NHSCANCER                                     NHS ImprovementDIAGNOSTICS              National roll-out of Primary PCI for...
ContentsForeword                 3Introduction             4The national picture     5The network picture      6Common the...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 3ForewordThe...
4 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report       Intr...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 5The nationa...
6 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   The netw...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 7Anglia  Ang...
8 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Avon, Gl...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 9Bedfordshir...
10 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Birming...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 11Black Coun...
12 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Cheshir...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 13Coventry a...
14 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Dorset ...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 15East Midla...
16 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Essex  ...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 17Greater Ma...
18 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Herefor...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 19Kent  Kent...
20 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Lancash...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 21North & Ea...
22 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   North C...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 23North East...
24 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   North T...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 25North West...
26 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   North o...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 27Peninsula ...
28 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Shropsh...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 29South Cent...
30 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   South E...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 31South West...
32 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Surrey ...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 33Sussex    ...
34 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   West Yo...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 35Common the...
36 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report   Cross-b...
National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 37Conclusion...
38 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim reportwww.improv...
ContactsCarol MarleyNational Improvement Lead, Reperfusion, NHS Improvementemail: carol.marley@improvement.nhs.ukSheelagh ...
NHSCANCER                                                                                NHS ImprovementDIAGNOSTICSHEART  ...
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National roll-out of Primary PCI for patients with ST segment elevation myocardinal infarction

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National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction
The Department of Health estimated that it was feasible for PPCI to be rolled out to at least 95% of the population over three about years, but implementation would be for local determination. NHS Improvement was available to support, guide and coordinate the 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.
(Published October 2010).

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National roll-out of Primary PCI for patients with ST segment elevation myocardinal infarction

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICS National roll-out of Primary PCI for patients with ST segment elevationHEART myocardial infarction: An interim reportLUNGSTROKE
  2. 2. ContentsForeword 3Introduction 4The national picture 5The network picture 6Common themes 35Conclusion 37AuthorsDr J M McLenachanNational Clinical Lead, Reperfusion, NHS Improvement,Consultant Cardiologist, Leeds General InfirmarySheelagh MachinDirector, NHS ImprovementCarol MarleyNational Improvement Lead, NHS Improvement
  3. 3. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 3ForewordThe 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, SouthamptonGateway Reference: 14878 www.improvement.nhs.uk/heart
  4. 4. 4 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Introduction 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.www.improvement.nhs.uk/heart
  5. 5. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 5The national pictureThe rate of increase in the proportion of eligible patientsreceiving PPCI, and the proportionate fall in the use of Figure 1: National MINAP Datathrombolysis is shown in figure 1. 100 90In the third quarter of 2008, 58% of those patients who 80received any reperfusion treatment were treated with 70thrombolysis and 42% were treated with PPCI. By the end 60of the first quarter of 2010, the proportion treated with 50PPCI had risen to 73% and the proportion treated with 40thrombolysis had fallen to 27%. 30 20It is important to understand that some patients with ST 10segment elevation myocardial infarction may receive 0neither PPCI or thrombolysis, usually for sound clinical 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1reasons. Review of the numbers of patients not receiving PPCI LYSISany form of reperfusion therapy shows no major increasein this group as a result of the switch from lysis to PPCI(figure 2). Figure 2: National MINAP Data - Patients not receiving reperfusion treatment 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 No Reperfusion Treatment www.improvement.nhs.uk/heart
