Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough.
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Transcript of Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough.
Patient TransferPatient Transfer
Mark de Belder
The James Cook University Hospital
Middlesbrough
Current Management Strategies for ACSCurrent Management Strategies for ACS
ACS
No ST Elevation
EarlyConservative
EarlyInvasive
Fibrinolysis
ST Elevation
PrimaryPCI
Fibrinolysis
ST Elevation
PrimaryPCI
Fibrinolysis
ST Elevation
PRIMARYPCI
Guidelines for the management of non-STEMIGuidelines for the management of non-STEMIAcute Coronary SyndromesAcute Coronary Syndromes
Coping with ACS angiographyCoping with ACS angiography
• Rapid turnover of patients required (pressure on ambulance services)
• Organisation of diagnostic and revascularisation services
• Cath lab spaces required every day in interventional centres
• Referral to a specific cath lab slot rather than a specific Consultant
• Increased use of Cath ? Proceed slots (for elective work as well)
• Referring hospitals need to take some patients back after revascularisation (?swaps)
• Weekend working?
• Elective work may have to slow pending an increase in the infrastructure for angiography
• Clinical networks with appropriate support from commissioners
Patient TransferPatient Transferin the setting ofin the setting of
STEMISTEMI
Meta-analysis of 23 randomised trialsMeta-analysis of 23 randomised trials7739 patients: 4-6 week data
Keeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20
0%
2%
4%
6%
8%
10%
12%
14%
Death Exc.Shock Non-fatal MI CVA Combined
PCILysis
P=0.0002 P=0.0003 P<0.0001 P=0.0004 P<0.0001
Meta-analysis of 8 randomised trialsMeta-analysis of 8 randomised trials
Streptokinase trials - 1837 patientsStreptokinase trials - 1837 patientsKeeley EC, Boura JA, Grines CL
The Lancet 2003;361:13-20
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Death Non-fatal MI CVA Combined
PCILysis
0.53 (0.37-0.75) 0.11 (0.05-0.26) 0.32 (0.09-1.21) 0.40 (0.28-0.58)
Meta-analysis of 15 randomised trialsMeta-analysis of 15 randomised trials
Fibrin-specific trials - 5902 patientsFibrin-specific trials - 5902 patientsKeeley EC, Boura JA, Grines CL
The Lancet 2003;361:13-20
0%
2%
4%
6%
8%
10%
12%
14%
Death Non-fatal MI CVA Combined
PCILysis
0.80 (0.66-0.96) 0.42 (0.31-0.55 0.49 (0.31-0.77) 0.57 (0.48-0.69)
Meta-analysis of 5 randomised trialsMeta-analysis of 5 randomised trials
Transfer for PCI vs On-Site LysisTransfer for PCI vs On-Site Lysis2909 patients: 4-6 week data2909 patients: 4-6 week data
Keeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20
0%
2%
4%
6%
8%
10%
12%
14%
16%
Death Non-fatal MI CVA Combined
PCILysis
P=0.057 P<0.0001 P=0.049 P<0.0001
Mortality by time to presentationMortality by time to presentation
0%
2%
4%
6%
8%
10%
12%
14%
<2 hrs 2-4hrs >4hrs
PCILysis
Ziljstra EHJ 2002;23:556
30-day mortality by time from enrollment 30-day mortality by time from enrollment to first balloon inflationto first balloon inflation
0%
2%
4%
6%
8%
10%
12%
14%
16%
<60mins 61-75mins 76-90mins >91mins No PTCA
PCI
Berger P et al, Circ 1999;100:14-20 (GUSTO-IIb)
Door-to-Balloon times in Primary PCI Door-to-Balloon times in Primary PCI outside of trialsoutside of trials
N=27,080N=27,080Cannon CP, Gibson CM, et al. JAMA 2000
11.14 1.15
1.41
1.62 1.61
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
0-60 61-90 91-120 121-150 151-180 >180
P=NS P=NS P=0.01 P=0.0007 P=0.0003
N=2,230 N=5734 N=6616 N=4461 N=2627 N=5412
Corrected for age, anterior MI location & gender
CAPTIMCAPTIMComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction
Bonnefoy E et al, The Lancet 2002;360:825-29Bonnefoy E et al, The Lancet 2002;360:825-29A trial of prehospital fibrinolysis A trial of prehospital fibrinolysis plus selected PCIplus selected PCI
5 p rim ary P C I1 4 n o lys is
134 (33% )unscheduled Urgent PCI
295 (70% )unscheduled PCI w ithin 30 days
4 0 0p re -h osp ita l
a ltep lase
4 1 9p re -h osp ita l
a ltep lase
1 6 h ad n o an g iog rap h y4 1 n o P C I
1 6 (4 % )u n sch ed u led u rg en t P C I
6 0 (1 4 % )u n sch ed u led P C I w ith in 3 0 d ays
