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NHSCANCER                                   NHS Improvement                                                     HeartDIAGN...
ContentsSummary                                                                    3Treatment of ST segment elevation MI: ...
Growth of Primary PCI for the treatment of heart attack patients in England   3                                    2008-20...
4    Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
Growth of Primary PCI for the treatment of heart attack patients in England   5                                     2008-2...
6    Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
Growth of Primary PCI for the treatment of heart attack patients in England   7                                      2008-...
8    Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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10   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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12   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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14   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
Growth of Primary PCI for the treatment of heart attack patients in England   15                                          ...
16   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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18   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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20   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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22   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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24   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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26   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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28   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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30   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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36   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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38   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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40   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
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Growth of Primary PCI for the treatment of heart attack patients in England   45      2008-2011: the role of NHS Improveme...
46   Growth of Primary PCI for the treatment of heart attack patients in England     2008-2011: the role of NHS Improvemen...
ContactsCarol MarleyNational Improvement Lead, Reperfusion, NHS Improvementemail: carol.marley@improvement.nhs.ukSheelagh ...
NHSCANCER                                                                                                NHS ImprovementDI...
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Growth of primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the cardiac networks

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Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks
Primary percutaneous coronary intervention (PPCI) is the optimum reperfusion treatment for patients presenting with ST segment elevation myocardial infarction (STEMI). During the third quarter of 2008, just 46% of those STEMI patients in England who received reperfusion treatment were being treated by PPCI while the remaining 54% were treated with thrombolysis. By the second quarter of 2011, 94% of patients were treated with PPCI. This document describes the role of NHS Improvement and the Cardiac Networks in achieving this rapid change in clinical practice. (Published January 2012)

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Growth of primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the cardiac networks

  1. 1. NHSCANCER NHS Improvement HeartDIAGNOSTICSHEART Growth of Primary PCI for the treatment of heart attack patients in EnglandLUNG 2008-2011: the role of NHS Improvement and the Cardiac NetworksSTROKE January 2012
  2. 2. ContentsSummary 3Treatment of ST segment elevation MI: thrombolysis vs PPCI 4The National Infarct Angioplasty Project (NIAP) 6The need for ‘a faster pace of change’ 7Roll of NHS Improvement and the Cardiac Networks in the roll-out of PPCI 8Results (1) - The national picture 9Results (2) - PPCI roll-out by network 10Outcomes - are we making a difference? 39Rehabilitation 40Patient and carer perspectives 41Unfinished business: 42a. patients who cannot receive PPCIb. patients who do not receive reperfusion therapyConclusions 43
  3. 3. Growth of Primary PCI for the treatment of heart attack patients in England 3 2008-2011: the role of NHS Improvement and the Cardiac NetworksSummaryPrimary percutaneous coronary intervention (PPCI)is the optimum reperfusion treatment for patientspresenting with ST segment elevation myocardialinfarction (STEMI). During the third quarter of2008, just 46% of those STEMI patients inEngland who received reperfusion treatment werebeing treated by PPCI while the remaining 54%were treated with thrombolysis. By the secondquarter of 2011, 94% of patients were treatedwith PPCI. This document describes the role ofNHS Improvement and the Cardiac Networks inachieving this rapid change in clinical practice. www.improvement.nhs.uk/heart
