Transformation of NSTEMI Care at the Golden Jubilee ... · Transformation of NSTEMI Care at the Golden Jubilee National Hospital Dr M Mitchell Lindsay. MD. ... Any Pathway (n=697)

Transformation of NSTEMI Care at the Golden

Jubilee National Hospital

Dr M Mitchell Lindsay. MD. FRCP

Acting Associate Medical Director

Consultant Cardiologist

Golden Jubilee National Hospital

Glasgow

Background

i) Coronary angiography and consequent revascularisation in NSTEMI reduces major adverse cardiovascular events (MACE).

ii) The reduction in MACE is most dramatic amongst high risk patients defined by high Grace Score (Grace Score is a clinical risk score which predicts in-patient and 6 month mortality).

iii) Patients presenting with a high risk NSTEMI should undergo angiography and revascularisation within 24hrs of admission to maximise this clinical benefit.

iv) Those presenting with intermediate risk should be treated within 72 hours of admission to maximise clinical benefit.

v) The admission to a hospital with no cardiac cath lab facilities versus a PCI capable hospital results in an average 20hr delay to coronary angiography and subsequent intervention (BCIS audit 2014).

Selection of non-ST-elevation acute coronary syndrome (NSTE-ACS)

treatment strategy and timing according to initial risk stratification.

Marco Roffi et al. Eur Heart J 2016;37:267-

315

© The European Society of Cardiology 2016. All rights reserved. For

permissions please email: [email protected]

TIMACS (Death/MI/Stroke)

N Engl J Med 2009;360:2165-75

Lancet 2017; 390: 737–46

All Cause Mortality

Jobs, Mehta, Montalescot Lancet 2017; 390: 737–46

All Cause Mortality

Jobs, Mehta, Montalescot Lancet 2017; 390: 737–46

BCSI audit 2014

BCSI audit 2014

Dept of Health NHS England10

Best practice tariffs for PCI & Catheterisation in 2017/18

HRG code HRG name

Non-best

practice

tariff (£)

Best

practice

tariff (£)

Difference

(£)% Difference

EY40A Complex Percutaneous Transluminal Coronary Angioplasty with CC Score 12+ 6,719 7,437 718 11%EY40B Complex Percutaneous Transluminal Coronary Angioplasty with CC Score 8-11 4,790 5,303 513 11%EY40C Complex Percutaneous Transluminal Coronary Angioplasty with CC Score 4-7 3,286 3,637 351 11%EY40D Complex Percutaneous Transluminal Coronary Angioplasty with CC Score 0-3 2,580 2,856 276 11%EY41A Standard Percutaneous Transluminal Coronary Angioplasty with CC Score 12+ 6,639 7,349 710 11%EY41B Standard Percutaneous Transluminal Coronary Angioplasty with CC Score 8-11 3,999 4,426 427 11%EY41C Standard Percutaneous Transluminal Coronary Angioplasty with CC Score 4-7 2,857 3,162 305 11%EY41D Standard Percutaneous Transluminal Coronary Angioplasty with CC Score 0-3 2,247 2,487 240 11%EY42A Complex Cardiac Catheterisation with CC Score 7+ 4,490 4,970 480 11%EY42B Complex Cardiac Catheterisation with CC Score 4-6 2,788 3,086 298 11%EY42C Complex Cardiac Catheterisation with CC Score 2-3 2,144 2,373 229 11%EY42D Complex Cardiac Catheterisation with CC Score 0-1 1,732 1,917 185 11%EY43A Standard Cardiac Catheterisation with CC Score 13+ 7,464 8,262 798 11%EY43B Standard Cardiac Catheterisation with CC Score 10-12 5,092 5,637 545 11%EY43C Standard Cardiac Catheterisation with CC Score 7-9 3,838 4,249 411 11%EY43D Standard Cardiac Catheterisation with CC Score 4-6 2,788 3,086 298 11%EY43E Standard Cardiac Catheterisation with CC Score 2-3 2,131 2,359 228 11%EY43F Standard Cardiac Catheterisation with CC Score 0-1 1,648 1,824 176 11%

Timely and evidence based care of

NSTEMI patients cannot be

provided via traditional hub and

spoke model.

Analysis performed by AstraZeneca as part of the Joint Working project between NHS Greater Glasgow and Clyde (GGC), Golden Jubilee National Hospital

(GJNH), GGC Managed Clinical Network and AstraZeneca UK Ltd.

