Developing a Primary PCI Service

- A practical guide

Dan BlackmanLeeds General Infirmary

Advanced Cardiovascular InterventionJanuary 29th 2009

Expert Panel

• Jim Hall James Cook, Middlesborough

• Jim McLenachan Leeds General Infirmary

• Mike Norell Wolverhampton Heart Centre

• Bernard Prendergast Wythenshawe & John Radcliffe

• Martin Rothman London Chest Hospital

NO CONFLICT OF INTEREST TO DECLARE

(1) Involve all the stakeholders from the start

• Co-ordinate the service centrally via the network– PPCI Subgroup

• Essential stakeholders – Commissioners (SCG, PCTs), Cardiac Network, Trust

managers, Ambulance service, Air Ambulance, DGH Cardiologists, DGH & Centre A & E staff, CCU nurses, Cath Lab staff, Cardiac rehab team

(2) Education

• Education crucial across the board– Ambulance management and crews– A & E doctors and nurses– Cardiology SpRs– Heart Attack Centre CCU Staff– Cath Lab Staff

• Presentations, Seminars, Workshops, Publications

• Simple pathways

• Education doesn’t stop after the PPCI service starts

(3) AMBULANCE SERVICE

• The ambulance service is THE key to a successful PPCI service

• Ambulance diagnosis and direct admission to the cath lab is a MUST

Impact of direct admission on call to balloon times

Direct Via A & E

NIAP 86 140/159

Leeds 111 136

West Yorkshire DGHs

120 160

40-60 minute saving in call to balloon time with direct admissions

6 key US D2B Initiative recommendations saved 8.2 – 19.3 minutes*

* Bradley Circ 2006 113:1079-85

Mechanisms for direct ambulance admissions

• Telemetry– ECGs sent to CCU nurse co-ordinator (Middlesborough)– ECGs sent to Interventionist mobile phone (Exeter)– Pros - High diagnostic accuracy / Reduced false positive rate

– Cons - Expensive / ? Slower

• Paramedic diagnosis– Paramedic makes the call & only phones to check the lab is available– Do not filter the paramedic through CCU/Scheduler/SpR– Pros – Empowers the paramedic / Cheap / ? Faster

– Cons – Requires STEMI trained staff on all ambulances / Higher false positive rate

Accept false positives as another benefit of a primary PCI service

Engage the ambulance service

• Thank ambulance crews every time

• Invite the crews to watch the case

• Never criticise mis-diagnosis– false positives are a good thing

(4) Simple lines of communication

• Single point of contact with dedicated phone line– Cath lab scheduler Mon-Fri 8-5– CCU Sister Out-of-hours

• Activation of cath lab team on receiving referral– Don’t wait for the patient to arrive– Don’t get into discussions with SpRs or Consultants– Don’t waste time faxing ECGs from A & Es to CCU

(5) Start 24/7 and roll out

• Start 24/7– Moving beyond office hours is the hardest thing

• Start with the centre, then roll out– Taking the whole region on at the start will be too much– Commit to roll-out from the start – Expand gradually but as quickly as possible

(6) Look after your cath lab staff

• Engage them with education from the outset

• Sell it to staff as the fantastic advance that it is– Make them proud

• Protect their hours– EWTD. 11 hours off after night-time calls

• Say thank you

(7) Plan the rota for interventionists

• Number of consultants required will depend on the number of cases

• Leeds only– Population 750,000; 240 cases per annum– 1 weekday per week; 1 3-day weekend in 5; 5 operators in total

• Leeds/Bradford– Population 1.25 million, 400 cases per annum– 1 weekday every 2 weeks ; 1 3-day weekend in 6; 8 operators in total

• West Yorkshire– Population 3.1 million, 1100 cases per annum– 1 weekday every 2 weeks, may fall to 1 in 3 ; 1 Friday/Sunday in 6 – 14 operators in total, may increase to 18

• Next morning or day free of clinical activities

• Everyone should be on the rota, including all visitors

PPCI and Time of Day

0

50

100

150

200

250

300

350

08:00- 17:00 17.00-MN MN-08:00

56%

23% 21%

250 cases per year – up 1 night in 4

400 cases per year – up 1 night in 3

1100 cases per year – up nearly every night

March 2005-07N = 611

(8) Audit, audit, audit

• Dedicated audit/data staff

• Continued audit of treatment times in perpetuity. Feedback. Set targets

• Not just door-to-balloon and call-to-balloon– Call for medical attention– Ambulance arrival at scene– Ambulance departure from scene– (Ambulance arrival at DGH)– (Time of referral from DGH)– (Time of departure from DGH)– Time of arrival at heart attack centre– Balloon time

• Outcomes

(9) Never stop developing

• Audit

• Education

• Feedback

• Continued stakeholder meetings