVATION ACUTE MYOCARDIAL INFARCTION STEMI
EFFECTIVE PATHWAY FOR STEMI PATIENTS
RIGHT PATIENT
RIGHT PLACE
RIGHT TIME
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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
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EFFECTIVE PATHWAY FOR STEMI PATIENTS
• SYSTEM DESIGN
Understand the steps in the processSimplify the systemSet your metricsMonitor
Modernisation Agency: Improving flow www.modern.nhs.uk
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Pre Hospital Barn door STEMI
No significant co-morbidities
A&E & AAUBarn door STEMI
No significant co-morbidities
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
Patient transferred directly to Cath Labs from
Ambulance/ A&E / AAU/CCU/Wards
STEMI / PPCI PATHWAY
WardsBarn door STEMI
No significant co-morbidities
Contact Cardiologist on call and Cath Lab team
Contact Cath LabCo-ordinator and
interventionist in Cath Lab
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Pre Hospital Barn door STEMI
No significant co-morbidities
A&E & AAUBarn door STEMI
No significant co-morbidities
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
Patient transferred directly to Cath Labs from
Ambulance/ A&E / AAU/CCU/Wards
STEMI / PPCI PATHWAY
WardsBarn door STEMI
No significant co-morbidities
Contact Cardiologist on call and Cath Lab team
Contact Cath LabCo-ordinator and
interventionist in Cath Lab
SINGLE POINT OF CONTACT
DIRECT TO CATH LAB
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REMOVING A STEP
- IMPACT ON PPCI D2B TIMES
CCU nurse initiationSpR initiation
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Pre Hospital Barn door STEMI
No significant co-morbidities
A&E & AAUBarn door STEMI
No significant co-morbidities
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
Patient transferred directly to Cath Labs from
Ambulance/ A&E / AAU/CCU/Wards
STEMI / PPCI PATHWAY24/7 HAC
WardsBarn door STEMI
No significant co-morbidities
Contact Cardiologist on call and Cath Lab team
Contact Cath LabCo-ordinator and
interventionist in Cath Lab
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Pre Hospital STEMI
A&E & AAUSTEMI
Patient transferred to Heart
Attack Centre Cath Lab
STEMI / PPCI PATHWAY24/7 HAC + 9-5 DGH
WardsSTEMI
5pm – 9am /Weekends
Contact Cardiologist on Call
Switchboard contacts on call Cath Lab team
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
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Pre Hospital STEMI
A&E & AAUSTEMI
Patient transferred to Heart
Attack Centre Cath Lab
STEMI / PPCI PATHWAY24/7 HAC + 9-5 DGH
WardsSTEMI
5pm – 9am /Weekends
Contact Cardiologist on Call
Switchboard contacts on call Cath Lab team
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
<25% of STEMI
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Pre Hospital STEMI
A&E & AAUSTEMI
Patient transferred to Heart
Attack Centre Cath Lab
STEMI / PPCI PATHWAY24/7 HAC + 9-5 DGH
WardsSTEMI
5pm – 9am /Weekends
Contact Cardiologist on Call
Switchboard contacts on call Cath Lab team
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
INEVITABLE CONFUSION AND DELAY
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Pre Hospital STEMI
A&E & AAUSTEMI
Patient transferred to Heart
Attack Centre Cath Lab
STEMI / PPCI PATHWAY24/7 HAC + 9-5 DGH
WardsSTEMI
5pm – 9am /Weekends
Contact Cardiologist on Call
Switchboard contacts on call Cath Lab team
Contact CCU Co-ordinator
External: 282618 (ambulance)
Internal: 54801/53624/52458Fax ECG: 282615
100% of STEMI
INEVITABLE CONFUSION AND DELAY
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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
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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
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PPCI
• 24/7
– key issue
INSTITUTIONAL COMPETENCE
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INSTITUTIONAL EXPERIENCE
ALKK database 2003 6268 PPCI 67 hospitals
Annual institutional PPCI volume and outcome
mortality
Zhan et al Heart 2008;94:329-335
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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
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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
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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
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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
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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
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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
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• JCUH database 2005-8 725 PPCIs
• IABP 10%
• VENTILATION 3%
• SHOCK 8%
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PPCI
• 24/7 – key issue
TRANSPORT TIMES
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TRADE-OFFS
• DOWNSIDE OF TRANSFER TO 24/7 HEART ATTACK CENTRE
– INCREASED ISCHAEMIA TIME
mortality increase ~ 1%/hr drive time
m
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EFFECTIVE PATHWAY FOR STEMI PATIENTS
STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR
deLuca et al Circ 2004:109;1223-25
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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 VOLUMEmortality increase ~ 3% LOW v HIGH
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Trade-off: drive time - institutional volume
0
20
40
60
80
100
120
140
160
180
>300 300 250 200 150 <100
High Low
INSITUTIONAL PPCI VOLUME
ISOMORTALITY
BREAK-EVEN LINE
DRIVE TIME3%
ACCEPTABLE
DRIVE TIMES
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Trade-off: drive time - institutional volume
High Low
INSITUTIONAL PPCI VOLUME
ISOMORTALITY
BREAK-EVEN LINE
DRIVE TIME3%
ACCEPTABLE
DRIVE TIMES
0
20
40
60
80
100
120
140
160
180
>300 300 250 200 150 <100
ACCEPTABLE
DRIVE TIMES
PROCESS DELAY
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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)
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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
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PPCI - it’s 24/7 or not at all!