NSTEMI mean time to referral and angiography for spells

transferred directly to the intervention centre

Hospitals with a small number of NSTEMI referrals are not included in this analysis

Cardiovascular Registry Project

99.1% 100.0% 100.0% 100.0% 100.0%

87.0%

49.8%

60.0%

83.3%

54.5%

36.0%

56.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Any Pathway

(n=697)

1Direct to GJNH

(n=30)

2Local A&E to GJNH

(n=6)

3Direct Transfer

(n=415)

4Discharged Home

with Referral

(n=200)

6Elective GJNH Only

(n=46)

Pe

rce

nt o

f S

pe

lls i

n t

he

Pa

th

wa

y

Care Pathway

NSTEMI Patients: Percentage of Spells Receiving Angiography and Percentage Receiving PCI By Pathway

Angiography

PCI

N=697

11.2(median=6)

0.6(median=0)

0.3(median=0)

5.0(median=4)

26.0(median=23)

-5.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Any Pathway

(n=651)

1Direct to GJNH

(n=30)

2Local A&E to GJNH

(n=6)

3Direct Transfer

(n=415)

4Discharged Home

with Referral

(n=200)

Me

an

Da

ys in

to

An

gio

gra

ph

y

Care Pathway

NSTEMI Patients: Mean Days from Acute Admission to Angiography

(Pathways 1-4)N=651

Analysis performed by AstraZeneca as part of the Joint Working project between NHS Greater Glasgow and Clyde (GGC), Golden Jubilee National

Hospital (GJNH), GGC Managed Clinical Network and AstraZeneca UK Ltd.

http://www.nhsresearchscotland.org. uk/uploads/tinymce/Acute%20Myoca rdial.pdf

NSTEMI Service Re-design

Two stages.

Optimisation of hub and spoke model

Introduction of Direct Admission model for high risk

NSTEMI ( Direct NSTEMI)

Service Re-design( Hub and spoke)

Medical Workforce Model

Consultant of the week

Capacity

Extra beds

Cath Lab Scheduling

Dedicated “hot” cath lab sessions and extended day

working.

Electronic referral.

GJNH experience.

Service pre-August 2016

Traditional hub and spoke. Catchment of 2.2 million.

7 referring hospitals generating circa 3000 NSTEMI angio referrals p.a

Patients presenting to the Emergency Department or the Scottish Ambulance Service with the clinical syndrome of NSTEMI are admitted to their local hospital.

Medical Rx and risk stratification -3 potential treatment paths:

Refer for in patient (IP) coronary Angiography

Refer for urgent OP angiography (patient is discharged and request made for urgent appointment at GJNH)

Medical management, where the patient is discharged when clinically stable.

Dept of National and Regional Medicine GJNH

Direct NSTEMI

Direct referral of high risk NSTEMI;

1. Scottish Ambulance Service.

2. A+E departments.

All patients will have coronary angiography within

24 hours.

Phased introduction.

Early direct discharge or repatriation if required.

Definition- High Risk NSTEMI

Cardiac chest Pain

ECG changes- ST depression or deep symmetrical T

wave inversion.

HEART score greater than 5

1. Backus BE, Six AJ, Kelder JC et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int

J Cardiol 2013;168(3):2153-8

Preparation and planning

Preparation and planning.




Assessment by the SAS

HEART Score: Risk scoring system developed for use

in unselected emergency presentations with chest

pain.

History

ECG

Age

Risk Factors

Troponin


Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast EG, Monnink SH, van Tooren RM,

Doevendans PA. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw

Cardiol. 2010 Sep: 9(3): 164-169

Outcome

Score > 5 – telemeter 12 lead ECG

contact CCU GJNH

agree care pathway – consider Aspirin, GTN,

Morphine, Metoclopramide.


A+E Referrals/M.A.U

Clinical Assessment

ECG.

Admission HsTn

CXR

Routine bloods.

HEART score.

Re-design of Chest Pain Protocol.


Adapted from GGC Acute Cardiac Pain Pathway

High risk chest pain

Ischaemic ECG changes

(for example 2mm ST depression in 2 adjacent

leads of deep symmetrical T wave inversion)

or ongoing typical cardiac pain

and HEART score >5

REFER GJNH FOR CONSIDERATION OF

DIRECT TRANSFER OF HIGH RISK NSTEMI.