  4. 4. 4 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Treatment of ST segment elevation myocardial infarction (STEMI) in England ST segment elevation myocardial infarction services throughout England. The paramedic (STEMI) is caused by acute thrombotic occlusion of ambulance personnel were trained in ECG one of the major epicardial coronary arteries. The interpretation and guidelines were drawn up for aim of treatment is to re-open the occluded the administration of fibrinolytic agents in coronary artery as quickly as possible in order to ambulances en-route to the nearest hospital. In minimise the damage to heart muscle. Normal 2009-10, of the 8,166 patients who were treated blood flow can be re-established either with thrombolysis, 1,706 (21%) received pharmacologically (with thrombolytic drugs) or thrombolysis in an ambulance (pre-hospital mechanically (with percutaneous coronary thrombolysis) while 6,460 received thrombolysis in intervention (PCI)). hospital (3). Thrombolysis in the UK Thrombolysis, however, has a number of Following the publication of the ISIS-2 study (1), limitations as a treatment for ST elevation MI. the use of thrombolysis in England spread rapidly First, some patients will have a contra-indication in the late 1980s and 1990s. Streptokinase was to thrombolysis; this may account for as many as the initial agent, followed by the fibrin-specific 25% of patients (4). Second, the thrombolytic agents including rtPA, reteplase and tenecteplase. agent may fail to re-open the occluded artery in All agents reduce mortality. With the publication around 25-35% of those presenting with ST of the National Service Framework for Cardiology elevation MI (5). Third, even if the lytic agent in 2000 (2), there was a new focus on the successfully re-opens the occluded artery, the performance of thrombolysis. National targets vessel may re-occlude resulting in further were set to ensure patients received treatment myocardial infarction (6). Fourth, all thrombolytic without undue delay. These included targets for agents carry a risk of haemorrhagic stroke, which the ‘door-to-needle’ time, this being the time is often fatal. In routine clinical practice, the risk of interval between the arrival of the patient at the stroke and other bleeding complications may be door of the Accident & Emergency Department very much higher than in the younger and fitter and the initiation of thrombolysis. Latterly this patients generally included in randomised clinical target time was set at 30 minutes. These times trials of new thrombolytic agents. This was one were recorded and entered into a national possible explanation for the discrepancy between database (Myocardial Ischaemia National Audit the 13-15% mortality rate for myocardial Project) which was them published annually (3). infarction in England around 2003-4 and the Other data collected included the percentage of 4-6% mortality rates being reported in MI patients treated with aspirin, the percentage contemporaneous clinical trials of new fibrinolytic treated with beta blockers and the percentage drugs which often excluded higher risk patients treated with statins. The setting of standards, and (patients over the aged of 70, patients with the subsequent collection and publication of data previous myocardial infarction and patients for individual hospitals, brought about a marked presenting in cardiogenic shock). improvement in the treatment of STEMI patients between 2000 and 2006. The awareness that early administration of thrombolysis was associated with better outcomes led to the organisation of pre-hospital thrombolysis (PHT)www.improvement.nhs.uk/heart
  5. 5. Growth of Primary PCI for the treatment of heart attack patients in England 5 2008-2011: the role of NHS Improvement and the Cardiac NetworksPrimary PCI for ST segment elevation MIThe first publications of PCI as a treatment for STsegment elevation myocardial infarction appearedin the 1990s. A metanalysis of the early studieswas published in 2003 (7). In a total of more than7,700 patients randomised to either PCI orthrombolysis, the rate of death was significantlylower in those who underwent PPCI (7% versus9%). PPCI also reduced the rates of non fatalre-infarction and, importantly, of stroke.Timing of PPCIThe superiority of PPCI over thrombolysis isbeyond doubt if the delay to treatment is thesame for both treatments. However, PPCI usuallyinvolves a longer delay to treatment thanthrombolysis, particularly in areas with asuccessful pre-hospital thrombolysis programme.The issue, therefore, was as follows: - at whattime delay are the clear advantages of PPCI overthrombolysis lost? This has been the source ofmuch debate. Initial recommendations were thatPPCI should be carried out with a delay of nomore than 90 minutes (8). However, a recentreview of the data suggested that PPCI remainedthe optimal treatment for STEMI patients providedthe PCI-related delay (ie the delay from the timethe patient would have received lysis to the timeof the PCI procedure) does not exceed 120minutes (9). The evidence that PPCI could still bebeneficial even with a longer PCI-related delayopened up the possibility of treating a muchgreater proportion of the population, and not justthose living close to PPCI centres. www.improvement.nhs.uk/heart
