ppci – national update ncbc workshop jim mclenachan, national clinical lead for ppci, nhs...
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PPCI – National UpdateNCBC Workshop
Jim McLenachan, National Clinical Lead for PPCI,
NHS Improvement, England.
London, 24th November, 2010
1NCBC Annual Workshop November 2010 - CONFIDENTIAL
National Cardiothoracic Benchmarking Collaborative (NCBC)
Annual Workshop 2010
Breakout Group
PPCI – National UpdateDr Jim McLenachan
National Clinical Lead for PPCI, NHS Improvement, England.
2NCBC Annual Workshop November 2010 - CONFIDENTIAL
Falling STEMI mortality (Source MINAP report 2010)
%
4NCBC Annual Workshop November 2010 - CONFIDENTIAL
NATIONAL MINAP DATA
0
10
20
30
40
50
60
70
80
90
100
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI
LYSIS
5NCBC Annual Workshop November 2010 - CONFIDENTIAL
NORTH CENTRAL LONDON MINAP DATA
0
10
20
30
40
50
60
70
80
90
100
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI
LYSIS
6NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010ESSEX MINAP DATA
0
10
20
30
40
50
60
70
80
90
100
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI
LYSIS
7NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010MANCHESTER AND CHESHIRE MINAP DATA
0
10
20
30
40
50
60
70
80
90
100
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI
LYSIS
8NCBC Annual Workshop November 2010 - CONFIDENTIAL
554
417
133
190
86
401
555
371
40
661
331
218
424 434
953
338
108
243
449
78
274
429
566
214
319
211158
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PP
CI
Cas
es
Sum of Answer
Year
NCBC 2010 - Primary PCINumber of PPCI Cases Undertaken , 2008/9 & 2009/10
2008/9 2009/10Data Points 21 27Median 185 331 Range - High 753 953 Range - Low 20 40
Median2009/10
9NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC Trusts - PPCI Cases per million population, 2009/10(Rate adjusted for weeks of operation by service operated)
596576
528
447 446 434413
377357 353
308 299282 278 265
238222
203 196 182 174156
126
79
11889
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24/7, 365 days a year Part time
PP
CIs
per
Mill
ion
Cat
chm
ent P
opul
atio
n
PPCI pmp adjData Points 26Median 280 Range - High 596 Range - Low 79
Median
10NCBC Annual Workshop November 2010 - CONFIDENTIAL
Primary PCI for Essex
Dr Paul Kelly
Lead Cardiologist, Essex CTC
12NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC - 2010Predicted Numbers - Essex
• Total STEMI for Essex = 823 (thrombolysis)
• From pre hospital setting = 655• From A+E depts = 132• From DGH wards = 36
(source MINAP & Discharge diagnosis 07/08)
13NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010Logistics
• Essex CTC located at Basildon (60 miles max)
• 8 Interventional Cardiologists• Increased cath lab staff numbers• East of England Ambulance Service• Provision of on call rooms• Change of post on call duties
14NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010Essex Protocols & Pathways
• Operational Policy for CTC • Operational Policy for A+E Depts• Operational Policy for DGH Wards• Policy and agreement for DGH admission post
PPCI • Patient pathways from pre hospital to cardiac
rehab
15NCBC Annual Workshop November 2010 - CONFIDENTIAL
Essex - Operational Policy for CTC
• Paramedic decision to activate pathway
• Inclusion criteria – ECG driven
• Exclusion criteria – relatively few
16NCBC Annual Workshop November 2010 - CONFIDENTIAL
Time Line for PPCI
• Total call to balloon = 165 mins
Call to paramedics leaving scene = 45 mins(call to scene, assess and mobilise patient)
Transfer to CTC = max 90 mins
Door to balloon = 30 mins
17NCBC Annual Workshop November 2010 - CONFIDENTIAL
Following Procedure
• Transfer to HDU ward in CTC• 24 - 48 day stay post PCI and transfer to
DGH • ? Some patients discharged home from CTC • Cardiac Rehabilitation Assessment
18NCBC Annual Workshop November 2010 - CONFIDENTIAL
Potential Problems
• Delays in pathway – concerns for CTB > 165m
• Excess demand (compared to predictions)
• Bed Capacity on Roding Ward/ ITU
DGH capacity to accept patients post PPCI
19NCBC Annual Workshop November 2010 - CONFIDENTIAL
Timetable for Implementation
• Big bang, pan Essex start date• 1st September 2009• Communication for all involved in
process• Information for patients
20NCBC Annual Workshop November 2010 - CONFIDENTIAL
Potential for Growth in Primary PCI Activity in NCBC Trusts
• Thrombolysis • Too late for reperfusion• Clinically ineligible for reperfusion
21NCBC Annual Workshop November 2010 - CONFIDENTIAL
80%76% 76%
68%60%
48%41% 41% 40% 38% 37% 34% 34% 32% 31% 30% 29%
24% 21% 19%
20%23% 23% 22%
32% 29% 26% 29% 32%
21%28% 27%
34% 32% 29% 32%25%
44%
29%25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nor
th E
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C To
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SW P
enin
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Nor
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n Ir
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Shro
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Sta
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Avo
n, G
los,
Wilt
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om
Suss
ex H
eart
Nor
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rent
Esse
x
Ches
hire
& M
erse
y
East
Mid
land
s
Lanc
s & S
Cum
bria
% o
f STE
MI
Case
s
no reperfusion
prehospital lysis
Inhospital lysis
pPCI
NCBC 2010 STEMI – Reperfusion % by Method - NCBC Trust Networks - 2009
Potential for growth (2)
Essex increased pPCI coverage since 2009
22NCBC Annual Workshop November 2010 - CONFIDENTIAL
Why does Newcastle have short door to balloon times?
