national roll-out of primary pci for patients with st segment elevation myocardinal infarction

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

NHSNHS Improvement

National roll-out of Primary PCI forpatients with ST segment elevationmyocardial infarction:An interim report

Foreword

Introduction

The national picture

The network picture

Common themes

Conclusion

Contents

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Authors

Dr J M McLenachanNational Clinical Lead, Reperfusion, NHS Improvement,Consultant Cardiologist, Leeds General Infirmary

Sheelagh MachinDirector, NHS Improvement

Carol MarleyNational Improvement Lead, NHS Improvement

The introduction and dissemination of primary PCI (PPCI) in England provides a good example of how a nationalised healthcaresystem can work at its very best. After randomised trials had established the potential superiority of primary PCI overthrombolysis for STEMI, the Department of Health and national societies (British Cardiovascular Society, British CardiovascularIntervention Society) conducted a feasibility study (National Infarct Angioplasty Project, NIAP), and concluded in its final report(October 2008) that the roll out of PPCI was both desirable, feasible and cost effective. Taking account of geographicalconsiderations it was estimated that PPCI could be offered as the treatment of choice to 95% of the STEMI population.Concerted implementation work then ensued, spearheaded by the cardiac networks and ably supported by NHS Improvementand its Clinical Lead, Dr Jim McLenachan.

Eighteen months later, more than 70% of STEMIs are now being treated by PPCI (an increase from <10% when the NIAPstarted) and with every network having robust plans to achieve 100% coverage for eligible patients. Given the complexity ofdelivering a PPCI service, at all hours of the day and night, and for every day of the year, it is remarkable that so much has beenachieved in such a short space of time. We shouldn’t forget that the decision to move to a PPCI dominated strategy was madeon the background of an existing excellent thrombolysis service, which had already delivered improved patient outcomes. It is allthe more remarkable that satisfaction with performance indicators for thrombolysis did not result in any complacency regardingchange. Far from it, as is demonstrated in this report, Ambulance Services, provider Trusts, and management at all levels haveresponded with commitment and enthusiasm in implementing a better treatment strategy, to the benefit of patients.

It is a testament to the NHS, and the collaborative working of its multidisciplinary teams, that the national implementation ofPPCI has been so successful, and we have no doubt that the aspiration to achieve near universal coverage will be achieved.Everyone involved in delivering this service improvement should feel immensely proud of their contribution.

Professor Roger Boyle Professor Huon GrayNational Director for Heart Disease & Stroke Deputy National Director,Department of Health Consultant Cardiologist, Southampton

Foreword

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 3

www.improvement.nhs.uk/heart

Gateway Reference: 14878

4 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report

The final report of the National Infarct Angioplasty Project (NIAP) was published in October 2008. NIAP was a feasibility

study sponsored jointly by the British Cardiovascular Society and the Department of Health. The NIAP document,

‘Treatment of Heart Attack - National Guidelines’, demonstrated that a strategy of primary percutaneous coronary

intervention (PPCI), as opposed to thrombolysis, as the default treatment for patients presenting with acute ST

segment elevation myocardial infarction, was possible in a UK setting.

The Department of Health estimated that it was feasible for PPCI to be rolled out to at least 95% of the population

over about three years, but implementation would be for local determination. NHS Improvement was available to

support, guide and coordinate the implementation of PPCI across the 28 Cardiac and Stroke Networks in England. The

purpose of this interim report is to document the progress that has been made after 18 months.

The authors gratefully acknowledge the help and cooperation of the staff of the Myocardial Infarction National Audit

Project (MINAP) and of the many hospital staff nationally that input data into MINAP. Without their cooperation, this

report, and the progress described herein, would not have been possible.

Introduction



The rate of increase in the proportion of eligible patientsreceiving PPCI, and the proportionate fall in the use ofthrombolysis is shown in figure 1.

