Myocardial Ischaemia National Audit Project - University College ...

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Our pPCI service can be illustrated by the case, a 68 yearold man who experienced pain across his chest at 11:45. Hefortunately called for help early at 12:13, and was attended toby the SECAMB within five minutes, see the ECG transmittedto the CCU (Figure 27).He was taken to St George’s Hospital, bypassing his localhospital (8 miles), arriving at the door of the HAC at 13:15 (15miles), and was taken to the CCU first as the pPCI team wasnot on site over the weekend, and then to the cardiac catheterlaboratory when the pPCI team was fully assembled. The callfor help to door time was therefore 62 minutes.He underwent right radial approach emergency coronaryangiography and was found to have occluded his right coronaryartery. The artery re-opened with wiring, without the need forthrombectomy, and it was directly stented at 13:52 (Figure 28,upper panel). Hence the door to balloon time was 35 minutes(well below the golden hour) and the call to balloon time was97 minutes (< 150 minutes).He was also found to have a sub-totally occluded left anteriordescending artery, the distal vessel was collateralised bycollaterals from the re-opened right coronary artery. As therewas high likelihood that he would be symptomatic from thislesion, the artery was wired and directly stented (Figure 28,lower panel). Subsequent echocardiogram revealed preservedcardiac function with mild hypokinesia in the right coronaryartery territory and apical akinesia suggestive of previousdistal left anterior descending artery MI. His recovery wasuneventful. He was discharged 3 days later and was followedup at his local hospital.It has now been one year since the patient’s MI, he hascompleted his cardiac rehabilitation program locally and heis completely asymptomatic. This case illustrates that it ispossible to deliver a world class primary PCI service whendifferent service components work in concert to achieve acommon goal.Figure 27. ECG transferredvia LIFENET system to StGeorge’s Hospital by theambulance crew showingacute ST segment elevationMI in inferoposterior leads.Figure 28. Stages of pPCI toright coronary artery (top),and left anterior descendingartery (bottom). Arrowindicates occluded vessel – leftpanel; star shows inflatedstent balloon – middle panel;and final result of followingstenting – right panel.94 MINAP How the NHS cares for patients with heart attack
12. Shifting the FocusNicola Manning – Cardiology <strong>Audit</strong> NurseEmma Gendall - Cardiology <strong>Audit</strong> NurseNorth Bristol NHS Trust (NBT)During the past 10 years we have been committed to MINAPdata collection at North Bristol NHS Trust (NBT), working hardto ensure our data is accurate and robust. We regularly reviewour data locally and discuss it with our clinicians.In 2009, NBT ceased to operate a primary PCI (pPCI) servicefollowing a strategic decision to transfer STEMI patients tothe nearby Heart Institute. This provided us with a uniqueopportunity to shift our focus toward nSTEMI patient care.We seized this opportunity and after securing additionalstaff, commenced data collection on all nSTEMI patients.This additional data enabled us to perform in-depth analysisof our nSTEMI pathway in order to identify potential areasfor improvement.The Avon, Gloucester, Wiltshire and Somerset (AGWS) Cardiac& Stroke Network and local clinicians were also keen to lookat nSTEMI care on a regional level. As a result, five standards,directly relating to NICE guidance (CG94) for Acute CoronarySyndrome (ACS), were devised. In formulating these standardsit was important to ensure they correlated with the MINAPdataset enabling easy data extraction and analysis. The 5standards are as follows:All hospitals within the AGWS Network agreed to provide thisdata from MINAP and this is currently reviewed at quarterlymeetings. This is an example of national audit being usedto improve regional services. At NBT this enables us todirectly compare ourselves in specific areas of nSTEMI careagainst other local hospitals. Where we identify variationin performance this is discussed with other hospital teamsto determine how performance can be improved. Thiscollaborative working has enabled us to progress nSTEMIpatient care and service provision network-wide.An example of this is the role of outreach ACS nurse specialists,which appeared to be a key element of those hospitalsperforming well. At NBT we were able to take this evidence,derived from MINAP, to aid development of a cardiologyoutreach nurse position. We have now appointed and a 6 monthtrial is due to commence shortly. With this nurse in post we areconfident that an improvement in our admission to angiographytimings and length of stay will be evident. The MINAP databasewill be instrumental in continually tracking this progress,enabling our service to evolve.Percentage of patients cared for in CCUPercentage of patients reviewed by a cardiologistwithin 24 hoursPercentage of patients reviewed by a cardiologistduring admissionPercentage of patients receiving Glycoprotein IIb/IIIainhibitorsPercentage of patients receiving angiography within72 & 96 hours of admissionMINAP Eleventh Public Report 201295
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Myocardial IschaemiaNational Audit
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Myocardial Ischaemia National Audit
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ForewordThe annual MINAP Report, no
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Patients who received thrombolytic
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considering such factors as the age
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egarding previous medical history.
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3. Improving quality,improving outc
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is an acute heart failure syndrome
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Alan KeysMINAP Steering Group patie
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Figure 7. Patients admitted with a
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Figure 11. Percentage of patients w
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transfers require a significant amo
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Table 8 shows the performance of th
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This year we report on the interval
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Conquest Hospital, St Leonards onSe
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Royal Derby Hospital, Derby 62 89%
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“During times of financial constr
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Broomfield Hospital, Chelmsford 0 0
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Leighton Hospital, Crewe 43 86% 49
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Royal Preston Hospital, Preston 48
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Wycombe Hospital, High Wycombe 11 1
Page 43 and 44: “I know that MINAP data has been
Page 45 and 46: Cheltenham General Hospital, Chelte
Page 47 and 48: Manchester Royal Infirmary, Manches
Page 49 and 50: Salford Royal Hospital, Manchester
Page 51 and 52: “MINAP, and its long history, is
Page 53 and 54: Table 6: Ambulance Services in Engl
Page 55 and 56: Bradford Royal Infirmary, Bradford
Page 57 and 58: Hexham General Hospital, Hexham 17
Page 59 and 60: Papworth Hospital, Cambridge 560 99
Page 61 and 62: Salisbury District Hospital, Salisb
Page 63 and 64: West Middlesex University Hospital,
Page 65 and 66: “We have participated in MINAP fr
Page 67 and 68: Dorset Cardiac and Stroke Network 7
Page 69 and 70: “Participation in MINAP has helpe
Page 71 and 72: Blackpool Victoria Hospital, Blackp
Page 73 and 74: Harefield Hospital 139 84% 156 94%
Page 75 and 76: Northern General Hospital, Sheffiel
Page 77 and 78: Royal Victoria Infirmary, Newcastle
Page 79 and 80: Warrington Hospital, Warrington 435
Page 81 and 82: Withybush General Hospital, Haverfo
Page 83 and 84: Part Three: Case Studies1. Call act
Page 85 and 86: 3. Implementing a high-risk nSTEACS
Page 87 and 88: The British Heart Foundation is a r
Page 89 and 90: of six individual criteria - all in
Page 91 and 92: 9. Use of MINAP data to develop and
Page 93: Figure 26. Part 2 collected by Card
Page 97 and 98: Figure 29. Funnel plot of hospital
Page 99 and 100: Figure 30. Estimated excess risk of
Page 101 and 102: Part 6: AppendicesAppendix 1: MINAP
Page 103 and 104: Coronary thrombosisThe formation of
Page 105 and 106: Birkhead J, Walker L. MINAP, a proj
Page 107: Heart attacks recorded in MINAP in
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