PPCI – National Update NCBC Workshop Jim McLenachan, National Clinical Lead for PPCI, NHS...

PPCI – National UpdateNCBC Workshop

Jim McLenachan, National Clinical Lead for PPCI,

NHS Improvement, England.

London, 24th November, 2010

1NCBC Annual Workshop November 2010 - CONFIDENTIAL

National Cardiothoracic Benchmarking Collaborative (NCBC)

Annual Workshop 2010

Breakout Group

PPCI – National UpdateDr Jim McLenachan

National Clinical Lead for PPCI, NHS Improvement, England.


Falling STEMI mortality (Source MINAP report 2010)

%


NATIONAL MINAP DATA

0

10

20

30

40

50

60

70

80

90

100

2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1

PPCI

LYSIS


NORTH CENTRAL LONDON MINAP DATA

0

10

20

30

40

50

60

70

80

90

100

2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1

PPCI

LYSIS


NCBC 2010ESSEX MINAP DATA

0

10

20

30

40

50

60

70

80

90

100

2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1

PPCI

LYSIS


NCBC 2010MANCHESTER AND CHESHIRE MINAP DATA

0

10

20

30

40

50

60

70

80

90

100

2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1

PPCI

LYSIS


554

417

133

190

86

401

555

371

40

661

331

218

424 434

953

338

108

243

449

78

274

429

566

214

319

211158

0

100

200

300

400

500

600

700

800

900

1,000

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PP

CI

Cas

es

Sum of Answer

Year

NCBC 2010 - Primary PCINumber of PPCI Cases Undertaken , 2008/9 & 2009/10

2008/9 2009/10Data Points 21 27Median 185 331 Range - High 753 953 Range - Low 20 40

Median2009/10


NCBC Trusts - PPCI Cases per million population, 2009/10(Rate adjusted for weeks of operation by service operated)

596576

528

447 446 434413

377357 353

308 299282 278 265

238222

203 196 182 174156

126

79

11889

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100

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24/7, 365 days a year Part time

PP

CIs

per

Mill

ion

Cat

chm

ent P

opul

atio

n

PPCI pmp adjData Points 26Median 280 Range - High 596 Range - Low 79

Median


The switch from lysis to PPCI...

NCBC Annual Workshop November 2010 - CONFIDENTIAL

Primary PCI for Essex

Dr Paul Kelly

Lead Cardiologist, Essex CTC


NCBC - 2010Predicted Numbers - Essex

• Total STEMI for Essex = 823 (thrombolysis)

• From pre hospital setting = 655• From A+E depts = 132• From DGH wards = 36

(source MINAP & Discharge diagnosis 07/08)


NCBC 2010Logistics

• Essex CTC located at Basildon (60 miles max)

• 8 Interventional Cardiologists• Increased cath lab staff numbers• East of England Ambulance Service• Provision of on call rooms• Change of post on call duties


NCBC 2010Essex Protocols & Pathways

• Operational Policy for CTC • Operational Policy for A+E Depts• Operational Policy for DGH Wards• Policy and agreement for DGH admission post

PPCI • Patient pathways from pre hospital to cardiac

rehab


Essex - Operational Policy for CTC

• Paramedic decision to activate pathway

• Inclusion criteria – ECG driven

• Exclusion criteria – relatively few


Time Line for PPCI

• Total call to balloon = 165 mins

Call to paramedics leaving scene = 45 mins(call to scene, assess and mobilise patient)

Transfer to CTC = max 90 mins

Door to balloon = 30 mins


Following Procedure

• Transfer to HDU ward in CTC• 24 - 48 day stay post PCI and transfer to

DGH • ? Some patients discharged home from CTC • Cardiac Rehabilitation Assessment


Potential Problems

• Delays in pathway – concerns for CTB > 165m

• Excess demand (compared to predictions)

• Bed Capacity on Roding Ward/ ITU

DGH capacity to accept patients post PPCI


Timetable for Implementation

• Big bang, pan Essex start date• 1st September 2009• Communication for all involved in

process• Information for patients


Potential for Growth in Primary PCI Activity in NCBC Trusts

• Thrombolysis • Too late for reperfusion• Clinically ineligible for reperfusion


80%76% 76%

68%60%

48%41% 41% 40% 38% 37% 34% 34% 32% 31% 30% 29%

24% 21% 19%

20%23% 23% 22%

32% 29% 26% 29% 32%

21%28% 27%

34% 32% 29% 32%25%

44%

29%25%

0%

10%

20%

30%

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100%

Nor

th E

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s

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% o

f STE

MI

Case

s

no reperfusion

prehospital lysis

Inhospital lysis

pPCI

NCBC 2010 STEMI – Reperfusion % by Method - NCBC Trust Networks - 2009

Potential for growth (2)

Essex increased pPCI coverage since 2009


How do we improve the quality

of the service?


Why does Newcastle have short door to balloon times?