In the third quarter of 2008, 58% of those patients whoreceived any reperfusion treatment were treated withthrombolysis and 42% were treated with PPCI. By the endof the first quarter of 2010, the proportion treated withPPCI had risen to 73% and the proportion treated withthrombolysis had fallen to 27%.

It is important to understand that some patients with STsegment elevation myocardial infarction may receiveneither PPCI or thrombolysis, usually for sound clinicalreasons. Review of the numbers of patients not receivingany form of reperfusion therapy shows no major increasein this group as a result of the switch from lysis to PPCI(figure 2).

The national picture

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PPCI LYSIS

Figure 1: National MINAP Data

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No Reperfusion Treatment

Figure 2: National MINAP Data - Patients not receivingreperfusion treatment


Even before the publication of the NIAP report, some areasof the country had well-established PPCI services. Theseareas included all of the London networks, the BlackCountry, West Yorkshire and North Yorkshire. Manyhospitals, however, were delivering only ad-hoc PPCI insmall numbers.

The next few pages summarise the progress madebetween October 2008 and April 2010 in each of the28 cardiac and stroke networks in England.

The network picture



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PPCI LYSIS

Anglia MINAP Data


Population2.3 million

Hospitals providing 24/7 PPCINorfolk and Norwich Hospital, NorwichPapworth Hospital, Cambridge

Hospitals providing limited hours PPCINone

Neighbouring centres where PPCI patientsmay be treatedBasildon Hospital, Basildon

CommentsApproximately 87% of the population is now covered byPPCI service. Pilot study of optimum treatment for EastSuffolk residents is in progress.

Anglia



Hospitals providing 24/7 PPCIMusgrove Park Hospital, TauntonBristol Royal infirmary, Bristol

Hospitals providing limited hours PPCIRoyal United Hospital Bath, BathCheltenham General Hospital, CheltenhamThe Great Western Hospital, Swindon

Neighbouring centres where PPCI patientsmay be treatedJohn Radcliffe Hospital, OxfordRoyal Berkshire Hospital, ReadingSouthampton General Hospital, SouthamptonRoyal Bournemouth General Hospital, BournemouthDorset County Hospital, Dorchester

Avon, Gloucestershire, Somerset and Wiltshire

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Avon, Gloucestershire, Somerset and Wiltshire MINAP Data


CommentsApproximately 56% of the population is now covered byPPCI service.

Planning to achieve 100% population coverage byNovember 2011.


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Bedfordshire and Hertfordshire MINAP Data



Hospitals providing 24/7 PPCINone

Hospitals providing limited hours PPCILister Hospital, StevenageWatford General Hospital, Watford

Neighbouring centres where PPCI patientsmay be treatedPapworth Hospital, CambridgeHarefield Hospital, Middlesex

Comments100% population coverage achieved.

Bedfordshire and Hertfordshire



Hospitals providing 24/7 PPCI• Heart of England NHS Foundation Trust• Birmingham Heartlands Hospital, Birmingham(Covering Good Hope Hospital and Solihull Hospital)

• University Hospitals Birmingham NHS Foundation Trust• Queen Elizabeth Hospital, Birmingham

• Sandwell and West Birmingham Hospitals NHS Trust –• Sandwell District Hospital, West Bromwich• City Hospital, Dudley Road, Birmingham

(Out of hours one on call team – attending the trust wherethe patient presents)


Birmingham, Sandwell and Solihull

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Birmingham, Sandwell and Solihull MINAP Data


Neighbouring centres where PPCI patientsmay be treatedNew Cross Hospital, WolverhamptonUniversity Hospital, Coventry

Comments100% populationcoverage achieved.


Population1 million

Hospitals providing 24/7 PPCINew Cross Hospital, Wolverhampton


Neighbouring centres where PPCI patientsmay be treatedBirmingham Hospitals


Black Country

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Black Country MINAP Data



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PPCI LYSIS

Cheshire and Merseyside MINAP Data


Hospitals providing 24/7 PPCILiverpool Heart and Chest Hospital, Liverpool


Neighbouring centres where PPCI patientsmay be treatedNone

CommentsApproximately 46% population coverage on1 April 2010.Coverage then increased to 100% on 1 June 2010.