  6. 6. 6 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report The network picture Even before the publication of the NIAP report, some areas of the country had well-established PPCI services. These areas included all of the London networks, the Black Country, West Yorkshire and North Yorkshire. Many hospitals, however, were delivering only ad-hoc PPCI in small numbers. The next few pages summarise the progress made between October 2008 and April 2010 in each of the 28 cardiac and stroke networks in England.www.improvement.nhs.uk/heart
  7. 7. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 7Anglia Anglia MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation2.3 millionHospitals providing 24/7 PPCINorfolk and Norwich Hospital, NorwichPapworth Hospital, CambridgeHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedBasildon Hospital, BasildonCommentsApproximately 87% of the population is now covered byPPCI service. Pilot study of optimum treatment for EastSuffolk residents is in progress. www.improvement.nhs.uk/heart
  8. 8. 8 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Avon, Gloucestershire, Somerset and Wiltshire Comments Avon, Gloucestershire, Somerset and Wiltshire MINAP Data Approximately 56% of the population is now covered by 100 PPCI service. 90 80 Planning to achieve 100% population coverage by 70 November 2011. 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 2.8 million Hospitals providing 24/7 PPCI Musgrove Park Hospital, Taunton Bristol Royal infirmary, Bristol Hospitals providing limited hours PPCI Royal United Hospital Bath, Bath Cheltenham General Hospital, Cheltenham The Great Western Hospital, Swindon Neighbouring centres where PPCI patients may be treated John Radcliffe Hospital, Oxford Royal Berkshire Hospital, Reading Southampton General Hospital, Southampton Royal Bournemouth General Hospital, Bournemouth Dorset County Hospital, Dorchesterwww.improvement.nhs.uk/heart
  9. 9. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 9Bedfordshire and Hertfordshire Bedfordshire and Hertfordshire MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.68 millionHospitals providing 24/7 PPCINoneHospitals providing limited hours PPCILister Hospital, StevenageWatford General Hospital, WatfordNeighbouring centres where PPCI patientsmay be treatedPapworth Hospital, CambridgeHarefield Hospital, MiddlesexComments100% population coverage achieved. www.improvement.nhs.uk/heart
  10. 10. 10 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Birmingham, Sandwell and Solihull Neighbouring centres where PPCI patients Birmingham, Sandwell and Solihull MINAP Data may be treated 100 New Cross Hospital, Wolverhampton 90 University Hospital, Coventry 80 70 Comments 60 100% population 50 coverage achieved. 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.50 million 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 where the patient presents) Hospitals providing limited hours PPCI Nonewww.improvement.nhs.uk/heart
  11. 11. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 11Black Country Black Country MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1 millionHospitals providing 24/7 PPCINew Cross Hospital, WolverhamptonHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedBirmingham HospitalsComments100% population coverage achieved. www.improvement.nhs.uk/heart
  12. 12. 12 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Cheshire and Merseyside Cheshire and Merseyside MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 2.0 million Hospitals providing 24/7 PPCI Liverpool Heart and Chest Hospital, Liverpool Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated None Comments Approximately 46% population coverage on1 April 2010. Coverage then increased to 100% on 1 June 2010.www.improvement.nhs.uk/heart
  13. 13. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 13Coventry and Warwickshire Coventry and Warwickshire MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation0.88 millionHospitals providing 24/7 PPCIUniversity Hospital, CoventryHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedBirmingham Heartlands Hospital, BirminghamComments100% population coverage achieved. www.improvement.nhs.uk/heart
  14. 14. 14 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Dorset Comments Dorset MINAP Data Daytime PPCI provided at Dorset and Bournemouth with 100 thrombolysis for out-of-hours presenters. Planning to 90 achieve 100% population coverage by November 2011. 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 0.78 million Hospitals providing 24/7 PPCI None Hospitals providing limited hours PPCI Royal Bournemouth Hospital, Bournemouth Dorset County Hospital, Dorchester Neighbouring centres where PPCI patients may be treated Southampton General Hospital, Southampton Royal Devon and Exeter Hospital, Exeter Musgrove Park Hospital, Tauntonwww.improvement.nhs.uk/heart
  15. 15. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 15East Midlands Comments East Midlands MINAP Data Extensive consultation process over last 18 months. Plans 100 now in place to have 100% population coverage by 90 November 2011. 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation3.8 millionHospitals providing 24/7 PPCIGlenfield Hospital, LeicesterHospitals providing limited hours PPCIRoyal Derby Hospital, DerbyKettering General Hospital, KetteringNorthampton General Hospital, NorthamptonNottingham City Hospital, NottinghamNeighbouring centres where PPCI patientsmay be treatedNorthern General Hospital, SheffieldJohn Radcliffe Hospital, OxfordUniversity Hospital, Coventry www.improvement.nhs.uk/heart
  16. 16. 16 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Essex Essex MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.7 million Hospitals providing 24/7 PPCI Essex Cardiothoracic Centre, Basildon Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Bart’s and the London NHS Trust, London Harefield Hospital, Middlesex Comments 100% population coverage achieved.www.improvement.nhs.uk/heart
