Myocardial Ischaemia National Audit Project - University College ...

Part 5: Conclusions/Recommendations1. Importance of nSTEMI data collectionSome years ago the Myocardial Infarction National AuditProject became the Myocardial Ischaemia NationalAudit Project. This subtle change of title was intendedto emphasise that participation in MINAP provided anopportunity to analyse the care of all patients admitted tohospital with ACS, and not just those with ST-elevation.Patients presenting with, rather than without, STelevationare more easy to identify and their immediatemanagement lends itself to audit – through reportingreperfusion rates and delays to reperfusion (e.g. Door-toballoon).However most patients with ACS have nSTEMI.Compared with STEMI, patients with nSTEMI tend to be olderand have more associated medical (and presumably social)problems. While most patients with STEMI are taken directlyto Heart Attack Centres for primary PCI, those with nSTEMI –who do not require immediate PCI – tend to be taken directlyto the nearest non-interventional hospital, and in some caseslater transferred to Heart Attack Centres. Their length of stayin hospital is longer and their risk of dying is greater – albeitthose at greatest risk can be identified using validated riskscoring systems.The identification of nSTEMI (and therefore the collectionof data about these patients) is not always easy – see thecase study by Fiona Robinson to understand the amount ofeffort and time that may need to be invested. Nevertheless,as that case study shows, it is not an impossible task, andshould, we believe, be the aspiration of all admitting hospitalsthat are interested in assuring and improving the quality ofcare provided to this group. Although there has been animprovement in nSTEMI data collection, there are still anumber of hospitals that are submitting limited, and in somecases no, data.MINAP is committed to provide its participating hospitals allpossible support, in term of understanding the database, thedataset and its definitions and the available analyses that willinform the hospital about their performance. We will facilitatepeer support, where possible, and networking to foster thesharing of good practice for hospitals to learn from eachother’s successes.2. Rapidity of transfer for angiography followingnSTEMIThe need for comparative audit is particularly pressing forpatients with nSTEMI given the significant variation in theinterval from admission to performance of coronary angiographypresented in this report. The optimum timing of angiography(and subsequent revascualrisation) remains unclear. Groupsdeveloping guidelines have interpreted differently the resultsof trials comparing medical treatment (drugs) and PCI withmedical treatment alone, suggesting maximum acceptabledelays of anything from 24 to 96 hours. Large numbers ofpatients are not yet receiving this standard of care. Even ifthere is no direct relationship between earlier angiographyand outcome (judged by mortality and further heart attack),those who do receive earlier angiography are more likely to bedischarged home and avoid prolonged hospitalisation.3. Continued investment in time, personnel andmoney in participation in national clinical auditSome perceive national clinical audit as a burden upon alreadybusy NHS staff, the collection and submission of data beingdivorced from caring for patients. During times of financialconstraint there is a temptation to reduce investment insuch exercises, even though participation in clinical auditis mandated by the Department of Health. Conversely, wewould argue that such conditions – a working environmentcharacterised by cost containment and efficiency – increase,rather than decrease the need for reliable contemporaryknowledge of hospital performance. As demonstrated in thecase studies, such information, when used wisely, can beused to inform local improvements. Further, it can be used toreassure users, providers and commissioners that the qualityof care provided to individual patients is not being sacrificed asservices are reconfigured.The quality of contemporary data is extremely important ifa true picture is to emerge. MINAP data are quite complexand its collection, often needing extraction from medicalnotes, requires experience – it becomes more manageableover time. We strongly recommend that each hospital/Trusthas a designated individual responsible for clinical auditdata and that they are supported by a local cardiologist asclinical input has shown to result in higher quality data. Highturnover and reduction in the number of staff in clinical auditdepartments is in no one’s interest.100 MINAP How the NHS cares for patients with heart attack