07976 986058

STEMI

(for example ≥2mm ST elevation in 2 consecutive

chest leads

or >1mm in 2 adjacent limb leads

or new LBBB

or >2mm ST depression V1-V3 suggestive of

posterior infarct)

Treat as presumed ACS

Refer to cardiology

Give aspirin 300mg stat

Arrange CXR

Clerk in and write kardex

DO NOT GIVE Ticagrelor or Fondaparinux

unless discussed with cardiology

Treat as STEMI

Call 999 for emergency PCI transfer

Refer GJNH 0141 951 5299

Fax ECG to 0141 951 5867

Aspirin 300mg stat

Ticagrelor 180mg stat

IV Heparin 5000u (if not anticoagulated)

HEART SCORE < 5

History suggests possible cardiac pain

and non-diagnostic ECG

Consider aspirin 300mg stat

Arrange CXR

No other unrelated complaints

and no other acute comorbidities

and pain not pleuritic

and not mainly epigastric or posterior

ECG and troponin within 15 minutes

Patient presents with chest pain to ED/AAU

Nursing assessment in triage

Multiple other complaints

or multiple comorbidities

or pleuritic pain

or pain mainly epigastric or posterior

Chest pain assessment form completed by

medical staff (HEART score)Usual medical management pathways

Troponin 6 hours post-admission (PEAK)

Review baseline troponinConsider aspirin 300mg stat

Arrange CXR

London Experience

BMJ Open 2014;4:e005525doi:10.1136

Reproduced with consent of Dr N Swanson

Fast track NSTEACS toolInclusion. Patients must have:

Symptoms strongly suggesting an acute coronary syndrome – typically chest pain at rest.

High sensitivity troponin result above the 99th percentile upper reference limit

And/or ECG abnormalities suggesting NSTEACS*

And/or conscious post cardiac arrest.

*ECG changes suggestive of an NSTEACS:

ST depression in any leads

T wave inversion in leads V1-V4

Dynamic T wave changes in more than one lead.

Exclusion. Patients should not be considered for Fast Track Pathway with ANY of the following:

ST elevation MI – treat according to existing PPCI pathways

Overt sepsis

Major trauma/surgery within one month.

Acute renal failure eGFR<60.

Hb<100 or recent active bleeding.

O2 saturation <90% on air.

Severe comorbidity – e.g. metastatic cancer, moderate/severe dementia or delirium, exercise

tolerance<100yds normally, frailty of old age, post-arrest ventilated patients. This list is not

exhaustive.

following.

NECVN- Fast track tool

Reproduced with consent of Dr N Swanson

Economic Benefits to the Region


Direct NSTEMI-13 Month Results

Our Commitments

We could identify high risk NSTEMI patients at their

presentation ( A+E or S.A.S)

We could admit this patient directly 24/7

We would undertake Angiography within 24 hrs of

admission

This high risk group would benefit from high rates of

revascularisation.

We would aim for direct discharge/ early

repatriation.


Detractors- numerous

“You can’t expect paramedics or A+E staff to

identify high risk group”

“Your wards will be full of acute abdomens and

broken hips...”

“ They will too sick to cath and have too much co-

rmobidity”

“You won’t be able to get any of them home”

Direct NSTEMI referrals

Dept of National and Regional

Medicine GJNH

DIRECT NSTEMI Patients

715 Patients Referred.

249 Patients accepted for direct admission (35% of

referrals)

Median Age 63 ( range 24-95)

Median HEART Score 7 ( Range 5-10)

Performance indicators.

Angiography 99%

Within 24hr Guarantee 98%

Median Time from Admission to angiography 3

hours 49 mins.

Management

75% revascularisation Rate ( 70% PCI. 5% CABG)

25% Intensive Medical management.

Discharge

26% Discharged directly from GJNH

Median stay 1 day.

Median stay of whole cohort 1 day ( Mean 1.86

days)

Patients Not Accepted

Aug-Nov analysed

93 Patients

Median Age 69 ( range 28-86)

Median Heart Score 6 (range 3-9)

51% subsequently underwent angiography

52 % PCI

35% Medical Rx

12% CABG


Our Commitments

We could identify high risk NSTEMI patients at their

presentation ( A+E or S.A.S)

We could admit this patient directly 24/7

We would undertake Angiography within 24 hrs of

admission

This high risk group would benefit from high rates of

revascularisation.

We would aim for direct discharge/ early

repatriation.


Data collection


Meeting the Challenges of

Current Practice

Benefits of direct NSTEMI service

Clinical

Economic

Widely applicable

Sustainable

#bacpr2017

Documents

Transformation of NSTEMI Care at the Golden Jubilee ... · Transformation of NSTEMI Care at the Golden Jubilee National Hospital Dr M Mitchell Lindsay. MD. ... Any Pathway (n=697)