  17. 17. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 17Greater Manchester and Cheshire Comments Greater Manchester and Cheshire MINAP Data 50% population coverage on 1 April 2010. This increased 100 to 80% on 6 September 2010 with plans to go to full 90 100% coverage in March 2011. 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation3.2 millionHospitals providing 24/7 PPCIManchester Royal Infirmary, ManchesterWythenshawe Hospital, ManchesterHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedUniversity Hospital of North Staffordshire, Stoke on Trent www.improvement.nhs.uk/heart
  18. 18. 18 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Hereford and Worcester Pre hospital thrombolysis with immediate transport to a Hereford and Worcester MINAP Data PCI centre will be the treatment of choice for areas with 100 long travel times. 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 0.8 million Hospitals providing 24/7 PPCI None Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated New Cross Hospital, Wolverhampton Queen Elizabeth Hospital, Birmingham University Hospital, Coventry Comments Plans to introduce daytime access to PPCI at Worcester Royal Hospital with out of hours transfer to existing PPCI services in Birmingham are in progress.www.improvement.nhs.uk/heart
  19. 19. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 19Kent Kent MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.6 millionHospitals providing 24/7 PPCINoneHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedGuys and St Thomas’s, LondonKing’s College Hospital, LondonCommentsKent now has 100% population coverage for PPCI basedat The William Harvey Hospital, Ashford. The servicecommenced on 12 April 2010. www.improvement.nhs.uk/heart
  20. 20. 20 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Lancashire and Cumbria There are plans to roll out PPCI to 75% of the population Lancashire and Cumbria MINAP Data over the next 12 months. Cumbria will continue with 100 thrombolysis because of the long travel times from this 90 area pending the development of a PCI / PPCI centre at 80 Carlisle. 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.9 million Hospitals providing 24/7 PPCI Victoria Hospital, Blackpool Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated None Comments The current service covers only the Blackpool catchment area (approximately 17% of the network population).www.improvement.nhs.uk/heart
  21. 21. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 21North & East Yorkshire and Northern Lincolnshire North & East Yorkshire and Northern Lincolnshire MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.3 millionHospitals providing 24/7 PPCICastle Hill Hospital, HullHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedLeeds General Infirmary, LeedsJames Cook University Hospital, MiddlesbroughCommentsPPCI currently covers 60% of the population. Planning toroll out to 100% by November 2011. www.improvement.nhs.uk/heart
  22. 22. 22 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report North Central London North Central London MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.2 million Hospitals providing 24/7 PPCI Royal Free Hospital, London The Heart Hospital, London Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Any other London hospital Comments 100% population coverage achieved.www.improvement.nhs.uk/heart
  23. 23. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 23North East London North East London MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.5 millionHospitals providing 24/7 PPCIBarts and the London HospitalHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedEssex Cardiothoracic Centre, BasildonComments100% population coverage achieved. www.improvement.nhs.uk/heart
  24. 24. 24 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report North Trent North Trent MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.75 million Hospitals providing 24/7 PPCI Northern General Hospital, Sheffield Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated None Comments 79% population coverage on 1 April 2010. Coverage increased to 100% on 6 April 2010.www.improvement.nhs.uk/heart
  25. 25. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 25North West London North West London MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.8 millionHospitals providing 24/7 PPCIHammersmith Hospital, LondonHarefield Hospital, MiddlesexHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedSt George’s Hospital, LondonBart’s and the London, LondonLondon Chest Hospital, LondonThe Heart Hospital, LondonComments100% population coverage achieved. www.improvement.nhs.uk/heart
  26. 26. 26 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report North of England North of England MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 2.8 million Hospitals providing 24/7 PPCI James Cook University Hospital, Middlesbrough Freeman Hospital, Newcastle Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Leeds General Infirmary, Leeds Comments 100% population coverage achieved.www.improvement.nhs.uk/heart
  27. 27. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 27Peninsula Cornwall patients may receive thrombolysis because of longer travel Peninsula MINAP Data times to the PPCI centre. At present South Devon patients receive 100 thrombolysis out of hours. Referral pathways to Derriford and Royal 90 Devon and Exeter NHS Foundation Trust are in discussion to ensure 80 a 24/7 service is provided for South Devon patients. 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.6 millionHospitals providing 24/7 PPCIRoyal Devon and Exeter Hospital, ExeterDerriford Hospital, PlymouthHospitals 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 www.improvement.nhs.uk/heart
