NHS

CANCER

NHS Improvement

DIAGNOSTICS

HEART

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

LUNG

STROKE

Contents
Foreword Introduction The national picture The network picture Common themes Conclusion 3 4 5 6 35 37

Authors Dr J M McLenachan National Clinical Lead, Reperfusion, NHS Improvement, Consultant Cardiologist, Leeds General Infirmary Sheelagh Machin Director, NHS Improvement Carol Marley National Improvement Lead, NHS Improvement

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

Foreword
The introduction and dissemination of primary PCI (PPCI) in England provides a good example of how a nationalised healthcare system can work at its very best. After randomised trials had established the potential superiority of primary PCI over thrombolysis for STEMI, the Department of Health and national societies (British Cardiovascular Society, British Cardiovascular Intervention 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 geographical considerations 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 Improvement and 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 NIAP started) and with every network having robust plans to achieve 100% coverage for eligible patients. Given the complexity of delivering 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 been achieved in such a short space of time. We shouldnt forget that the decision to move to a PPCI dominated strategy was made on the background of an existing excellent thrombolysis service, which had already delivered improved patient outcomes. It is all the more remarkable that satisfaction with performance indicators for thrombolysis did not result in any complacency regarding change. Far from it, as is demonstrated in this report, Ambulance Services, provider Trusts, and management at all levels have responded 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 of PPCI 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 National Director for Heart Disease & Stroke Department of Health

Professor Huon Gray Deputy National Director, Consultant Cardiologist, Southampton

Gateway Reference: 14878

www.improvement.nhs.uk/heart

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 5

The national picture

The rate of increase in the proportion of eligible patients receiving PPCI, and the proportionate fall in the use of thrombolysis is shown in figure 1. In the third quarter of 2008, 58% of those patients who received any reperfusion treatment were treated with thrombolysis and 42% were treated with PPCI. By the end of the first quarter of 2010, the proportion treated with PPCI had risen to 73% and the proportion treated with thrombolysis had fallen to 27%. It is important to understand that some patients with ST segment elevation myocardial infarction may receive neither PPCI or thrombolysis, usually for sound clinical reasons. Review of the numbers of patients not receiving any form of reperfusion therapy shows no major increase in this group as a result of the switch from lysis to PPCI (figure 2).
Figure 1: National MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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 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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 7

Anglia
Anglia MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 2.3 million Hospitals providing 24/7 PPCI Norfolk and Norwich Hospital, Norwich Papworth Hospital, Cambridge Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Basildon Hospital, Basildon Comments Approximately 87% of the population is now covered by PPCI service. Pilot study of optimum treatment for East Suffolk residents is in progress.

www.improvement.nhs.uk/heart

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

Avon, Gloucestershire, Somerset and Wiltshire

Avon, Gloucestershire, Somerset and Wiltshire MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Comments Approximately 56% of the population is now covered by PPCI service. Planning to achieve 100% population coverage by November 2011.

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, Dorchester

www.improvement.nhs.uk/heart

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 9

Bedfordshire 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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.68 million Hospitals providing 24/7 PPCI None Hospitals providing limited hours PPCI Lister Hospital, Stevenage Watford General Hospital, Watford Neighbouring centres where PPCI patients may be treated Papworth Hospital, Cambridge Harefield Hospital, Middlesex Comments 100% population coverage achieved.

www.improvement.nhs.uk/heart

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

Birmingham, Sandwell and Solihull

Birmingham, Sandwell and Solihull MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Neighbouring centres where PPCI patients may be treated New Cross Hospital, Wolverhampton University Hospital, Coventry Comments 100% population coverage achieved.

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

www.improvement.nhs.uk/heart

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 11

Black Country
Black Country MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1 million Hospitals providing 24/7 PPCI New Cross Hospital, Wolverhampton Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Birmingham Hospitals Comments 100% population coverage achieved.

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 13

Coventry 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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 0.88 million Hospitals providing 24/7 PPCI University Hospital, Coventry Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Birmingham Heartlands Hospital, Birmingham Comments 100% population coverage achieved.

www.improvement.nhs.uk/heart

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

Dorset
Dorset MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Comments Daytime PPCI provided at Dorset and Bournemouth with thrombolysis for out-of-hours presenters. Planning to achieve 100% population coverage by November 2011.

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, Taunton

www.improvement.nhs.uk/heart

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 15

East Midlands
East Midlands MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Comments Extensive consultation process over last 18 months. Plans now in place to have 100% population coverage by November 2011.

