ppci: why i can’t sustain a 1:6 on-call …...jah pci audit data total acute stemi ppci rota •...
TRANSCRIPT
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
DRJIMHALLJAMESCOOKUNIVERSITYHOSPITAL
MIDDLESBROUGH
NOCONFLICTOFINTERESTTODECLARE
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Background
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Background–Whyme?
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Appointedconsultant1993
MIDDLESBROUGH
MAPSHOWINGNATIONALPARKSINTHEUK
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Appointedconsultant1993>1000emergencySTEMIcasesØ outofhours~66%
Middlesbrough STEMI protocol
1993♦ Thrombolysis first line therapy ♦ PCI if
ØContraindication to thrombolysisØCardiogenic shock ØRe-infarction (failed thrombolysis)ØRescue
JAHPCIauditdata
total acuteSTEMIPPCI rota• 1994 107 6 0• 1995 123 23 1 1:2• 1996 143 22 0• 1997 191 36 0Arthur• 1998 204 48 9 1:3• 1999 227 75 10 Merlin• 2000 273 87 9• 2001 205 79 4 1:4• 2002 160 20 6• 2003 230 40 9Prague
JAHPCIauditdata
total PPCI rota• 2004 239 20 MiddlesbroughPPCI• 2005 259 32 1:5• 2006 250 43 +NYorks• 2007 215 47 1:6• 2008 240 92 +regionalroll-out• 2009 228 89 1:7• 2010 205 73• 2011 180 84• 2012 177 62• 2013 143 60 1:8
1:2ROTA36
1:2ROTA36
1:5ROTA47
1:2ROTA36
1:5ROTA47
1:7ROTA57
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Whyme• Issues– 1:6rota– Impactof‘on-callduties’– Influenceofincreasingage– Implicationsforservicemodels
– Can’torwon’torneedn’torshouldn’t?
– RecommendationsallwillbeLEVEL1C
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Issues– 1:6rota
PPCI:WHYIWON’TDOA1:6ON-CALLSERVICEUNTILI’M65!
• Issues– 1:6rota
PPCI:WHYIWON’TDOA1:6ON-CALLSERVICEUNTILI’M65!
• Issues– 1:6rota– whenI’m65nolongernecessaryinEngland
EFFECTIVE PATHWAY FOR STEMI PATIENTS
STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HRdeLuca et al Circ 2004:109;1223-25
RIGHT PATIENTRIGHT PLACERIGHT TIME
5NV Craven
5NV Harrogate
5KF Gateshead
5D7 New castle 5D8 North Tyneside
5KL Sunderland
5KG South Tyneside
5NV Hambleton
5NV Scarborough
5NV Ryedale
5QR Redcar and Cleveland
5KM Middlesbrough
5D9 Hartlepool
5E1 Stockton-on-Tees
5J9 Darlington
5NV Richmondshire
TAC Tynedale
TAC Castle Morpeth
TAC Wansbeck
TAC Blyth Valley
5ND Teesdale
5ND Wear Valley
5ND Derw entside
5ND Chester-le-Street
5ND Durham
5ND Sedgefield
5ND Easington
A 1(M )
A 1(M )
A 64 (M )
25 km
5NE Carlisle
5NE Eden
5NE South Lakeland and Barrow
5NV Craven
5NV Harrogate
5KF Gateshead
5D8 North Tyneside
5KL Sunderland
5KG South Tyneside
5NV Hambleton
5NV Scarborough
5NV Ryedale
5QR Redcar and Cleveland
5KM Middlesbrough
5D9 Hartlepool
5E1 Stockton-on-Tees
5J9 Darlington
5NV Richmondshire
TAC Tynedale
5ND Teesdale
5ND Wear Valley
5ND Derwentside
5ND Chester-le-Street
5ND Durham
5ND Sedgefield
5ND Easington
A 1(M)
15 km
A: <=5 minB: <=10 minC: <= 15 minD: <= 20 minE: <= 30 minF: <= 45 minF: <= 60 minG: > 60 min
Drive-time zones to JCUH Middlesbrough
Primary angioplasty within 150 minutes of call for help
MINAP public report 2009
WYT
AMG WAL
VICSTO
UCL
TOR
STHSTM
GEO
SGH
SAN
RSC
RFHRDE
BOU
BHR
QEB
QAP
PAPNGS
NCR
MRIBHL
LIS
LGI
KCH
RAD
JCUH
HH
HAM
GRL
FRE
ESU
DUD
BRI
EBH
BAL
30%
40%
50%
60%
70%
80%
90%
100%
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 800 850 900 950 1000
Number of cases
Perc
enta
ge m
eetin
g do
or to
bal
loon
90
min
utes
(%)
England average = 79%
Primary angioplasty within 150 minutes of Call for HelpMINAP Public report 2009
Primary angioplasty within 150 minutes of Call for HelpMINAP Public report 2014
PPCI:WHYIWON’TNEEDTOSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Issues– 1:6rotas– whenI’m65nolongernecessaryinEngland
– Largerinstitutionalvolumes– Biggerteams– Lessonerousrotas–Morereliableprocesses– Betterperformancemetrics
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Issues– Impactof‘on-callduties’– Atthetime?– Thenextday?– Thenextweek?– Influenceofincreasingage?– Lessonsfromotherprofessions?
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
ONCALLDUTIES=SLEEPDEPRIVATION• Sleepdeprivationisreducedtotalsleeptime(decreased
quantity)orfragmentationofsleep(decreasedquality).• Acutesleepdeprivation
– measurablechangesincognitiveperformance,alertness,andneurobehavioralfunction.Susceptibilitytosuchchangesvariesamongindividuals.