  28. 28. 28 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Shropshire and Staffordshire Shropshire and Staffordshire MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.5 million Hospitals providing 24/7 PPCI University Hospital of North Staffordshire, Stoke on Trent Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated New Cross Hospital, Wolverhampton Heart of England NHS Foundations Trust Comments 100% population coverage achieved.www.improvement.nhs.uk/heart
  29. 29. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 29South Central PPCI from their nearest 24/7 centre from 14 April 2010 onwards South Central MINAP Data and Buckinghamshire patients have had access to PPCI from their 100 nearest 24/7 centre since 26 May 2010. Portsmouth have provided 90 a 24/7 service since 1 September 2010. Population coverage of 80 97% has now been achieved. 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation4.2 millionHospitals providing 24/7 PPCIJohn Radcliffe Hospital, OxfordSouthampton General Hospital, SouthamptonRoyal Berkshire Hospital, ReadingNorth Hampshire Hospital, BasingstokeHospitals providing limited hours PPCIWycombe General Hospital, High WycombeQueen Alexandra Hospital, PortsmouthNeighbouring centres where PPCI patients may be treatedHarefield Hospital, MiddlesexFrimley Park Hospital, SurreyCommentsCoverage 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 www.improvement.nhs.uk/heart
  30. 30. 30 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report South East London South East London MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.3 million Hospitals providing 24/7 PPCI Guy’s and St Thomas’s Hospital, London Kings College Hospital, London Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated None Comments 100% population coverage achieved.www.improvement.nhs.uk/heart
  31. 31. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 31South West London South West London MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.4 millionHospitals providing 24/7 PPCISt George’s Hospital, LondonHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedNoneComments100% population coverage achieved. www.improvement.nhs.uk/heart
  32. 32. 32 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Surrey Comments Surrey MINAP Data Current population coverage is around 85-90% for 100 daytime presenters and 20% for out-of-hour’s presenters. 90 Planning to achieve 100% population coverage by 80 November 2011. 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 1.1 million Hospitals providing 24/7 PPCI Frimley Park Hospital, Frimley Hospitals providing limited hours PPCI St Peters Hospital, Chertsey East Surrey Hospital, Redhill Neighbouring centres where PPCI patients may be treated St George’s Hospital, Londonwww.improvement.nhs.uk/heart
  33. 33. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 33Sussex Comments Sussex MINAP Data 75% population coverage on 1 April 2010. Planning to achieve 100 100% by March 2011. 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSISPopulation1.6 millionHospitals providing 24/7 PPCIRoyal Sussex County Hospital, BrightonEastbourne District General Hospital, EastbourneConquest Hospital, St Leonards on SeaHospitals providing limited hours PPCIWorthing Hospital, WorthingNeighbouring centres where PPCI patientsmay be treatedSouthampton General Hospital, SouthamptonEast Surrey Hospital, RedhillWilliam Harvey Hospital, AshfordFrimley Park Hospital, Frimley www.improvement.nhs.uk/heart
  34. 34. 34 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report West Yorkshire West Yorkshire MINAP Data 100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1 PPCI LYSIS Population 2.2 million Hospitals providing 24/7 PPCI Leeds General infirmary, Leeds Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Northern General Hospital, Sheffield Castle Hill Hospital, Hull James Cook University Hospital, Middlesbrough Comments 100% population coverage achieved.www.improvement.nhs.uk/heart
  35. 35. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 35Common themesWhile formulating and implementing the individual The PCI-related delay is made up mainly of the travel timenetwork plans for the delivery of PPCI, a number of to the PCI centre and the so called ‘door-to-balloon’ timecommon themes emerged. at the PCI centre. For patients with longer travel times, there is evidence that the ‘door-to-balloon’ time can beLocal politics shortened to around 30 minutes because the PCI centre isCardiology has seen considerable decentralisation over the ready and prepared for the patient’s arrival. This allows alast two decades with many procedures that were once the travel time of 70-90 minutes. In some rural areas ofpreserve of tertiary referral centres now being performed England, a travel time of 90 minutes may still not bein large numbers in district general hospitals. A primary enough to reach a PCI centre (eg. Cumbria, East Suffolk,PCI service requires 24/7 catheter lab availability, a service Isle of Wight). This should apply to less than 5% of thenot available in many district hospitals. In some areas, the English population. If patients from these areas cannotdevelopment of a PPCI service has been perceived as a receive PPCI, it is very important that they receive the next‘centralisation’ process which threatens some district best standard of care. This involves pre-hospitalgeneral hospitals. This has occasionally led to a desire to thrombolysis followed by immediate transfer to a PCIretain local thrombolysis over what is seen as a distant centre. It is well established that 25%-35% of thesePPCI service. It is very important that the needs of the patients will fail to reperfuse following thrombolysis; if thispatient, rather than the needs of the hospital, dictate how