Myocardial Ischaemia National Audit Project - University College ...

3. Improving quality,improving outcome3.1 Use of primary PCIPerhaps the most important, andcertainly the most high profile,change in the management ofheart attack during the twelveyears of MINAP has been theimplementation of a policy to provideprimary PCI, rather than thrombolytictherapy, in cases of STEMI (see Figure10). The advantage of timely primaryPCI over thrombolysis has beendescribed above – though there is stillan important role for thrombolysis inthose rural areas where travel times tohospitals that provide primary PCI arelong enough to negate the advantage ofthe procedure.This rapid change largely has been driven bylocal clinicians and promoted by members ofthe British Cardiovascular Interventional Societyand Cardiac Networks in response to a governmentchallenge to ‘roll-out’ a primary PCI national service.Consecutive annual MINAP reports have recorded thechanges and a final NHS report on the ‘roll-out’ project waspublished in 2012 11 . The policy has had major knock-on effectson the organisation of hospital-based cardiac services, requiringthe continuous availability of expert teams of clinicians and‘High Tech’ equipment. This has led to centralisation of services.Substantial numbers of district general hospitals no longeradmit patients with STEMI. Rather, it is recommended that suchpatients are taken directly to a smaller number of Heart AttackCentres, serving large populations – for example the two HeartAttack Centres in Manchester serve 3 million people – and anetwork of smaller feeder hospitals. In some networks patientsare ‘repatriated’ from the Heart Attack Centre to their localhospital following primary PCI, but often patients are dischargeddirectly home after a stay in hospital of as little as 3 days.National and international guidance 12 13 recommend that in theemergency treatment of patients with STEMI, primary PCI shouldbe performed as soon as possible: within 90 minutes of arrivalat hospital (door-to-balloon time) and within 150 minutes of apatient’s call for help (call-to-balloon time). Results are presentedagainst these best practice standards, and against a morestringent ‘aspirational’ call-to-balloon target of 120 minutes, inTable 1 in the Results section.The call-to-balloon time reflects the interval from a call forprofessional help to the time that the primary PCI procedure isperformed. To reliably achieve this within 120 minutes, or even150 minutes, requires significant coordination between ambulanceand hospital services. Ideally, ambulance crews make anaccurate diagnosis, through expert assessment of the patient andinterpretation of their ECG, before taking the patient directly to thenearest Heart Attack Centre. At the hospital the provision of timelyprimary PCI is complex and involves close collaboration betweenambulance, portering, nursing, medical, and radiographic teams.This is particularly important during ‘out of hours’ working. Thepercentage of patients with an admission diagnosis of STEMIwho receive primary PCI within 90 minutes of arrival at theHeart Attack Centre has increased from 52% in 2003/4 to 92% in2011/12 and is a reflection of this close collaboration [Figure 11].In particular direct transfer of the patient from ambulance to thecatheter lab without involvement of other hospitals, departmentsor wards has reduced delays. However, it remains the case thatassessment at a local non-interventional hospital is associatedwith added delay and prolonged call-to-balloon times. In someareas a new metric has been introduced to record this addeddelay and promote the shortest possible safe assessment andstabilisation period in the initial receiving local hospital – theDoor-In-Door-Out interval (DIDO) (see part three, case study 8).3.2 From coronary care to cardiac careChanging demographics of the UK population, coupled withreorganisation of acute services to deliver primary PCI acrossCardiac Networks, has caused a significant change in theacute cardiology workload for all acute hospitals; more elderlypeople are being admitted with more complex cardiac problems.This prompted the British Cardiovascular Society (BCS) – theprofessional body associated with MINAP – to set up a WorkingGroup on Acute Cardiac Care in 2010. The Group examined thechanging nature of acute cardiac care in the UK and how, whereand by whom it should best be delivered. The final report waspublished on the BCS website last autumn 14 and reviewed in aneditorial in Heart 15 .Briefly, the report calls for enhanced access to specialisedcardiac care, in dedicated acute cardiac care units, for allpatients presenting with any acute cardiovascular condition.11. NHS Improvement. Growth of primary PCI for the treatment of heart attackpatients in England 2008-2011: the role of NHS Improvement and the CardiacNetworks. January 2012. Available at: http://www.improvement.nhs.uk/LinkClick.aspx?fileticket=PWttejHG45M%3D&tabid=63 (accessed 6 Aug 2012).12. The Task Force on the Management of ST-segment elevation acutemyocardial infarction of the European Society of Cardiology, (2012) ESCguidelines for the management of acute myocardial infarction in patientspresenting with ST-segment elevation. Eur Heart J doi:10.1093/eurheartj/ehs21513. Antman EM, Hand M, Armstrong PW et al. (2008) 2007 focused update of theACC/AHA 2004 Guidelines for the Management of Patients With ST-ElevationMyocardial Infarction. J Am Coll Cardiol 2008; 51: 210–247.14. From Coronary Care Unit to Acute Cardiac Care Unit – the evolving role ofspecialist cardiac care. Recommendations of the British Cardiovascular SocietyWorking Group on Acute Cardiac Care. Accessible at http://www.bcs.com/documents/9A6_BCS_Report_on_Coronary_Care_Units.pdf15. Walker DM, West NEJ, Ray SG. From coronary care unit to acute cardiac careunit: the evolving role of specialist cardiac care. Heart 2012; 98: 350-2.MINAP Eleventh Public Report 201213