  6. 6. 6 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks The National Infarct Angioplasty Project (NIAP)10 By 2004, some areas of the United Kingdom, The key findings from NIAP were as follows: particularly the London area, were offering a 24/7 PPCI service for patients with ST segment 1. PPCI was deliverable in a UK setting within elevation MI. Outside London, the service was acceptable treatment times. patchy and there were doubts about whether it 2. The shortest times to treatment were achieved was possible to organise this type of service on a through direct admission to the cardiac cath national level. The National Infarct Angioplasty lab. Project (NIAP) was a feasibility study designed to 3. Longer times to treatment occurred if the examine whether it was possible to set up PPCI as patients were first assessed in an Accident & the default treatment for STEMI patients in the Emergency Department or at a local (non PPCI) UK. The project was co-sponsored by the hospital. Department of Health and the British 4. Longer times to treatment were associated Cardiovascular Society. 2245 patients were with a higher mortality rate. recruited in the 12 month period from April 2005 5. Although PCCI was more expensive to deliver to April 2006. The results, including one year than thrombolysis, PPCI was both clinically follow-up data, were published in October 2008 effective and cost effective when delivered (10). within 120 minutes. 6. Although NIAP was not a randomised trial, PPCI was associated with few complications, a lower recurrence rate of heart attack, a low incidence of stroke and a low mortality rate, all of which compared favourably with thrombolysis data published in clinical trials and registries.www.improvement.nhs.uk/heart
  7. 7. Growth of Primary PCI for the treatment of heart attack patients in England 7 2008-2011: the role of NHS Improvement and the Cardiac NetworksThe need for ‘a faster pace of change’The final report of the National Infarct AngioplastyProject was published in October 2008 under thetitle ‘Treatment of Heart Attack NationalGuidance.’ In the foreword to the NIAPpublication, Ann Keen, Parliamentary UnderSecretary of State for Health commended thefeasibility project and said that a faster pace ofchange was needed with a rapid expansion ofPPCI throughout England. The NHS waschallenged with the task of rolling PPCI out tocover 95% of the population of England within aperiod of three years. www.improvement.nhs.uk/heart
  8. 8. 8 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Role of NHS Improvement and the Cardiac Networks in the roll-out of PPCI Following the announcement that PPCI would be To assist each network in developing a local rolled out to cover 95% of the population over a implementation plan, resources were provided by period of three years, there was discussion as to NHS Improvement. NHS Improvement hosted a how this might be achieved. It was clear that any number of national meetings including bi-annual PPCI service had to operate 24 hours a day, seven meetings that brought together the clinical leads days a week. It was equally clear that for all of the 28 networks. The purpose of these hospitals providing a PCI service to move to a 24/7 meetings was to reflect on progress and to share PPCI service would be difficult and hugely successful experiences. NHS Improvement also inefficient. The task of developing a roll-out published two documents to aid the networks in strategy for England was given to the 28 cardiac developing their strategy. A Guide to networks (or cardiac and stroke networks) who Implementing Primary Angioplasty was published work closely with NHS Improvement, the aims of in June 2008 and National Roll-out of Primary PCI which are “to achieve sustainable effective for patients with ST segment elevation myocardial pathways, to share improvement resources and infarction: an interim report was published in learning, to ensure value for money and to September 2009. In addition, NHS Improvement improve the efficiency and quality of NHS provided bespoke advice to individual networks as services.” requested and provided expert opinion to local network meetings when invited to do so. In this Different cardiac networks faced different way, each network developed its own local challenges. In some rural areas, with longer implementation plan, tailored to its pre-existing transport times, decisions had to be made about infrastructure, to allow them to commission this whether all patients should be transferred for PPCI new service (PPCI) in line with national strategy. or whether a pre-hospital thrombolysis service should continue for those patients more than 90- 100 minutes drive from the PPCI centre. In other networks, there were issues about whether some smaller hospitals should provide a limited hours PPCI service (9am to 5pm, Monday to Friday) with out of hours patients travelling to the more distant centres or whether all PPCI patients should be transferred directly to the 24/7 centre. Some issues were common to all networks. All networks had to develop pathways for patient referral and transfer to ensure the shortest possible call-to- balloon and door-to-balloon times. All networks had to resolve local issues relating to 24 / 7 staffing of the service by medical, nursing, technical and radiography staff. All had to reach agreement with the non-PPCI hospitals in the network about whether those patients treated by PPCI should spend their entire hospital stay in the PPCI centre or whether they should be transferred to their local hospital after their PPCI procedure. Different networks reached different solutions.www.improvement.nhs.uk/heart
