BCIS Annual MeetingLondon January 2006

Dr Bernard Prendergast DM FRCPWythenshawe Hospital Manchester UK

Primary Angioplasty for Acute MIWho are the Stakeholders?

NO CONFLICT OF INTEREST TO DECLARE

Manchester Cardiac Services 2001

PCI projections Greater Manchester 2005-6

Population 3.8 millionPCI @ 1050/million:

4000/annumWythenshawe 1500MRI 1750DGH (250x3) 750

● FebruaryFebruary: MRI commences 8am – 4pm primary PCI service for A&E patients.

● June:June: Greater Manchester Cardiac Board allows PCI Group to consider provision of a city wide service. 

● SeptemberSeptember: Multidisciplinary process mapping meeting.

● OctoberOctober: Two day Network meeting attended by DOH representatives to establish a network PCI programme.

● NovemberNovember: “Primary PCI: The Challenge” – national UK conference (193 delegates).

● DecemberDecember: Invitation to submit a NIAP proposal.  2 year phased proposal signed by chief Executives of the two PCI centres, the Ambulance Trust and the Cardiac Network.

 

● February:February: Successful NIAP bid with six other UK centres. 

● March / April:March / April: Meetings to discuss implementation of primary PCI proposals.

● April:April:  Wythenshawe commences 8am – 4pm primary PCI service for A&E patients.

● June:June: A&E Consultants meeting.● July:July: NMGH & Hope meeting.● August:August: Stepping Hill Hospital meeting.● September:September: Greater Manchester

Ambulance Service commissioning meeting. ● October:October: Appointment of PCI Project

Manager and Clinical Audit/Information Officer.

● November: 3 initial pilot sites confirmed

2004

2005

Primary PCI StakeholdersThe Patient

● Local vs. specialist care

● Inequity of access to PPCI

● When for my DGH?

● Informed consent

● Relatives

● Confusion/bewilderment

Primary PCI StakeholdersThe Ambulance Service

Thrombolysis in Greater Manchester 2005● CTS < 8 min 75%● CTD < 30 min 55% < 40 min 89%● CCG 86%● DTN < 20 min 64% < 30 min 88%● CTN < 60 min 82%

Outstanding IssuesSkills in ECG interpretationImpact on other emergency servicesGeographical imbalance of ambulance poolAlternative strategies for urban and rural populations

Primary PCI StakeholdersThe Referring DGH A&E Department

● “Why should we replace optimal thrombolysis with an experimental PPCI service”

● “What about our stars – we’re about to bid for foundation status, you know!”

● “We’re not going back to the dark ages of assessment in the back of ambulances”

● “Who’s responsible if the patient dies in transit?”● “We will need informed consent for transfer”● “This clinical trial – what about ethical approval?”

Primary PCI StakeholdersThe Catheter Lab Team

Nurses, Radiographers, Technicians, Audit Team, Activity Managers

Primary PCI StakeholdersThe DGH Cardiac Team

• The backlog of ACS transfers is a greater day-to-day headache

• Guaranteed repatriation at 24 hrs (and perhaps sooner) and need for altered nursing skill mix

• Abbreviated IP stay diminishes time for Phase 1 rehabilitation and education

• GPs may be unprepared or unwilling to cope• Limited exposure to AMI for doctors in training

Primary PCI StakeholdersThe Bed Manager

Time spent in A&E

Locker, T. E et al. BMJ 2005;330:1188-9.

Primary PCI StakeholdersTertiary Centre NHS Trusts

The clinical/political conflict

● 3/12 waiting list target met as a priority

● Current mean wait 7-10 days (range 2-21 days)

● Constant pool of 40-50 patients awaiting transfer to tertiary care

Elective Non-elective (ACS)

Primary PCI StakeholdersHealthcare commissioners/Cardiac Network● Current activity projections are conservative and

account only for elective and ACS work● In 2005-2006, a 40% reduced rate non-elective short

stay tariff will apply for in-patient stays <48hrs*● Only in the NHS could attempts at increased efficiency

be rewarded by diminished reimbursement!!● Who pays for:

– Ambulance activity– Clopidogrel– Abciximab– etc, etc *Currently being addressed by DOH/BCS

Primary PCI StakeholdersThe Government/Department of Health

To address:● Logistic difficulties of

providing a PPCI service● Challenges in different

geographical settings● Robust data collection and

audit● Costs of service provision● Patient’s experience of such a

service

● Detailed outcome analysis● Patient and carer experience● Workforce implications● Outcome using different models

of service delivery● Implementation and feasibility

issues● Economic evaluation

THE NATIONAL INFARCT ANGIOPLASTY PROJECTBritish Cardiac Society and Department of Health - a joint project.

AIMS OUTCOMES

“Ultimately, a hybrid model of PPCI and pre-hospital thrombolysisseems likely.” Sue Dodd, DOH, Manchester November 2005.

Primary angioplasty is arriving!

Primary PCI in the UKEvolution not REvolution