Cheshire and Merseyside




Hospitals providing 24/7 PPCIUniversity Hospital, Coventry


Neighbouring centres where PPCI patientsmay be treatedBirmingham Heartlands Hospital, Birmingham


Coventry and Warwickshire

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Coventry and Warwickshire MINAP Data



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PPCI LYSIS

Dorset MINAP Data



Hospitals providing limited hours PPCIRoyal Bournemouth Hospital, BournemouthDorset County Hospital, Dorchester

Neighbouring centres where PPCI patientsmay be treatedSouthampton General Hospital, SouthamptonRoyal Devon and Exeter Hospital, ExeterMusgrove Park Hospital, Taunton

DorsetCommentsDaytime PPCI provided at Dorset and Bournemouth withthrombolysis for out-of-hours presenters. Planning toachieve 100% population coverage by November 2011.




Hospitals providing 24/7 PPCIGlenfield Hospital, Leicester

Hospitals providing limited hours PPCIRoyal Derby Hospital, DerbyKettering General Hospital, KetteringNorthampton General Hospital, NorthamptonNottingham City Hospital, Nottingham

Neighbouring centres where PPCI patientsmay be treatedNorthern General Hospital, SheffieldJohn Radcliffe Hospital, OxfordUniversity Hospital, Coventry

East Midlands

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East Midlands MINAP DataCommentsExtensive consultation process over last 18 months. Plansnow in place to have 100% population coverage byNovember 2011.



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PPCI LYSIS

Essex MINAP Data


Hospitals providing 24/7 PPCIEssex Cardiothoracic Centre, Basildon


Neighbouring centres where PPCI patientsmay be treatedBart’s and the London NHS Trust, LondonHarefield Hospital, Middlesex


Essex




Hospitals providing 24/7 PPCIManchester Royal Infirmary, ManchesterWythenshawe Hospital, Manchester


Neighbouring centres where PPCI patientsmay be treatedUniversity Hospital of North Staffordshire, Stoke on Trent

Greater Manchester and Cheshire

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Greater Manchester and Cheshire MINAP DataComments50% population coverage on 1 April 2010. This increasedto 80% on 6 September 2010 with plans to go to full100% coverage in March 2011.



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PPCI LYSIS

Hereford and Worcester MINAP Data




Neighbouring centres where PPCI patientsmay be treatedNew Cross Hospital, WolverhamptonQueen Elizabeth Hospital, BirminghamUniversity Hospital, Coventry

CommentsPlans to introduce daytime access to PPCI at WorcesterRoyal Hospital with out of hours transfer to existingPPCI services in Birmingham are in progress.

Hereford and WorcesterPre hospital thrombolysis with immediate transport to aPCI centre will be the treatment of choice for areas withlong travel times.






Neighbouring centres where PPCI patientsmay be treatedGuys and St Thomas’s, LondonKing’s College Hospital, London

CommentsKent now has 100% population coverage for PPCI basedat The William Harvey Hospital, Ashford. The servicecommenced on 12 April 2010.

Kent

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Kent MINAP Data



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Lancashire and Cumbria MINAP Data


Hospitals providing 24/7 PPCIVictoria Hospital, Blackpool



CommentsThe current service covers only the Blackpool catchmentarea (approximately 17% of the network population).

Lancashire and CumbriaThere are plans to roll out PPCI to 75% of the populationover the next 12 months. Cumbria will continue withthrombolysis because of the long travel times from thisarea pending the development of a PCI / PPCI centre atCarlisle.