  9. 9. Growth of Primary PCI for the treatment of heart attack patients in England 9 2008-2011: the role of NHS Improvement and the Cardiac NetworksResults (1) - The national pictureFigure 1 summarises the increase in PPCI, and the International comparisons are difficult because ofconsequent fall in the use of thrombolysis, in differences in the completeness of data collectionEngland between the second quarter of 2008 and in different countries. However, an analysis of PPCIthe second quarter of 2011. The numbers are rates in Western Europe published in thepercentages of all those patients with ST segment European Heart Journal showed that the Unitedelevation myocardial infarction who underwent Kingdom, in 2007-8, was lagging behind manyreperfusion treatment. Patients who did not European countries in the development of PPCIreceive reperfusion treatment, for whatever services (figure 2) (11). Figure 4 shows the samereason, are not included. data with the rates for PPCI in England for the second quarter of 2011 superimposed. Whilst thisDuring the third quarter of 2008, around the time is not a valid comparison, since the data shownof the publication of the NIAP report, 45.8% of for the European countries are mostly fromthose STEMI patients who received reperfusion 2007-8, the rate of growth of PPCI in Englandtreatment were being treated by PPCI. The between 2008 and 2011 was almost certainlyremaining patients (54.2%) were treated with higher than in most European counties.thrombolysis, either in-hospital or pre-hospital. Bythe second quarter of 2011, a dramatic shifttowards PPCI had occurred with 93.8% ofpatients now being treated with PPCI. Figure 1: PPCI and Lysis - England PERCENTAGE PPCI LYSIS www.improvement.nhs.uk/heart
  10. 10. 10 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Results (2) - PPCI roll-out by network The trend line in figure 1, showing a steady rise in In other cardiac networks, the changeover was PPCI over the period of three years, might suggest more gradual. East Midlands is one of the largest that the national roll-out of PPCI proceeded at a cardiac networks in the country, covering a constant pace throughout England. This was not population of around three million. The network the case. Some areas, notably the London cardiac includes two cardiac surgical centres (Leicester networks, were already delivering close to 100% and Nottingham) and a number of large district PPCI prior to 2008. Most other areas had a lysis- hospitals (Derby, Lincoln, Northampton and based strategy with only occasional ad-hoc PPCI. Kettering), many of which were already providing a daytime PCI service. The cardiac network, on The challenges faced by the 28 cardiac networks behalf of the SHA, undertook a major were very different, and depended on pre-existing consultation exercise which included: infrastructure, pre-existing clinical practice and local geography. As a result, PPCI services were • Service models developed by the network planned and developed at very different rates up • Pre-qualification questionnaires sent to potential and down the country. Kent, for example, had no providers tertiary centre. Historically, patients from Kent • Accreditation documentation requested from requiring emergency out-of-hours PCI were providers transferred to a London centre. The development • Accreditation documentation evaluated by a of a 24/7 PPCI service for Kent, therefore, required group appointed by the network the cooperation and collaboration of • Service assessment reviews undertaken by interventional cardiologists from different NHS network (including external clinicians and trusts to decide on an appropriate site for the patients). single 24/7 centre. At a time when provider hospitals, and the cardiologists they employ, find A report and recommendations were then themselves increasingly in competition with each produced for the PCTs and the commissioners. other, the ‘honest broker’ role of the cardiac The report was accepted and implemented. The network in hosting these discussions was of great activity graph for East Midlands (page 19) shows importance. In Kent, the decision was to that the rate of change, as different centres came commission a single 24/7 PPCI centre in Ashford. on-line at different times, was very different to The Kent 24/7 PPCI service started in April 2010; Kent. Nevertheless, by the second quarter of as the graph of PPCI activity for Kent shows, (page 2011, PPCI had become the dominant reperfusion 23), this resulted in an almost instantaneous strategy for STEMI patients in East Midlands. switch from lysis to PPCI for the population of Kent. The next few pages describe the development of PPCI services across the 28 cardiac networks in England. For each network, the centres in which PPCI is performed are listed, the roll-out strategy is summarised and the graph shows the % of patients treated with PPCI and thrombolysis (expressed as a % of all those receiving reperfusion treatment) by quarter from the second quarter of 2008 to the second quarter of 2011.www.improvement.nhs.uk/heart