3 6 4p rim ary P C I
4 2 1p rim ary
P C I
8 4 0 ran d om ised
CAPTIMCAPTIMComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction
Bonnefoy E et al, The Lancet 2002;360:825-29Bonnefoy E et al, The Lancet 2002;360:825-29
Pre-hospital lysis n=419
Primary PCI n=421
P value
30 day Composite
34 (8.2%) 26 (6.2%) 0.29
Death 16 (3.8%) 20 (4.8%) 0.61
Reinfarction 15 (3.7%) 7 (1.7%) 0.13
Death & recurrent ischaemia
57 (13.5%) 41 (9.8%) 0.06
Disabling Stroke 4 (1%) 0 0.12
Physician-manned mobile emergency-care units (Service d’Aide Medicale d’Urgence – SAMU)Planned for 1200 patientsTrial terminated early due to lack of funding
Pre-hospital lysis - ER-TIMI19Pre-hospital lysis - ER-TIMI19Morrow DA et al, JACC 2002;40:71-7Morrow DA et al, JACC 2002;40:71-7
315 pts (65 cath’d) vs 650 in-hospital lysis pts
0 30 60 90 120 150 mins
0 30 60 90 120 150
mins
EMSArrival
EMSArrival
Pre-hosprPA
In-hospitallysis
EDArrival
13%>70% STres
90mins post-lysis49%
>70% STres
33%>70% STres
90mins post-lysis48%
>70% STres
4.7% death3.3% reMI1% ICH65 (21%) cath’d56 (18%) PCI
Why so little primary PCI in UK?Why so little primary PCI in UK?• Lack of evidence?
• Belief in pre-hospital lysis?
• Insufficient PCI centres?
• Too few cardiologists?
• (Interventional) cardiologists have too many other things to do?
• Reluctance to take on nocturnal work?
• Competing demands for finances (statins, ACE-I, DES, ICDs etc)?
• Lack of organisation?
Transferring patients for Primary PCITransferring patients for Primary PCIZijlstra F et al, Heart 1997;78:333-6Zijlstra F et al, Heart 1997;78:333-6The Weezenlanden Hospital, ZwolleThe Weezenlanden Hospital, Zwolle
Local patients
N=416
Transferred
N=104
Symptom-onset to admission
129 (69) mins 90 (60) mins
Local admission to WZL admission
- 70 (27) mins
WZL door-to-balloon time
67 (28) mins 39 (31) mins
Total ischaemia time 196 (74) mins 200 (62) mins
10 in shock (1 died)1 ventilated prior to transfer1 intubated during transfer1 VT – lignocaine2 VF – defibrillated2 required IV fluids
Transfer patients (104)
Helicopter vs Ambulance transfer for Helicopter vs Ambulance transfer for Primary PCIPrimary PCI
Straumann E et al, Heart 1999;82:415-9Straumann E et al, Heart 1999;82:415-9Triemli Hospital, ZurichTriemli Hospital, Zurich
Ambulance N=54
Helicopter N=14
Total N=68
Sig
Distance (km)
8 (5-68) 42 (24-122) 9 (5-122) 0.0001
Journey time (mins)
47 (15-126) 37 (7-60)
Total transfer time (mins)
50 (18-110) 63 (40-115) 55 (18-115) 0.02
3 patients died in shock prior to transfer0 patients transferred died8 patients were ventilated during transfer0 defibrillation during transfer (15 resuscitated prior to transfer)
AIR PAMIAIR PAMI138 patients: 30 day data (trial stopped for poor recruitment)138 patients: 30 day data (trial stopped for poor recruitment)
Grines CL et al, JACC 2002;39:1713-9
0%
5%
10%
15%
20%
25%
30%
35%
Death Non-fatalreMI
CVA MACE Ischaemia
PCILysis
P=0.46 P=1.0 P=0.11 P=0.33 P=0.007
79% ambulance transfer 26±28 miles; 21% Helicopter 57±50 miles0 patients needed resuscitation during transfer, 0 patients diedER to treatment times 174±80 for transfer vs 63±39 mins for local lysis
DANAMI-2DANAMI-2• 22 referring hospitals
• 5 PCI centres
• Serving two thirds of the Danish population (5.4million)
• Plan for 1100 patients at referring hospitals and 800 patients at invasive centres
• Average distance 35 miles (56km)
• Up to 95 miles (153km)
• Halted by Safety & Efficacy Committee after 1129 patients enrolled because of clear efficacy in PCI patients
DANAMI-2 Trial designDANAMI-2 Trial design
Primary Endpoint: Death, Reinfarction, or Disabling Stroke through
30 days
ST-elevation MI < 12 hours
Randomization (total planned 1900 pts)* Referral Hospital: Planned 1100 pts at 24 sites* Angioplasty Center: Planned 800 pts at 5 sites
FibrinolysisAccelerated tPA
(max. 100 mg)
StentAcute transfer for
1° PTCA + stent
Anderson HR et al, ACC 2002; Oral Presentation
DANAMI-2 - Time from Symptom Onset DANAMI-2 - Time from Symptom Onset to Admission and Time from Door to Rxto Admission and Time from Door to Rx
Door to t-PA
Door to PCI (Balloon)
transferadmit to transfer
Symptom to Hosp.