Hospitals providing 24/7 PPCICastle Hill Hospital, Hull


Neighbouring centres where PPCI patientsmay be treatedLeeds General Infirmary, LeedsJames Cook University Hospital, Middlesbrough

CommentsPPCI currently covers 60% of the population. Planning toroll out to 100% by November 2011.

North & East Yorkshire and Northern Lincolnshire

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North & East Yorkshire and Northern Lincolnshire MINAP Data



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North Central London MINAP Data


Hospitals providing 24/7 PPCIRoyal Free Hospital, LondonThe Heart Hospital, London


Neighbouring centres where PPCI patientsmay be treatedAny other London hospital


North Central London




Hospitals providing 24/7 PPCIBarts and the London Hospital


Neighbouring centres where PPCI patientsmay be treatedEssex Cardiothoracic Centre, Basildon


North East London

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North East London MINAP Data



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North Trent MINAP Data


Hospitals providing 24/7 PPCINorthern General Hospital, Sheffield



Comments79% population coverage on 1 April 2010. Coverageincreased to 100% on 6 April 2010.

North Trent




Hospitals providing 24/7 PPCIHammersmith Hospital, LondonHarefield Hospital, Middlesex


Neighbouring centres where PPCI patientsmay be treatedSt George’s Hospital, LondonBart’s and the London, LondonLondon Chest Hospital, LondonThe Heart Hospital, London


North West London

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North West London MINAP Data



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North of England MINAP Data


Hospitals providing 24/7 PPCIJames Cook University Hospital, MiddlesbroughFreeman Hospital, Newcastle


Neighbouring centres where PPCI patientsmay be treatedLeeds General Infirmary, Leeds


North of England




Hospitals providing 24/7 PPCIRoyal Devon and Exeter Hospital, ExeterDerriford Hospital, Plymouth

Hospitals providing limited hours PPCITorbay Hospital, Torbay (24/5)

Neighbouring centres where PPCI patients may be treatedA small number of patients from North Devon may be transferredto Musgrove Park Hospital, Taunton due to exceptionalcircumstances. A PPCI service is being established for North Devonpatients with the Royal Devon and Exeter NHS Foundation Trust.This service is hoping to commence formally in October 2010.

CommentsRoyal Cornwall Hospitals NHS Trust is keen to commencea PPCI service but there have been difficulties in recruitinga cardiologist. A small number of North Devon and

Peninsula

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Peninsula MINAP DataCornwall patients may receive thrombolysis because of longer traveltimes to the PPCI centre. At present South Devon patients receivethrombolysis out of hours. Referral pathways to Derriford and RoyalDevon and Exeter NHS Foundation Trust are in discussion to ensurea 24/7 service is provided for South Devon patients.



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Shropshire and Staffordshire MINAP Data


Hospitals providing 24/7 PPCIUniversity Hospital of North Staffordshire, Stoke on Trent


Neighbouring centres where PPCI patientsmay be treatedNew Cross Hospital, WolverhamptonHeart of England NHS Foundations Trust


Shropshire and Staffordshire




Hospitals providing 24/7 PPCIJohn Radcliffe Hospital, OxfordSouthampton General Hospital, SouthamptonRoyal Berkshire Hospital, ReadingNorth Hampshire Hospital, Basingstoke

Hospitals providing limited hours PPCIWycombe General Hospital, High WycombeQueen Alexandra Hospital, Portsmouth

Neighbouring centres where PPCI patients may be treatedHarefield Hospital, MiddlesexFrimley Park Hospital, Surrey

CommentsCoverage was 83% on 1 April 2010. This included allareas except Portsmouth, East Berkshire and the Isle ofWight. East Berkshire patients have had access to 24/7

South Central

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South Central MINAP DataPPCI from their nearest 24/7 centre from 14 April 2010 onwardsand Buckinghamshire patients have had access to PPCI from theirnearest 24/7 centre since 26 May 2010. Portsmouth have provideda 24/7 service since 1 September 2010. Population coverage of97% has now been achieved.