  11. 11. Growth of Primary PCI for the treatment of heart attack patients in England 11 2008-2011: the role of NHS Improvement and the Cardiac NetworksAnglia Anglia Stroke and Heart Network PERCENTAGE 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, BasildonComments100% population coverage achieved www.improvement.nhs.uk/heart
  12. 12. 12 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Avon, Gloucestershire, Somerset and Wiltshire Avon, Gloucestershire, Somerset and Wiltshire Cardiac and Stroke Network PERCENTAGE PPCI LYSIS Population 2.8 million Hospitals providing 24/7 PPCI Musgrove Park Hospital, Taunton Bristol Royal infirmary, Bristol Southampton General Hospital, Southampton 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 Royal Bournemouth General Hospital, Bournemouth Comments 100% population coverage achievedwww.improvement.nhs.uk/heart
  13. 13. Growth of Primary PCI for the treatment of heart attack patients in England 13 2008-2011: the role of NHS Improvement and the Cardiac NetworksBedfordshire and Hertfordshire Bedfordshire and Hertfordshire Heart and Stroke Network PERCENTAGE 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
  14. 14. 14 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Birmingham, Sandwell and Solihull Birmingham, Sandwell and Solihull Cardiac and Stroke Network PERCENTAGE 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 None Neighbouring centres where PPCI patients may be treated New Cross Hospital, Wolverhampton University Hospital, Coventry Comments 100% population coverage achievedwww.improvement.nhs.uk/heart
  15. 15. Growth of Primary PCI for the treatment of heart attack patients in England 15 2008-2011: the role of NHS Improvement and the Cardiac NetworksBlack Country Black Country Cardiovascular Network PERCENTAGE 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
  16. 16. 16 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Cheshire and Merseyside Cheshire and Merseyside Cardiac Network PERCENTAGE 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 100% population coverage achievedwww.improvement.nhs.uk/heart
  17. 17. Growth of Primary PCI for the treatment of heart attack patients in England 17 2008-2011: the role of NHS Improvement and the Cardiac NetworksCoventry and Warwickshire Coventry and Warwickshire Cardiovascular Network PERCENTAGE PPCI LYSISPopulation0.88 millionHospitals providing 24/7 PPCIUniversity Hospitals Coventry and Warwickshire NHS TrustHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedBirmingham Heartlands Hospital, BirminghamComments100% population coverage achieved www.improvement.nhs.uk/heart
  18. 18. 18 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Dorset Dorset Cardiac and Stroke Network PERCENTAGE PPCI LYSIS Population 0.78 million Hospitals providing 24/7 PPCI None Hospitals providing limited hours PPCI 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, Taunton Comments Daytime PPCI provided at Dorset and Bournemouth with thrombolysis for out-of-hours presenterswww.improvement.nhs.uk/heart
  19. 19. Growth of Primary PCI for the treatment of heart attack patients in England 19 2008-2011: the role of NHS Improvement and the Cardiac NetworksEast Midlands East Midlands Cardiac and Stroke Network PERCENTAGE PPCI LYSISPopulation3.8 millionHospitals providing 24/7 PPCIGlenfield Hospital, LeicesterRoyal Derby Hospital, DerbyKettering General Hospital, KetteringNorthampton General Hospital, NorthamptonNottingham City Hospital, NottinghamHospitals providing limited hours PPCIUnited Lincolnshire Hospitals NHS Trust, LincolnNeighbouring centres where PPCI patientsmay be treatedNorthern General Hospital, SheffieldJohn Radcliffe Hospital, OxfordWalsgrave Hospital, CoventryCommentsRural population of Lincolnshire will receive PPCI inspring 2012 www.improvement.nhs.uk/heart
  20. 20. 20 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Essex Essex Cardiac and Stroke Network PERCENTAGE 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 achievedwww.improvement.nhs.uk/heart
  21. 21. Growth of Primary PCI for the treatment of heart attack patients in England 21 2008-2011: the role of NHS Improvement and the Cardiac NetworksGreater Manchester and Cheshire Greater Manchester and Cheshire Cardiac and Stroke Network PERCENTAGE 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 TrentComments100% population coverage achieved www.improvement.nhs.uk/heart
  22. 22. 22 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Herefordshire and Worcestershire Herefordshire and Worcestershire Cardiac and Stroke Network PERCENTAGE PPCI LYSIS Population 0.8 million Hospitals providing 24/7 PPCI None Hospitals providing limited hours PPCI Worcester Royal Hospital, Worcester Neighbouring centres where PPCI patients may be treated None Comments Extended daytime PPCI at Worcester Royal Infirmary working towards 24/7. Pre hospital thrombolysis with immediate transport to a PCI centre will be the treatment of choice for areas with long travel timeswww.improvement.nhs.uk/heart