Richard Edwards
Primary PCI lead
Freeman Hospital Newcastle
24NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010 - Primary PCIMedian Door to Balloon Time (Minutes), by average number of PPCIs
per week, 2009/10
68
31 31
24 24
65
58
50 49 49 48
40
33 33
7570 69
63 6257 55
52
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Med
ian
Tim
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inu
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Average number of PPCI per week
2009/10Data Points 28Median 50 Range - High 1,289 Range - Low 23
Median
NCBC Annual Workshop November 2010 - CONFIDENTIAL
Is it because…
• As a larger volume centre we have developed more routine processes & therefore have quicker DTB time?
• Do we just cover a larger geography & have more warning to activate the team?
Both….26
NCBC Annual Workshop November 2010 - CONFIDENTIAL
7570 69 68 65 63 62 58 57 55 55 52 50 49 49 48
40 3934 33 33 33 31 31
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2009/10
Primary PCIMedian Door to Balloon Time (Minutes), 2008/9 & 2009/10
Median2009/10
2008/9 2009/10Data Points 20 28Median 54 50 Range - High 1,102 1,289 Range - Low 30 23
27NCBC Annual Workshop November 2010 - CONFIDENTIAL
-24%
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36%
-50%
-39%
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-37%-39%
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NCBC 2010 - Primary PCI% Change in Median Door to Balloon Time (Minutes), 2008/9 & 2009/10
(Trusts with data for both years)
Lon
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Med
ian
Doo
r to
Bal
loon
Tim
es
Sho
rtes
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edia
n D
oor
to B
allo
on T
imes
Improvements in % reduction in Median DTB Times irrespective of whether Trusts had longer or Shorter DTB time
in 2008/9
N Staffs increasedIts catchment area
28NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010 - Primary PCIMedian Call to Balloon Time (Minutes), 2008/9 & 2009/10
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Median2009/10
2008/9 2009/10Data Points 18 27Median 112 113 Range - High 180 147 Range - Low 52 54
NCBC Annual Workshop November 2010 - CONFIDENTIAL
Half an hour to Freeman
March 31st 2008 Roll out NewcastleMay 1st 2008 Roll out South of TyneJuly 1st 2008 Roll out North of Tyne
30NCBC Annual Workshop November 2010 - CONFIDENTIAL
Is it because…
• As a larger volume centre we have developed more routine processes & therefore have quicker DTB time?
• Do we just cover a larger geography & have more warning to activate the team?
Both….31
NCBC Annual Workshop November 2010 - CONFIDENTIAL
554
417
133
190
86
401
555
371
40
661
331
218
424 434
953
338
108
243
449
78
274
429
566
214
319
211158
0
100
200
300
400
500
600
700
800
900
1,000
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PP
CI
Cas
es
Sum of Answer
Year
NCBC 2010 - Primary PCINumber of PPCI Cases Undertaken , 2008/9 & 2009/10
2008/9 2009/10Data Points 21 27Median 185 331 Range - High 753 953 Range - Low 20 40
Median2009/10
32NCBC Annual Workshop November 2010 - CONFIDENTIAL
routine processes…
• Ergonomics– CCU has its own ambulance admission point– Cath lab and CCU on ground floor (50yds apart)– Pt taken straight to cath lab (Not to CCU, NOT to
A&E)– Interventionists live < 3miles from Freeman
• Communication – Paramedics and CCU gatekeepers and
telecommunicate– Cardiologist not part of routing decision making
• minimise bureaucracy
33NCBC Annual Workshop November 2010 - CONFIDENTIAL
routine processes…
• Process– history and examination take place whilst
patient transferred to cath lab – out of hours patient waits in CCU for team to
arrive– verbal consent taken– culprit vessel treated first
• Economy of scale– Redeployed staff in an emergency– Always make an empty lab
34NCBC Annual Workshop November 2010 - CONFIDENTIAL
routine processes…
• Motivated team– Published D to B times motivate staff to
improve– Low staff turnover– Some staff voluntarily stay overnight– Staff much more willing to work generically
in an emergency
35NCBC Annual Workshop November 2010 - CONFIDENTIAL
Is it because…• As a larger volume centre we have
developed more routine processes & therefore have quicker DTB time?
• Do we just cover a larger geography & have more warning to activate the team?
Both….
Saves 26 minutes
Saves 7 minutes
36NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010 - Primary PCIMedian Call to Door & Door to Balloon Time (Minutes), by average
number of PPCIs per week, 2009/10
68
3123 24
3124
4050
3349 48 49
5865
55
33 33
52
69 7563 62 57
34
7055
39
79
7782 76 65
65
8372
8871 71 67 53 45
54
65
47
91 59 4254 55
58
79
40
51
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Median Call to Door
Median Door to Balloon
2009/10Data Points 27Median 113 Range - High 147 Range - Low 54
MedianCTB
38NCBC Annual Workshop November 2010 - CONFIDENTIAL
NCBC 2010 - Primary PCIMedian Door to Balloon Time (Minutes), by average number of PPCIs per
week, 2009/10
68
31 31
24 24
65
58
50 49 49 48
40
33 33
7570 69
63 6257 55
52
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ian
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tes)
Average number of PPCI per week
2009/10Data Points 28Median 50 Range - High 1,289 Range - Low 23
Median
39NCBC Annual Workshop November 2010 - CONFIDENTIAL