Population 3.8 million Hospitals providing 24/7 PPCI Glenfield Hospital, Leicester Hospitals providing limited hours PPCI Royal Derby Hospital, Derby Kettering General Hospital, Kettering Northampton General Hospital, Northampton Nottingham City Hospital, Nottingham Neighbouring centres where PPCI patients may be treated Northern General Hospital, Sheffield John Radcliffe Hospital, Oxford University Hospital, Coventry

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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 Barts and the London NHS Trust, London Harefield Hospital, Middlesex Comments 100% population coverage achieved.

www.improvement.nhs.uk/heart

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 17

Greater Manchester and Cheshire

Greater Manchester and Cheshire MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Comments 50% population coverage on 1 April 2010. This increased to 80% on 6 September 2010 with plans to go to full 100% coverage in March 2011.

Population 3.2 million Hospitals providing 24/7 PPCI Manchester Royal Infirmary, Manchester Wythenshawe Hospital, Manchester Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated University Hospital of North Staffordshire, Stoke on Trent

www.improvement.nhs.uk/heart

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

Hereford and Worcester

Hereford and Worcester MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Pre hospital thrombolysis with immediate transport to a PCI centre will be the treatment of choice for areas with long travel times.

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 19

Kent
Kent MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.6 million Hospitals providing 24/7 PPCI None Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Guys and St Thomass, London Kings College Hospital, London Comments Kent now has 100% population coverage for PPCI based at The William Harvey Hospital, Ashford. The service commenced on 12 April 2010.

www.improvement.nhs.uk/heart

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

Lancashire and Cumbria

Lancashire and Cumbria MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

There are plans to roll out PPCI to 75% of the population over the next 12 months. Cumbria will continue with thrombolysis because of the long travel times from this area pending the development of a PCI / PPCI centre at Carlisle.

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 21

North & 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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.3 million Hospitals providing 24/7 PPCI Castle Hill Hospital, Hull Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Leeds General Infirmary, Leeds James Cook University Hospital, Middlesbrough Comments PPCI currently covers 60% of the population. Planning to roll out to 100% by November 2011.

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 23

North 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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.5 million Hospitals providing 24/7 PPCI Barts and the London Hospital Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated Essex Cardiothoracic Centre, Basildon Comments 100% population coverage achieved.

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 25

North 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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.8 million Hospitals providing 24/7 PPCI Hammersmith Hospital, London Harefield Hospital, Middlesex Hospitals providing limited hours PPCI None Neighbouring centres where PPCI patients may be treated St Georges Hospital, London Barts and the London, London London Chest Hospital, London The Heart Hospital, London Comments 100% population coverage achieved.

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 27

Peninsula
Peninsula MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Cornwall patients may receive thrombolysis because of longer travel times to the PPCI centre. At present South Devon patients receive thrombolysis out of hours. Referral pathways to Derriford and Royal Devon and Exeter NHS Foundation Trust are in discussion to ensure a 24/7 service is provided for South Devon patients.

Population 1.6 million Hospitals providing 24/7 PPCI Royal Devon and Exeter Hospital, Exeter Derriford Hospital, Plymouth Hospitals providing limited hours PPCI Torbay Hospital, Torbay (24/5) Neighbouring centres where PPCI patients may be treated A small number of patients from North Devon may be transferred to Musgrove Park Hospital, Taunton due to exceptional circumstances. A PPCI service is being established for North Devon patients with the Royal Devon and Exeter NHS Foundation Trust. This service is hoping to commence formally in October 2010. Comments Royal Cornwall Hospitals NHS Trust is keen to commence a PPCI service but there have been difficulties in recruiting a cardiologist. A small number of North Devon and

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 29

South Central
South Central MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

PPCI from their nearest 24/7 centre from 14 April 2010 onwards and Buckinghamshire patients have had access to PPCI from their nearest 24/7 centre since 26 May 2010. Portsmouth have provided a 24/7 service since 1 September 2010. Population coverage of 97% has now been achieved.

Population 4.2 million Hospitals providing 24/7 PPCI John Radcliffe Hospital, Oxford Southampton General Hospital, Southampton Royal Berkshire Hospital, Reading North Hampshire Hospital, Basingstoke Hospitals providing limited hours PPCI Wycombe General Hospital, High Wycombe Queen Alexandra Hospital, Portsmouth Neighbouring centres where PPCI patients may be treated Harefield Hospital, Middlesex Frimley Park Hospital, Surrey Comments Coverage was 83% on 1 April 2010. This included all areas except Portsmouth, East Berkshire and the Isle of Wight. East Berkshire patients have had access to 24/7

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.3 million Hospitals providing 24/7 PPCI Guys and St Thomass 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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 31

South 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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Population 1.4 million Hospitals providing 24/7 PPCI St Georges 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

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

Surrey
Surrey MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Comments Current population coverage is around 85-90% for daytime presenters and 20% for out-of-hours presenters. Planning to achieve 100% population coverage by November 2011.