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South East London MINAP Data


Hospitals providing 24/7 PPCIGuy’s and St Thomas’s Hospital, LondonKings College Hospital, London




South East London




Hospitals providing 24/7 PPCISt George’s Hospital, London




South West London

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South West London MINAP Data



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Surrey MINAP Data


Hospitals providing 24/7 PPCIFrimley Park Hospital, Frimley

Hospitals providing limited hours PPCISt Peters Hospital, ChertseyEast Surrey Hospital, Redhill

Neighbouring centres where PPCI patientsmay be treatedSt George’s Hospital, London

SurreyCommentsCurrent population coverage is around 85-90% fordaytime presenters and 20% for out-of-hour’s presenters.Planning to achieve 100% population coverage byNovember 2011.




Hospitals providing 24/7 PPCIRoyal Sussex County Hospital, BrightonEastbourne District General Hospital, EastbourneConquest Hospital, St Leonards on Sea

Hospitals providing limited hours PPCIWorthing Hospital, Worthing

Neighbouring centres where PPCI patientsmay be treatedSouthampton General Hospital, SouthamptonEast Surrey Hospital, RedhillWilliam Harvey Hospital, AshfordFrimley Park Hospital, Frimley

Sussex

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Sussex MINAP DataComments75% population coverage on 1 April 2010. Planning to achieve100% by March 2011.



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West Yorkshire MINAP Data


Hospitals providing 24/7 PPCILeeds General infirmary, Leeds


Neighbouring centres where PPCI patientsmay be treatedNorthern General Hospital, SheffieldCastle Hill Hospital, HullJames Cook University Hospital, Middlesbrough


West Yorkshire



While formulating and implementing the individualnetwork plans for the delivery of PPCI, a number ofcommon themes emerged.

Local politicsCardiology has seen considerable decentralisation over thelast two decades with many procedures that were once thepreserve of tertiary referral centres now being performedin large numbers in district general hospitals. A primaryPCI service requires 24/7 catheter lab availability, a servicenot available in many district hospitals. In some areas, thedevelopment of a PPCI service has been perceived as a‘centralisation’ process which threatens some districtgeneral hospitals. This has occasionally led to a desire toretain local thrombolysis over what is seen as a distantPPCI service. It is very important that the needs of thepatient, rather than the needs of the hospital, dictate howthe service is organised. This is vital during patient andpublic engagement; the setting up of a PPCI service shouldbe seen as something to reduce the rate of death andstroke in local patients, based on the best availablescientific evidence, and not as something being takenaway from the local hospital.

Long travel timesThe time delay between the patient (or relative) first callingfor medical help and the patient later receiving reperfusiontreatment will almost always be longer for PPCI than forthrombolysis. There has been much debate about what isan ‘acceptable’ PCI-related delay. In other words, at whatlength of PCI-related delay are the clear benefits of PPCIover thrombolysis lost? There is some consensus that thebenefits of PPCI are retained unless the PCI related delayexceeds 120 minutes.

Common themesThe PCI-related delay is made up mainly of the travel timeto the PCI centre and the so called ‘door-to-balloon’ timeat the PCI centre. For patients with longer travel times,there is evidence that the ‘door-to-balloon’ time can beshortened to around 30 minutes because the PCI centre isready and prepared for the patient’s arrival. This allows atravel time of 70-90 minutes. In some rural areas ofEngland, a travel time of 90 minutes may still not beenough to reach a PCI centre (eg. Cumbria, East Suffolk,Isle of Wight). This should apply to less than 5% of theEnglish population. If patients from these areas cannotreceive PPCI, it is very important that they receive the nextbest standard of care. This involves pre-hospitalthrombolysis followed by immediate transfer to a PCIcentre. It is well established that 25%-35% of thesepatients will fail to reperfuse following thrombolysis; if thishappens, then the patient should receive rescue PCI asquickly as possible. This cannot happen if the patient hasbeen given pre-hospital thrombolysis and has then beentaken to a hospital without PCI facilities.

