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  • Shropshire & Staffordshire Heart and Stroke Network

    Operational Policy for Primary Angioplasty (PPCI)

    across Shropshire and Staffordshire

    May 2010

  • Contents

    Section Page No 1. Introduction 3 2. Aims and objectives 3 3. Definitions 4 4. Policy Statement UHNS 5 5. Arrangements 5 6. Responsibilities 7 7. Clinical outcomes and monitoring 14 8. Audit and review 15

    References 16 Appendix 1a: Map indicating appropriate PPCI centre Shropshire

    Appendix 1b: Map indicating appropriate PPCI centre Staffordshire

    Appendix 2: PPCI management of STEMI Appendix 3: West Midlands guideline for acute STEMI care Appendix 4: Procedure for patients presenting with STEMI for acute hospitals without PPCI catheter laboratory on site

    Appendix 5: Referral for cardiac rehabilitation Appendix 6: Management of acute myocardial infarction (AMI)

    Appendix 7: Directions to the PPCI centre at University Hospital of North Staffordshire

    Appendix 8: Directions to the PPCI centre at Heart and Lung Centre, New Cross Hospital

    Document Version Date Comments Reason Draft Version 0.1 November 2009 For distribution For comments /

    amendments Draft Version 0.2 December 2009 For distribution For comments /

    amendments Final Version 0.3 March 2010 For distribution

    For implementation

    Final Draft Version 0.4

    April 2010 For distribution For final comments

    Final Version 0.6 May 2010 For distribution Operational Policy


  • 1. Introduction

    The Health Oversight and Scrutiny Committees for Shropshire and Staffordshire have jointly approved the introduction of PPCI for the network. The Shropshire and Staffordshire Heart and Stroke Network will establish a network-wide full 24/7 PPCI service by the following timelines:

    PCT 24/7 PPCI Northern Staffs/Stoke February 2009 South Staffordshire (exc Burton) 1 November 2009 South Staffordshire (Burton) 1 December 2009 Shropshire, Telford & Wrekin 1 February 2010

    The Service Specification for the Management of ST Elevated Myocardial Infarction (STEMI) for the West Midlands specifies that where a Primary Angioplasty (PPCI) centre can be accessed within 90 minutes from time of call then appropriate patients should be transferred to the PPCI centre and Pre Hospital Thrombolysis (PHT) withheld. Where the estimated time of arrival at the PPCI centre is in excess of 90 minutes then PHT should be administered.

    2. Aims and objectives

    This operational policy aims to establish clear guidelines and responsibilities with regard to the delivery of PPCI across Shropshire and Staffordshire. This policy adheres strictly with the guidelines set out in the Whole System Service Specification for the Management of STEMI across the West Midlands document, developed by the West Midlands Cardiac Steering Group. Objectives are: 2.1 To enable the consistent management of patients on first contact with

    medical practitioners across Shropshire and Staffordshire. 2.2 To enable collaborative working with paramedic crews, the Heart

    Attack Centres that serve this network, cardiology wards and local Accident and Emergency departments.

    2.3 Repatriation of patients back home and into their appropriate rehabilitation service.


  • 3. Definitions

    Primary Percutaneous Coronary Intervention (PPCI) is a technique for unblocking arteries carrying blood to the heart muscle. A small balloon at the tip of a catheter tube is inserted via an artery in the groin or arm and guided to the blocked artery. It is then inflated and removed, leaving in place a stent a rigid support which squashes the fatty deposit blocking the artery, allowing blood to flow more easily. Primary angioplasty is the use of this technique as the main or first treatment for patients suffering a heart attack.

    The key to improving outcomes after a heart attack is to re-establish coronary artery flow as quickly as possible and limit damage to the heart muscle.

    Call-to-balloon (device) (CTB) the time from the patient calling for medical help to the time when an angioplasty balloon is first inflated, or coronary reperfusion is confirmed on angiography

    Door-to-balloon (device) (DTB) the time from the patient arriving in hospital (whether this be a primary angioplasty centre or a non-primary angioplasty centre) to the time when an angioplasty balloon is first inflated, or coronary reperfusion is confirmed on angiography.