happens, then the patient should receive rescue PCI asthe service is organised. This is vital during patient and quickly as possible. This cannot happen if the patient haspublic engagement; the setting up of a PPCI service should been given pre-hospital thrombolysis and has then beenbe seen as something to reduce the rate of death and taken to a hospital without PCI facilities.stroke in local patients, based on the best availablescientific evidence, and not as something being taken Call-to-balloon time of 150 minutesaway from the local hospital. For the reasons outlined above, it has been proposed that the threshold used to assess the performance of a PPCILong travel times service should be the proportion of patients in whom aThe time delay between the patient (or relative) first calling call-to-balloon time of less than 150 minutes is achieved.for medical help and the patient later receiving reperfusion Experience has shown that this time is readily achievable intreatment will almost always be longer for PPCI than for most parts of the country where diagnosis of ST segmentthrombolysis. There has been much debate about what is elevation MI is made by the ambulance service and thean ‘acceptable’ PCI-related delay. In other words, at what patient is taken directly to the PPCI centre. In contrast,length of PCI-related delay are the clear benefits of PPCI it is much harder to achieve if the patient is taken initiallyover thrombolysis lost? There is some consensus that the to a non-PPCI hospital. Call-to-balloon time (likebenefits of PPCI are retained unless the PCI related delay ‘call-to-needle’ time) measures performance across theexceeds 120 minutes. whole patient pathway which will include the ambulance service, the non-PPCI hospital and the PPCI centre. www.improvement.nhs.uk/heart
  36. 36. 36 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report Cross-boundary working Workforce and training issues There are well established routes of referral between PPCI involves a major shift towards out-of-hours working. For general practitioners and local hospitals and between many centres, this has involved employing and training district hospitals and tertiary centres. These have evolved additional nursing, physiology and radiography staff. For largely for elective and urgent care. Because time delays existing catheter lab staff, the move towards more frequent are critical when setting up a PPCI Service, networks have night time and weekend working has sometimes been had to consider where patients might receive PPCI with the difficult to manage. Whatever local arrangements are made, minimum time delay. For some patients, the nearest PPCI it is clearly important that the PPCI service is sustainable in the centre may not be within the cardiac network, or even long term. within the Strategic Health Authority, in which they live. All networks, therefore, have had to consider where patients, Response from the networks particularly those patients close to the network As part of this survey, cardiac networks were asked whether boundaries, are likely to receive the speediest care. any specific issues had delayed their plans to implement PPCI. Three networks reported that discussion over the funding of Limited hours and 24/7 centres the necessary additional ambulance activity had led to delays Most PPCI centres in England operate 24 hours per day, in implementing the service. Three networks cited delays in seven days per week. Some smaller hospitals operate a recruiting interventional cardiologists and two mentioned PCI service which includes treating ST segment elevation delays in recruiting nursing and other cardiac catheter lab MI patients during working hours (9am to 5pm, or 7am to staff. 7pm Monday to Friday). Patients outside of these times are then taken to the nearest 24/7 Centre. This requires careful planning between the limited hours centre, the 24/7 centre and the ambulance service. The service should be centred around what is best for the patient; there is little point in having a 9-5 service if the busiest times on the roads (and hence the longest transfer times) are 8-9am and 5-6pm.www.improvement.nhs.uk/heart
  37. 37. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 37ConclusionConsiderable 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 as many patients as possible are diagnosed by the ambulance service and taken directly to the PPCI centre, avoiding accident and emergency units and coronary care units.2. Minimising door-to-balloon times at PPCI centres.3. Developing strategies for dealing with simultaneous referrals. Most PPCI centres can only treat one patient at a time, particularly out-of-hours. If two or more referrals are made to the same centre within a few minutes, then it clearly benefits the second patient if they can be taken to an alternative PPCI centre which is not already treating a STEMI patient provided the procedure is still carried out within an acceptable time frame. In urban areas, this will involve cooperation between neighbouring PPCI centres. www.improvement.nhs.uk/heart
  38. 38. 38 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim reportwww.improvement.nhs.uk/heart
  39. 39. ContactsCarol MarleyNational Improvement Lead, Reperfusion, NHS Improvementemail: carol.marley@improvement.nhs.ukSheelagh MachinDirector, Heart, NHS Improvementemail: sheelagh.machin@improvement.nhs.uk
  40. 40. NHSCANCER NHS ImprovementDIAGNOSTICSHEART NHS Improvement With ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money toLUNG improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services.STROKE NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Publication Ref: IMP/comms002 - October 2010 ©NHS Improvement 2010 | All Rights Reserved Delivering tomorrow’s improvement agenda for the NHS

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