Myocardial Ischaemia National Audit Project - University College ...

3. Implementing a high-risk nSTEACSpathway across London as part of the LondonCardiovascular ProjectSotiris Antoniou - Consultant Pharmacist, Barts & theLondon NHS Trust, North-East London Cardiovascular andStroke NetworkSue Sawyer - Assistant Director of North-East LondonCardiovascular and Stroke NetworkJanet Lailey - Director of North-East London Cardiovascularand Stroke NetworkOn behalf of the London NSTEACS working group (Cardiacand Stroke network).Whilst primary PCI is recommended as the treatment ofchoice for patients with ST-elevation myocardial infarction(STEMI), evidence suggests that patients with acute coronarysyndromes presenting without ST elevation (nSTEACS)also benefit from early angiography and intervention. Thismanagement strategy reduces the likelihood of re-infarction,recurrent angina, hospital readmission, and long-term deathrates compared with medical therapy alone in this group ofpatients. This has led international professional bodies, suchas European Society of Cardiology to recommend that PCIshould be performed within 48 hours of hospital admission forpatients with high-risk nSTEACS.The London Cardiovascular Project was developed as a casefor change to improve cardiovascular services in London. Theavailable evidence suggested that clinical outcomes for thehigh-risk nSTEACS could be improved and the service for thesepatients further developed. The London Cardiac Networks weredirected by NHS London to support local implementation acrossthe capital with North East London Cardiac and Stroke Networkleading on the nSTEACS workstream.The nSTEACS model describes a pathway across a clinicalnetwork that sees the direct transfer of ‘high risk’ nSTEACSpatients from A&E to a specialist interventional centre forassessment and, if indicated, coronary intervention. In thismodel, patients are offered angiography within 24 hours ofinitial assessment. If a patient is triaged in a hospital thatcannot provide angiography within 24 hours, the patient isto be transferred to a unit that can provide this service. Thispathway improves access to the interventional centre, avoidsan admission at the district general hospital and long waits forinter-hospital transfer.The initiative involved close collaboration across organisations,including the London Ambulance Service, the local primarycare trusts (PCTs) and emergency physicians. The workincluded defining the patient group and clinical assessmentcriteria, education and training to DGH accident andemergency departments and modelling capacity implicationsat the interventional centre. Quality standards have alsobeen developed and agreed with the involvement of Londonclinicians and patient representatives to ensure the highestpossible quality of care is available at each stage of thepatients’ journey.With the avoidance of an inpatient admission, PCTs will nolonger be charged for the “actual or suspected myocardialinfarction”, and thus save the tariff of £3,662.Early implementers of the pathway started in September2011 and since March 2012, all London hospitals “fast-track”high-risk nSTEACS patients. The network has commissioned ajoint evaluation of this service with results expected in the nextfinancial year.4. Using the Myocardial Ischaemia National AuditProject (MINAP) to improve patient care in EastMidlands Ambulance Service (EMAS)Deborah Shaw – Clinical Audit and Research ManagerEast Midlands Ambulance ServiceMINAP was established to examine the quality of managementof heart attacks (myocardial infarctions (MI)) in hospitals inEngland and Wales. Participation in MINAP has helped tostrengthen the partnerships EMAS has with local hospitaltrusts. This has benefited our cardiac patients as workingtogether with the hospitals has helped us to identify areas ofcare which could be improvedThere is strong evidence to show that mortality rates in MIimprove the faster thrombolytic treatment or angioplastyare delivered. 22 23 24 EMAS therefore take seriously breachesin the time to treatment targets set in MINAP. To this end,representatives from EMAS attend regular meetings with thelocal hospital trusts where individual cases identified as beingpossible breaches in the MI care pathway are discussed. Oncediscrepancies between ambulance records and the entereddata have been identified the remaining cases are examined.Breaches identified as having occurred whilst the patient wasin the care of EMAS are taken back and discussed with theclinicians who attended the patient. Valid reasons for delaysare fed back to the group and, where appropriate, amended inthe MINAP data. This process also allows us to identify training22. De Luca G, van’t Hof AWJ, de Boer M et al; Time-to-treatment significantlyaffects the extent of ST - segment resolution and myocardial blush in patientswith acute myocardial infarction treated by primary angioplasty. Eur Heart J2004:25: 1009-101323. Brodie BR, Stuckey TD, Wall TC, et al. Importance of time to reperfusion for30-day and late survival and recovery of left ventricular function after primaryangioplasty for acute myocardial infarction. J Am Coll Cardiol 1998 32(5): 1312-924. Gibert AB. Importance of time delay in selecting reperfusion therapy. Rev EspCardiol 2007:60(8):791-3MINAP Eleventh Public Report 201285