Call-to-balloon time of 150 minutesFor the reasons outlined above, it has been proposed thatthe threshold used to assess the performance of a PPCIservice should be the proportion of patients in whom acall-to-balloon time of less than 150 minutes is achieved.Experience has shown that this time is readily achievable inmost parts of the country where diagnosis of ST segmentelevation MI is made by the ambulance service and thepatient is taken directly to the PPCI centre. In contrast,it is much harder to achieve if the patient is taken initiallyto a non-PPCI hospital. Call-to-balloon time (like‘call-to-needle’ time) measures performance across thewhole patient pathway which will include the ambulanceservice, the non-PPCI hospital and the PPCI centre.



Workforce and training issuesPPCI involves a major shift towards out-of-hours working. Formany centres, this has involved employing and trainingadditional nursing, physiology and radiography staff. Forexisting catheter lab staff, the move towards more frequentnight time and weekend working has sometimes beendifficult to manage. Whatever local arrangements are made,it is clearly important that the PPCI service is sustainable in thelong term.

Response from the networksAs part of this survey, cardiac networks were asked whetherany specific issues had delayed their plans to implement PPCI.Three networks reported that discussion over the funding ofthe necessary additional ambulance activity had led to delaysin implementing the service. Three networks cited delays inrecruiting interventional cardiologists and two mentioneddelays in recruiting nursing and other cardiac catheter labstaff.

Cross-boundary workingThere are well established routes of referral betweengeneral practitioners and local hospitals and betweendistrict hospitals and tertiary centres. These have evolvedlargely for elective and urgent care. Because time delaysare critical when setting up a PPCI Service, networks havehad to consider where patients might receive PPCI with theminimum time delay. For some patients, the nearest PPCIcentre may not be within the cardiac network, or evenwithin the Strategic Health Authority, in which they live. Allnetworks, therefore, have had to consider where patients,particularly those patients close to the networkboundaries, are likely to receive the speediest care.

Limited hours and 24/7 centresMost PPCI centres in England operate 24 hours per day,seven days per week. Some smaller hospitals operate aPCI service which includes treating ST segment elevationMI patients during working hours (9am to 5pm, or 7am to7pm Monday to Friday). Patients outside of these timesare then taken to the nearest 24/7 Centre. This requirescareful planning between the limited hours centre, the24/7 centre and the ambulance service. The service shouldbe centred around what is best for the patient; there islittle point in having a 9-5 service if the busiest times onthe roads (and hence the longest transfer times) are 8-9amand 5-6pm.



Conclusion



Considerable progress has been made over the periodOctober 2008 to April 2010. All 28 cardiac and strokenetworks now have a strategy to deliver PPCI to most ofthe population by October 2011. Increasingly, the focuswill be on outcomes. All centres delivering primary PCIshould strive to deliver the best possible quality of PPCI toall eligible patients. Factors that will help to improveoutcomes will include the following:

1. Minimising the call-to-balloon time by ensuring that asmany patients as possible are diagnosed by theambulance service and taken directly to the PPCI centre,avoiding accident and emergency units and coronarycare units.

2. Minimising door-to-balloon times at PPCI centres.

3. Developing strategies for dealing with simultaneousreferrals. Most PPCI centres can only treat one patientat a time, particularly out-of-hours. If two or morereferrals are made to the same centre within a fewminutes, then it clearly benefits the second patient ifthey can be taken to an alternative PPCI centre which isnot already treating a STEMI patient provided theprocedure is still carried out within an acceptable timeframe. In urban areas, this will involve cooperationbetween neighbouring PPCI centres.

Carol MarleyNational Improvement Lead, Reperfusion, NHS Improvementemail: [email protected]

Sheelagh MachinDirector, Heart, NHS Improvementemail: [email protected]

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national roll-out of primary pci for patients with st segment elevation myocardinal infarction

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