  23. 23. Growth of Primary PCI for the treatment of heart attack patients in England 23 2008-2011: the role of NHS Improvement and the Cardiac NetworksKent Kent Cardiovascular Network PERCENTAGE PPCI LYSISPopulation1.6 millionHospitals providing 24/7 PPCIWilliam Harvey Hospital, AshfordHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patientsmay be treatedGuys and St Thomas’s, LondonKing’s College Hospital, LondonComments100% population coverage achieved www.improvement.nhs.uk/heart
  24. 24. 24 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Lancashire and Cumbria Cardiac and Stroke Networks in Lancashire and Cumbria PPCI LYSIS PERCENTAGE 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 Cumbria will continue with thrombolysis because of the long travel times from this area pending the development of a PCI/PPCI centre at Carlisle.www.improvement.nhs.uk/heart
  25. 25. Growth of Primary PCI for the treatment of heart attack patients in England 25 2008-2011: the role of NHS Improvement and the Cardiac NetworksNorth & East Yorkshire and Northern Lincolnshire North & East Yorkshire and Northern Lincolnshire Cardiac and Stroke Network PERCENTAGE 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, MiddlesbroughComments100% population coverage achieved www.improvement.nhs.uk/heart
  26. 26. 26 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks North Central London North Central London Cardiac and Stroke Network PERCENTAGE 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 achievedwww.improvement.nhs.uk/heart
  27. 27. Growth of Primary PCI for the treatment of heart attack patients in England 27 2008-2011: the role of NHS Improvement and the Cardiac NetworksNorth East London North East London Cardiovascular and Stroke Network PERCENTAGE 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
  28. 28. 28 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks North Trent North Trent Cardiac Network PERCENTAGE 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 100% population coverage achievedwww.improvement.nhs.uk/heart
  29. 29. Growth of Primary PCI for the treatment of heart attack patients in England 29 2008-2011: the role of NHS Improvement and the Cardiac NetworksNorth West London North West London Cardiac and Stroke Network PERCENTAGE 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
  30. 30. 30 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks North of England North of England Cardiovascular Network PERCENTAGE 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 achievedwww.improvement.nhs.uk/heart
  31. 31. Growth of Primary PCI for the treatment of heart attack patients in England 31 2008-2011: the role of NHS Improvement and the Cardiac NetworksPeninsula Peninsula Heart and Stroke Network PERCENTAGE PPCI LYSISPopulation1.6 millionHospitals providing 24/7 PPCIDerriford Hospital, PlymouthRoyal Devon and Exeter Hospital, ExeterSouth Devon Healthcare Trust, TorbayHospitals providing limited hours PPCINoneNeighbouring centres where PPCI patients may be treatedNoneComments100% population coverage achieved www.improvement.nhs.uk/heart
  32. 32. 32 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Shropshire and Staffordshire Shropshire and Staffordshire Heart and Stroke Network PERCENTAGE 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 achievedwww.improvement.nhs.uk/heart
  33. 33. Growth of Primary PCI for the treatment of heart attack patients in England 33 2008-2011: the role of NHS Improvement and the Cardiac NetworksSouth Central South Central Vascular Networks PERCENTAGE 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, SurreyComments97% population coverage achievedThrombolysis out of hours on the Isle of Wight www.improvement.nhs.uk/heart
  34. 34. 34 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks South East London South East London Cardiac and Stroke Network PERCENTAGE 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 achievedwww.improvement.nhs.uk/heart
  35. 35. Growth of Primary PCI for the treatment of heart attack patients in England 35 2008-2011: the role of NHS Improvement and the Cardiac NetworksSouth West London South West London Cardiac and Stroke Network PERCENTAGE 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
  36. 36. 36 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Surrey Surrey Heart and Stroke Network PERCENTAGE PPCI LYSIS Population 1.1 million Hospitals providing 24/7 PPCI Frimley Park Hospital, Frimley Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated None Comments 100% population coverage achievedwww.improvement.nhs.uk/heart
  37. 37. Growth of Primary PCI for the treatment of heart attack patients in England 37 2008-2011: the role of NHS Improvement and the Cardiac NetworksSussex Sussex Heart Network PERCENTAGE 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, FrimleyComments100% population coverage achieved www.improvement.nhs.uk/heart
  38. 38. 38 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks West Yorkshire West Yorkshire Cardiovascular Network PERCENTAGE 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 achievedwww.improvement.nhs.uk/heart