• Chronicsleepdeprivation– associatedwithavarietyofadverseoutcomesinobservational
studies– reducedperformance,increasedriskforaccidentsanddeath,and
detrimentaleffectsonbothpsychologicalandphysicalhealth.
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’– Atthetime?physiciancrossoverstudyof24hrworkingtest– reducedconcentrationendurancePsychoneuroendocrinology 2014;47:221-31
poston-calltestingofconcentration<4hourssleepincreasederrorsJBoneJSurg 2012;94:1975-81
physiciancrossoverstudyof24hrworkingIncreasedVPBsandBPEur HeartJ2009;30:2606-13
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’– Thenextday?– Thenextweek?
RecoveryfromsleepdeprivationMeanage25Largeinter-individualvariabilityinrecoveryØSleepiness ~1.1dayØLapses ~3.2daysØReactiontime ~6.6days
Chronobiol Int 2008;25:297-308
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘oncallduties’- lessonsfromotherprofessions?
– USFighterPilots3hrlyflightsimulatortestsover35hrs
performancesignificantlydeclinedafter20hrsJAppResearchMemoryandCognition2012127-33
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’– ThenextdayPCI?PCIperformed11pmto7amPCIthenextday“sleepdeprivedcases”
Singlecentredata- 5years167“sleepdeprivedcases”MortalityRR6.8(0.7-39)
Cath Cardiovasc Interv 2012:80;1149-54
Registrydata- 3years36,049“sleepderivedcases”MortalityRR1.02(0.94– 1.12)
JACC:CardiovascularInterventions2015;8:49-56
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’– ThenextdayPCI?PCIperformed11pmto7amPCIthenextday“sleepdeprivedcases”
Sonoproblem?
– .
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’– ThenextdayPCI?PCIperformed11pmto7amPCIthenextday“sleepdeprivedcases”
Sonoproblem?But… 1945of5014interventionistsdon’tdo
“sleepdeprivedcases”97.6%ofcasesperformedwerenot“sleepdeprivedcases”
– Resipsa loquitor
PPCI:WHYIMIGHTSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Influenceofincreasingage?Age22v68– 26hourwakeperiodbettertoleratedbyoldersubjects!
JAmGS2009;57:1245-51
– Sleepresistancenotrelatedtoage– Sleepresistanceafeatureofgreaterprefrontal/executivefunctioning
Aviat SpaceEnvironM2009;80:81-7
PPCI:WHYIMIGHTSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactofincreasingage- lessonsfromotherprofessions?– Upperagelimitforcommercialpilots
1919- 45yearsagelimit1963- ICAO 60yearsagelimit2007- ICAO 65yearsagelimit
Mainissue-suddenincapacitatingdiseases•Coronaryheartdisease•Stroke•Seizure
••••
DrAnthonyEvansofInternationalCivilAviationOrganization
PPCI:WHYIMIGHTSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactofincreasingage- lessonsfromotherprofessions?– Upperagelimitforcommercialpilots
1919- 45yearsagelimit1963- ICAO 60yearsagelimit2007- ICAO 65yearsagelimit
Mainissue-suddenincapacitatingdiseases•Coronaryheartdisease•Stroke•Seizure
otherissue- gradualperformancedegradation•Reactiontime•Shorttermmemory•Flexibility•Physicaldegradation– Vision– Hearing
Performancedegradationriskincreaseswithincreasingage•Simulationchecks+peerreviewwilldetectmostcasesofsignificantdeterioration
DrAnthonyEvansofInternationalCivilAviationOrganization
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
AgeisnotaparticularlyinterestingsubjectAnyonecangetold
Allyouhavetodoislivelongenough
GrouchoMarx(1890– 1977)
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’Nextday-PCIthenextday?OPDclinicdecisions?Managementdecisions?Behaviour?Cardriving?
PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Impactof‘on-callduties’Longertermavailabilityforotheractivities?ResearchTAVICTOetc.Teaching/trainingLeadershipManagement
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
• Issues– 1:6rotas
– Impactof‘on-callduties’
– Impactofincreasingage
– Implicationsforservicemodelse.g.dutiesafteron-call?
e.g.oncallafterlabdays?e.g.12hourw/eshifts?
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Conclusions1– Beawareofthisasanissue– IntegrateintoplanningaPCIservice– Integrateintoplanningacardiologyservice– Nosimplerules- pragmaticflexibleapproach– Teamdecisions
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Conclusions2• CouldI?• ShouldI?
• WillIhaveto?
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Conclusions2• CouldI– yes• ShouldI– no– Notnecessary– Nothealthy– Notsafe– Notsustainable
• WillIhaveto?
PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!
Conclusions2• CouldI– yes• ShouldI– no– Notnecessary– Nothealthy– Notsafe– Notsustainable
• WillIhaveto– no– thankstomycolleagues
JAHPCIauditdata
total PPCI rota• 2004 239 20 MiddlesbroughPPCI• 2005 259 32 1:5• 2006 250 43 +NYorks• 2007 215 47 1:6• 2008 240 92 +regionalroll-out• 2009 228 89 1:7• 2010 205 73• 2011 180 84• 2012 177 62• 2013 143 60 1:8• 2014 149 401:17
1:2ROTA36
1:5ROTA47
1:17ROTA58
DRJIMHALLJAMESCOOKUNIVERSITYHOSPITAL
MIDDLESBROUGH
WHYIDON’TNEEDTOSUSTAINA1:6ONCALLSERVICEUNTILI’M65!