Richard Edwards

Primary PCI lead

Freeman Hospital Newcastle


NCBC 2010 - Primary PCIMedian Door to Balloon Time (Minutes), by average number of PPCIs

per week, 2009/10

68

31 31

24 24

65

58

50 49 49 48

40

33 33

7570 69

63 6257 55

52

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10 plus per week 5-<10 per week <5 per week

Med

ian

Tim

e (M

inu

tes)

Average number of PPCI per week

2009/10Data Points 28Median 50 Range - High 1,289 Range - Low 23

Median


Is it because…

• As a larger volume centre we have developed more routine processes & therefore have quicker DTB time?

• Do we just cover a larger geography & have more warning to activate the team?

Both….26


7570 69 68 65 63 62 58 57 55 55 52 50 49 49 48

40 3934 33 33 33 31 31

24 24 23

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(M

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2009/10

Primary PCIMedian Door to Balloon Time (Minutes), 2008/9 & 2009/10

Median2009/10

2008/9 2009/10Data Points 20 28Median 54 50 Range - High 1,102 1,289 Range - Low 30 23


-24%

3%

36%

-50%

-39%

12%

-23%

-47%

0%

-37%-39%

-18%

3%

-30%

-7%

-19%-9%

-11%-9%

-60%

-50%

-40%

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0%

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NCBC 2010 - Primary PCI% Change in Median Door to Balloon Time (Minutes), 2008/9 & 2009/10

(Trusts with data for both years)

Lon

gest

Med

ian

Doo

r to

Bal

loon

Tim

es

Sho

rtes

t M

edia

n D

oor

to B

allo

on T

imes

Improvements in % reduction in Median DTB Times irrespective of whether Trusts had longer or Shorter DTB time

in 2008/9

N Staffs increasedIts catchment area


NCBC 2010 - Primary PCIMedian Call to Balloon Time (Minutes), 2008/9 & 2009/10

0

20

40

60

80

100

120

140

160

180

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2009/10

Median2009/10



Half an hour to Freeman

March 31st 2008 Roll out NewcastleMay 1st 2008 Roll out South of TyneJuly 1st 2008 Roll out North of Tyne


Is it because…

• As a larger volume centre we have developed more routine processes & therefore have quicker DTB time?


Both….31


554

417

133

190

86

401

555

371

40

661

331

218

424 434

953

338

108

243

449

78

274

429

566

214

319

211158

0

100

200

300

400

500

600

700

800

900

1,000

Bar

ts &

Lon

don

Bas

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Bel

fast

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anch

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LH

PP

CI

Cas

es

Sum of Answer

Year

NCBC 2010 - Primary PCINumber of PPCI Cases Undertaken , 2008/9 & 2009/10


Median2009/10


routine processes…

• Ergonomics– CCU has its own ambulance admission point– Cath lab and CCU on ground floor (50yds apart)– Pt taken straight to cath lab (Not to CCU, NOT to

A&E)– Interventionists live < 3miles from Freeman

• Communication – Paramedics and CCU gatekeepers and

telecommunicate– Cardiologist not part of routing decision making

• minimise bureaucracy



• Process– history and examination take place whilst

patient transferred to cath lab – out of hours patient waits in CCU for team to

arrive– verbal consent taken– culprit vessel treated first

• Economy of scale– Redeployed staff in an emergency– Always make an empty lab



• Motivated team– Published D to B times motivate staff to

improve– Low staff turnover– Some staff voluntarily stay overnight– Staff much more willing to work generically

in an emergency


Is it because…• As a larger volume centre we have

developed more routine processes & therefore have quicker DTB time?


Both….

Saves 26 minutes

Saves 7 minutes


NCBC 2010 - Primary PCIMedian Call to Door & Door to Balloon Time (Minutes), by average

number of PPCIs per week, 2009/10

68

3123 24

3124

4050

3349 48 49

5865

55

33 33

52

69 7563 62 57

34

7055

39

79

7782 76 65

65

8372

8871 71 67 53 45

54

65

47

91 59 4254 55

58

79

40

51

15

0

20

40

60

80

100

120

140

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arts

& L

ondo

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rial

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am


Med

ian

Tim

e (m

inut

es)

Median Call to Door

Median Door to Balloon

2009/10Data Points 27Median 113 Range - High 147 Range - Low 54

MedianCTB


NCBC 2010 - Primary PCIMedian Door to Balloon Time (Minutes), by average number of PPCIs per

week, 2009/10

68

31 31

24 24

65

58

50 49 49 48

40

33 33

7570 69

63 6257 55

52

3934

0

10

20

30

40

50

60

70

80B

arts

& L

ond

on

So

uth

Tees

Bas

ildo

n

New

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Har

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S M

anch

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No

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ffs

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ld

C M

anch

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fast

Bris

tol

Imp

eria

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Pap

wo

rth

Live

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Brig

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n

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utha

mp

ton

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No

ttin

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ord


Med

ian

Tim

e (M

inu

tes)

Average number of PPCI per week

2009/10Data Points 28Median 50 Range - High 1,289 Range - Low 23

Median


Summary

• Population coverage• Performance• Size vs outcome


PPCI – National Update NCBC Workshop Jim McLenachan, National Clinical Lead for PPCI, NHS...

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