  39. 39. Growth of Primary PCI for the treatment of heart attack patients in England 39 2008-2011: the role of NHS Improvement and the Cardiac NetworksOutcomes - are we making a difference?Figure 2 shows the 30 day mortality for allpatients having ST segment elevation myocardialinfarction. Mortality data are obtained from theNHS Central Register by the Central Cardiac AuditDatabase (CCAD) and are published in the annualMINAP Public Report. The graph demonstratesthat 30 day mortality for STEMI has fallen fromaround 12.4% in 2003-4 to around 8.6% in2010-11. It is clear that many different factorswill have contributed to the falling mortality butthe switch to PPCI is likely to have been a majorfactor from the time of recruitment to the NIAPstudy in 2005, publication of the NIAP study in2008 and the NHS Improvement led roll-outprogramme between 2008 and 2011. Figure 2: 30 day mortality (with 95% confidence limits) for all patients with STEMI (Source MINAP Public report September 2011) www.improvement.nhs.uk/heart
  40. 40. 40 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Rehabilitation Primary PCI is a major step forward in the management of patients with ST segment elevation MI. However, the speed of treatment can leave patients bewildered and confused about exactly what has happened to them (12). Patients may see their heart attack as an acute event from which they have been cured. Access to cardiac rehabilitation services is key in allowing patients, and their carers, to understand that they should return to a fully productive life but to understand also that coronary artery disease is a chronic condition and that lifestyle modification (smoking cessation etc) and compliance with prescribed medication will greatly reduce the risk of further adverse events. This is dealt with in more detail in the NHS Improvement web-based document entitled ‘Primary Angioplasty and Health Information Provision’ (13). A vital part of each network’s pathway, therefore, was to ensure that all PPCI patients were offered timely access to cardiac rehabilitation services. Full descriptions of the role of cardiac rehabilitation are available elsewhere (14).www.improvement.nhs.uk/heart
  41. 41. Growth of Primary PCI for the treatment of heart attack patients in England 41 2008-2011: the role of NHS Improvement and the Cardiac Networks Unfinished business a. Patients who cannot receive PPCI One option, therefore, for these patients is to A small proportion of patients, probably around recommend pre-hospital thrombolysis followed by 5%, will be unable to reach a PPCI centre within immediate transfer to a 24/7 PPCI centre. the appropriate time period for PPCI. This will apply to those patients living in more rural areas b. Patients who do not receive reperfusion of England where the journey time to a PPCI therapy centre exceeds 90-100 minutes. It is important Some patients who are initially thought to be that these patients receive the ‘next best’ having an ST segment elevation MI do not receive treatment. This should comprise early either PPCI or thrombolysis. Figure 3 shows the administration of fibrinolysis, either pre-hospital or proportion of patients in this category and in-hospital. Current guidelines suggest that these demonstrates a small rise in the numbers from patients should have immediate ‘rescue’ PCI if around 25% in 2008 to almost 30% in 2011. their symptoms and ST segments have failed to Furthermore, the proportion of STEMI patients resolve. This will apply to around 30% of patients. who do not receive reperfusion therapy shows Even if they are pain-free with resolving ECG marked variability between networks. Figure 4 changes, these patients are at high risk of re- shows the percentage of STEMI patients receiving infarction and should have angiography, with no reperfusion therapy for the 28 networks during follow-on PCI if required, within 24 hours. the second quarter of 2011; the rate varies between 6% and 33%. What is not clear is whether it was clinically appropriate that thoseFigure 3: Percentage of patients not receiving reperfusion therapy patients did not receive reperfusion therapy or whether there were missed opportunities for PPCI or lysis. There are a number of entirely justifiable clinicalPERCENTAGE reasons why patients who have a final diagnosis of ST elevation MI might not receive reperfusion therapy. Two ongoing audits should help in clarifying whether the differences between networks are attributable to differences in clinical practice or to differences in data collection and coding and whether the decision not to give reperfusion treatment to this group of patients was clinically appropriate or not. These comprise:Figure 4: Variation between networks in % of patients receiving • An audit at network level of all ‘PPCIno reperfusion therapy: Data second quarter of 2011 pathway activations’. This audit is summarised in figure 5. The audit will capture the reasons why patients may present as a probable STEMI, and hence be referred to as ‘pathway activations’, but not ultimately receive aPERCENTAGE successful PPCI procedure • A retrospective audit of patients who have a discharge diagnosis of ST elevation MI from MINAP but who did not receive PPCI or lysis. www.improvement.nhs.uk/heart