Symptom to Hosp.
Symptom to Hosp.
Door to PCI
0 60 120 180 240minutes
Referral
Invasive
Referral
Invasive
Lys
is1°
PC
I
Hospital
Average Door to Balloon (jncludestransfer) < 120 minutes
Door to t-PASymptom to Hosp.
ACC 2002; Oral presentation
DANAMI-2 DANAMI-2 Transfer problemsTransfer problems
• AF in 2.5%
• VT in 0.2%
• VF 1.4%
• 2/3 heart block in 2.3%
• 0 intubations
• 0 deaths
DANAMI-2: 30 day Primary EndpointDANAMI-2: 30 day Primary Endpoint
13.7
7.66.3
2.0
6.6
1.6 1.1
8.0
0
5
10
15
20p = 0.0003
p = 0.35p < 0.001
p = 0.15
Accel. t-PA (n=782) PCI (n=790)
Combined* Death Reinfarction DisablingStroke
*Primary Endpoint: Death, Reinfarction, or Stroke
% o
f P
atie
nts
All Patients
ACC 2002; Oral presentation
DANAMI-2: 30 day Primary Endpoint*DANAMI-2: 30 day Primary Endpoint*
13.7 14.2
12.3
8.56.7
8.0
0
5
10
15
20
p=0.0003 p=0.002
p=0.048
Accel. t-PA PCI
All patients(n=1572)
Referral hospitals(n=1129)
Invasive Centers(n=443)
*Primary Endpoint: Death or Reinfarction or Stroke
% o
f P
atie
nts
Referral vs. Invasive Hospitals
ACC 2002; Oral presentation
DANAMI 2: Time to treatmentDANAMI 2: Time to treatment30 day results30 day results
0%
2%4%
6%8%
10%12%
14%16%
18%20%
<1.5hrs 1-5-2.5hrs 2.5-4hrs >4-12hrs
PCItPA
Combined end-point - All significant
DANAMI 2: Results by age groupDANAMI 2: Results by age group30 day results30 day results
0%
5%
10%
15%
20%
25%
30%
<55yrs 55-64 65-74 75+
PCItPA
Combined end-point - All significant
PRAGUE 2PRAGUE 2
Tim e to trea tm en t2 4 5 m in u tes
4 2 1T'lys is
T im e to trea tm en t2 7 7 m in u tes
(+ 3 2 m in u tes )
4 2 5 tran sp orted2 d ied an d 3 V F
in tran s it1 .2 % com p lica tion s
4 s tayedE arly S h ock
T 'lys is3 d ied
4 2 9Tran sp ort
Widimsky P et al, ESC 2002
PRAGUE 2: 30 day mortalityPRAGUE 2: 30 day mortality
0%
2%
4%
6%
8%
10%
12%
14%
16%
Death 0-3hrs 3-12hrs
PCISK
P<0.02P=0.12 P=NS
Widimsky P et al, ESC 2002
Trial stopped early because of reluctance to enrol patients >3 hours
Shock patientsShock patientsHochman JS et al, NEJM 1999;341:625-34Hochman JS et al, NEJM 1999;341:625-34
Revascularisationpatients n=152
Medical Therapypatients n=150
Transfer patients 55.3% 55.3%Thrombolysis 49.3% 63.3%IABP 86.2% 86%PCI 54.6% 14%CABG 37.5% 11.3%PCI or CABG 86.8% 25.3%
Ambulance transferAmbulance transfer
Strategy for centres with door-to-balloon Strategy for centres with door-to-balloon times >120 mins?times >120 mins?
• Send anyway for primary PCI?
• Make do with best lysis strategy?
• As above and select out patients for rescue?
• Conventional lysis and send for rescue on arrival if required?
• Half-dose lysis ± GP IIb/IIIa inhibitor and send?