    THE CLINICAL PRESENTATION OF STEMI, NEW OR PRESUMED NEW LBBB MUST BE WITHIN 12 HOURS OF SYMPTOM ONSET (European Heart Journal 2008, European society of cardiology guidelines) (ESC)

    Taking into account the ESC guidelines PPCI should be performed in

    less than 120 minutes of time of call

    The time from call for professional help to arrival at hospital (call to door) will be less than 90 minutes

    The time from arrival at the PPCI centre door to balloon should be

    achieved in less than 30 minutes

    The patient should be assessed for pre hospital thrombolysis if geographical or operational issues (as per MINAP) would result in the inability to achieve satisfactory call to balloon time, and where indicated this should be given per the protocol following administration the patient should be transferred directly to a PPCI centre as an emergency. If thrombolysis is contraindicated the patient should still be transferred directly to the PPCI centre.

    Time to treatment - Acceptable C.T.B. and D.T.B. times are achievable by direct or indirect admission to the primary angioplasty centre but the ideal is undoubtedly direct admission to the catheter laboratory at the primary angioplasty centre. (NIAP 2008)


  • 4. Policy Statements UHNS/RWH/HEFT

    Primary angioplasty at the University Hospital of North Staffordshire (UHNS), Royal Wolverhampton Hospitals (RWH) and Birmingham Heartlands Hospital (HEFT) will be available for all patients with ST elevation myocardial infarction within the Staffordshire/Shropshire cardiac network area, 24 hours a day, all year round.

    5. Arrangements

    Following 999 call, paramedic team identify acute ST elevation myocardial infarction according to standard criteria. Oxygen, analgesia and 300 mg of aspirin administered at the scene

    The paramedic team notifies the nearest Heart Attack Centre of

    incoming patient, determined by the operational maps (appendix 1a and 1b) - UHNS telephone number is 01782 553465 - RWH telephone number is 01902 694339 - HEFT telephone number is 07812 635834

    The Heart Attack Centre Co-ordinator alerts the interventional team.

    The paramedic team takes the patient directly to the Heart Attack

    Centre / or to the catheter laboratory at UHNS / or directly to the Heart and Lung Centre at New Cross Hospital as directed by the Heart Attack Centre co-ordinator.

    All West Midlands Ambulance Service (WMAS) ambulance crews will

    have directions and instructions to each centre (appendices 7 and 8).

    Consent is taken by registrar/consultant, and clopidogrel administered.

    Following the PCI, the patient is returned to catheter lab recovery area. A monitored admission bed will be arranged.

    On the ward, standard secondary prevention measures will be

    implemented and cardiac rehabilitation process initiated. In uncomplicated cases discharge should be scheduled for 3 days after index admission.

    The vast majority of patients will be accommodated on the ward and

    discharged home from there. Where residual medical or social issues require attention, interim transfer to district hospital may be considered after consultation with the local cardiologist.

    Follow-up arrangements will be made with the local cardiologist in the

    vast majority of cases.


  • For a minority of cases it may be appropriate for patients to return to the HAC for follow up depending on individual clinical circumstances

    5.1 Remote Transfers

    The Staffordshire/Shropshire/South Cheshire network encompasses a wide geographical area. At its most remote limits the transfer time to UHNS/RWH may be appreciable.

    Helicopter transfer should be considered to optimise delivery time of

    the remote patient to UHNS/RWH.

    If it is envisaged that the transfer time to UHNS/RWH cardiology department will exceed 90 minutes, thrombolysis should be administered at the scene by the paramedic crew, and the patient taken to the nearest Heart Attack Centre.

    5.2 Cardiac Rehabilitation

    UHNS, RWHT and HEFT will deliver phase I cardiac rehabilitation for all PPCI patients in order to provide early education, support, advice and start the lifestyle changes required.

    Patients from Northern Staffordshire (NHS North Stoke and NHS Stoke on Trent PCTs) will also receive phase II and III.

    Out of area PPCI patients will receive phase I cardiac rehabilitation at the Tertiary Centres. Phase I will be delivered by either the Rehabilitation Team (Monday-Friday 9am 5 pm) or outside of these hours by trained nursing staff on the cardiac ward.

    Once the patient is discharged from either the angioplasty centre, the responsibility for the patients rehabilitation will transfer back to the local cardiac rehabilitation team.

    A detailed discharge letter will be faxed by the ward clerk directly to the relevant Cardiac Rehabilitation Team (this information is located in the British Heart Foundation Register of Cardiac Rehabilitation Programmes in the UK Guide). A standardised form will be used.(See example appendix 5) Information regarding the reh


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