  42. 42. 42 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networks Conclusion Primary PCI is the optimum reperfusion strategy Networks can have a major role in the for patients with ST elevation MI. The number of development of other services for patients, patients treated in this way in England rose particularly specialist services that will not be steadily between 2004 and 2008, but in an ad- provided by every hospital but will require close hoc way. The National Infarct Angioplasty Project, cooperation between hospitals with rapid and co-sponsored by the British Cardiovascular Society safe inter-hospital transfer of patients in order to and the Department of Health, followed by the optimise their care. PPCI roll-out programme between 2008 and 2011, organised by NHS Improvement and the 28 cardiac networks in England, achieved a change in clinical practice that was both swift and consistent across the country. This change in practice has brought about immediate benefits for patients in terms of a reduction in deaths and shortened hospital stays. At a time when individual hospitals may be competing for patients with neighbouring hospitals, the role of the cardiac networks has been pivotal in ensuring that the patient pathways developed have been safe and sustainable. Figure 5: PPCI pathwaywww.improvement.nhs.uk/heart
  43. 43. Growth of Primary PCI for the treatment of heart attack patients in England 43 2008-2011: the role of NHS Improvement and the Cardiac NetworksReferences1. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial ofintravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acutemyocardial infarction: ISIS-2. Lancet 1988; ii: 349-3602. Coronary heart disease: national service framework for coronary heart disease - modern standards andservice models. Department of Health Publcation, 2000.3. How the NHS cares for patients with heart attack. Ninth public report 2010. Prepared on behalf of theMINAP steering group. www.rcplondon.ac.uk/clinical-standards/organisation/partnership/Pages/MINAP-.aspx4. Juliard J-M, Himbert D, Golmard J-L, et al. Can we provide reperfusion therapy to all unselected patientsadmitted with acute myocardial infarction? J Am Coll Cardiol 1997;30:157-1645. The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, orboth on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. NEngl J Med 1993;329:1615-16226. Gibson CM, Karha J, Murphy SA, et al. Early and long-term clinical outcomes associated withreinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials. J AmColl Cardiol 2003;42:7-167. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acutemyocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20.8. Task Force on the management of ST-segment elevation acute myocardial infarction of the EuropeanSociety of Cardiology. Management of acute myocardial infarction in patients presenting with persistentST-segment elevation. The: Eur Heart J (2008) 29 (23): 2909-2945.9. Terkelsen CJ, Chritiansen EH, Sorensen JT, at al. Primary PCI as the preferred reperfusion therapy inSTEMI: it is a matter of time. Heart 2009;95:362-369 doi:10.1136/hrt.2007.13949310. Treatment of Heart Attack. National Guidance. Final Report of the National Infarct Angioplasty Project(NIAP). (2008)11. European Association for Percutaneous Cardiovascular Interventions. Reperfusion therapy for STelevation acute myocardial infarction in Europe: description of the current situation in 30 countries. EurHeart J 2010;31:943-95712. Astin F, Closs SJ, McLenachan J, Hunter S and Priestley C. Primary angioplasty for heart attack:mismatch between expectations and reality? Journal of Advanced Nursing 65(1), 72–83doi: 10.1111/j.1365-2648.2008.04836.x13. NHS Improvement. Primary Angioplasty and Health Information Provision.14. NICE Clinical Guideline 48 MI:Secondary Prevention www.improvement.nhs.uk/heart
  44. 44. 44 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networkswww.improvement.nhs.uk/heart
  45. 45. Growth of Primary PCI for the treatment of heart attack patients in England 45 2008-2011: the role of NHS Improvement and the Cardiac Networks www.improvement.nhs.uk/heart
  46. 46. 46 Growth of Primary PCI for the treatment of heart attack patients in England 2008-2011: the role of NHS Improvement and the Cardiac Networkswww.improvement.nhs.uk/heart
  47. 47. ContactsCarol MarleyNational Improvement Lead, Reperfusion, NHS Improvementemail: carol.marley@improvement.nhs.ukSheelagh MachinDirector, Heart, NHS Improvementemail: sheelagh.machin@improvement.nhs.uk www.improvement.nhs.uk/heart
  48. 48. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKENHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung andstroke and demonstrates some of the most leading edge improvement work in England whichsupports improved patient experience and outcomes.Working closely with the Department of Health, trusts, clinical networks, other health sectorpartners, professional bodies and charities, over the past year it has tested, implemented, sustainedand spread quantifiable improvements with over 250 sites across the country as well as providingan improvement tool to over 1,000 GP practices.NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NBTelephone: 0116 222 5184 | Fax: 0116 222 5101www.improvement.nhs.ukDelivering tomorrow’s Publication Ref: IMP/comms033 - October 2012 ©NHS Improvement 2012 | All Rights Reservedimprovement agendafor the NHS

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