Facilitated PCIFacilitated PCI
• Studies such as PACT, SPEED, TIMI-14 and GUSTO V suggest that
– combination pharmacotherapy may improve effects of fibrinolysis, and
– pharmacotherapy combined with a PCI strategy may improve results of PCI
• FINESSE and ASSENT IV ongoing
• High risk patients who cannot be treated with early PCI
Current Process for Infarct Current Process for Infarct AngioplastyAngioplasty
MI
AmbulanceCentre
MI CentresMI Centres
MI
AmbulanceCentre
DANAMI-2 - DANAMI-2 - Time from Symptom Onset Time from Symptom Onset to Admission and Time from Door to Rxto Admission and Time from Door to Rx
Potential impact of MI centresPotential impact of MI centres
Door to t-PA
Door to PCI (Balloon)
transfer
Symptom to Hosp.
Symptom to Hosp.
Symptom to Hosp.
Door to PCI
0 60 120 180 240minutes
Referral
Invasive
Referral
Invasive
Lys
is1°
PC
I
Hospital
Could reduce time by 50-60 mins
Door to t-PASymptom to Hosp.
Paradox: referral patients might get more rapid reperfusion!
MI CentresMI Centres
MI
AmbulanceCentre
MI
AmbulanceCentre
As per C-PORT
Emergency Ambulance ServiceEmergency Ambulance Service
Hartlepool 3Stockton 3Carlton How 1Redcar 3Middlesbrough 3Coulby Newham 1/2
Blue light trained 1
Government policyGovernment policy
• Get the best out of the old treatments before looking at new ones
• Pilot studies of pre-hospital lysis– But data already available from Scotland, N. Ireland,
France, Holland, Germany, Belgium, USA and Israel!
Is there one?
• Get the best out of the old treatments and look at new ones
• Look at studies of pre-hospital lysis and allow (ie fund) introduction (?via NICE)
• Look at studies of primary PCI and allow (ie fund) introduction (?via NICE)
A better approach?
ConclusionsConclusions
If clinical investigators can organise trials, then governments, commissioners and clinical cardiologists should be able to organise an infarct angioplasty service
ConclusionsConclusionsPatient transfer in AMIPatient transfer in AMI
• Feasible
• Cardiovascular events are uncommon
• Need paramedics, ALS trained nurses or doctors
• Appropriately equipped ambulances– Continuous ECG monitoring– Defibrillation– Mechanical ventilation– Thrombolytic agents– IV fluids– Resuscitation drugs– Ability to transfer IABP
• Need new law to oblige rapid ambulance response to AMI transfer requests (<8 minute response time)
ConclusionsConclusionsPrimary PCI vs FibrinolysisPrimary PCI vs Fibrinolysis
• If hospital fibrinolysis is local strategy, change to primary PCI, at least for all patients presenting >3 (?>2) hours after symptom onset
• If pre-hospital fibrinolysis is local strategy, need appropriate numbers of appropriately equipped and staffed ambulances
• Such a strategy requires a PCI strategy – Contraindication to lysis– Early shock– High risk rescues– Re-infarction
• If such ambulance crews exist, then use them for transfer for primary PCI (as the PCI team exists anyway)!
ConclusionsConclusions
• For PCI centres (on-site surgery) with 4 or more interventionists –
– primary PCI should be preferred treatment for STEMI
– ??offer fibrin-specific lysis to patients presenting in first 3 hours at night)
• For PCI centres with off-site surgery - Local arrangements needed for surgical candidates.
ConclusionsConclusions
• For centres that cannot offer PCI but transfer possible within 3 hours -
– transfer patients to local PCI centre for primary PCI
– ??offer fibrin-specific lysis to patients presenting in first 3 hours – but respond to ongoing problems).
• For centres that cannot offer PCI, when transfer within 3 hours not possible -
– use fibrinolysis but consider protocol for immediate transfer of patients to PCI centre (?all-comers or selective).
• Role of facilitated PCI to be determined
DANAMI 2: 30 day resultsDANAMI 2: 30 day results
0%
5%
10%
15%
20%
25%
Death
reMINo reMI
P<0.0001
DANAMI-2DANAMI-2600 day data (6months-4 years)600 day data (6months-4 years)
300.111.9%15.3%Mortality - Referral hospitals
400.2613.4%16%Mortality - All patients
150.00416.9%23.3%Combined - Referral hospitals
180.00217.8%24.2%Combined - All patients
NNTP valuePCIFibrinolysisEnd-point
Anderson HR et al, XIVth World Congress of Cardiology 2002
Is simple primary PCI still going to be best?Is simple primary PCI still going to be best?Vermeer et al, Heart 1999;82:426-31Vermeer et al, Heart 1999;82:426-31
0%
2%
4%
6%
8%
10%
12%
14%
16%
In-hospital mortality
ConservativeRescuePrimary PCI