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 Georges Hospital, London

www.improvement.nhs.uk/heart

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 33

Sussex
Sussex MINAP Data
100 90 80 70 60 50 40 30 20 10 0 2008/2 2008/3 2008/4 2009/1 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

Comments 75% population coverage on 1 April 2010. Planning to achieve 100% by March 2011.

Population 1.6 million Hospitals providing 24/7 PPCI Royal Sussex County Hospital, Brighton Eastbourne District General Hospital, Eastbourne Conquest Hospital, St Leonards on Sea Hospitals providing limited hours PPCI Worthing Hospital, Worthing Neighbouring centres where PPCI patients may be treated Southampton General Hospital, Southampton East Surrey Hospital, Redhill William Harvey Hospital, Ashford Frimley Park Hospital, Frimley

www.improvement.nhs.uk/heart

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 PPCI 2009/2 LYSIS 2009/3 2009/4 2010/1

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

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 35

Common themes
While formulating and implementing the individual network plans for the delivery of PPCI, a number of common themes emerged. Local politics Cardiology has seen considerable decentralisation over the last two decades with many procedures that were once the preserve of tertiary referral centres now being performed in large numbers in district general hospitals. A primary PCI service requires 24/7 catheter lab availability, a service not available in many district hospitals. In some areas, the development of a PPCI service has been perceived as a centralisation process which threatens some district general hospitals. This has occasionally led to a desire to retain local thrombolysis over what is seen as a distant PPCI service. It is very important that the needs of the patient, rather than the needs of the hospital, dictate how the service is organised. This is vital during patient and public engagement; the setting up of a PPCI service should be seen as something to reduce the rate of death and stroke in local patients, based on the best available scientific evidence, and not as something being taken away from the local hospital. Long travel times The time delay between the patient (or relative) first calling for medical help and the patient later receiving reperfusion treatment will almost always be longer for PPCI than for thrombolysis. There has been much debate about what is an acceptable PCI-related delay. In other words, at what length of PCI-related delay are the clear benefits of PPCI over thrombolysis lost? There is some consensus that the benefits of PPCI are retained unless the PCI related delay exceeds 120 minutes. The PCI-related delay is made up mainly of the travel time to the PCI centre and the so called door-to-balloon time at the PCI centre. For patients with longer travel times, there is evidence that the door-to-balloon time can be shortened to around 30 minutes because the PCI centre is ready and prepared for the patients arrival. This allows a travel time of 70-90 minutes. In some rural areas of England, a travel time of 90 minutes may still not be enough to reach a PCI centre (eg. Cumbria, East Suffolk, Isle of Wight). This should apply to less than 5% of the English population. If patients from these areas cannot receive PPCI, it is very important that they receive the next best standard of care. This involves pre-hospital thrombolysis followed by immediate transfer to a PCI centre. It is well established that 25%-35% of these patients will fail to reperfuse following thrombolysis; if this happens, then the patient should receive rescue PCI as quickly as possible. This cannot happen if the patient has been given pre-hospital thrombolysis and has then been taken to a hospital without PCI facilities. Call-to-balloon time of 150 minutes For the reasons outlined above, it has been proposed that the threshold used to assess the performance of a PPCI service should be the proportion of patients in whom a call-to-balloon time of less than 150 minutes is achieved. Experience has shown that this time is readily achievable in most parts of the country where diagnosis of ST segment elevation MI is made by the ambulance service and the patient is taken directly to the PPCI centre. In contrast, it is much harder to achieve if the patient is taken initially to a non-PPCI hospital. Call-to-balloon time (like call-to-needle time) measures performance across the whole patient pathway which will include the ambulance service, the non-PPCI hospital and the PPCI centre.

www.improvement.nhs.uk/heart

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

Cross-boundary working There are well established routes of referral between general practitioners and local hospitals and between district hospitals and tertiary centres. These have evolved largely for elective and urgent care. Because time delays are critical when setting up a PPCI Service, networks have had to consider where patients might receive PPCI with the minimum time delay. For some patients, the nearest PPCI centre may not be within the cardiac network, or even within the Strategic Health Authority, in which they live. All networks, therefore, have had to consider where patients, particularly those patients close to the network boundaries, are likely to receive the speediest care. Limited hours and 24/7 centres Most PPCI centres in England operate 24 hours per day, seven days per week. Some smaller hospitals operate a PCI service which includes treating ST segment elevation MI patients during working hours (9am to 5pm, or 7am to 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.

Workforce and training issues PPCI involves a major shift towards out-of-hours working. For many centres, this has involved employing and training additional nursing, physiology and radiography staff. For existing catheter lab staff, the move towards more frequent night time and weekend working has sometimes been difficult to manage. Whatever local arrangements are made, it is clearly important that the PPCI service is sustainable in the long term. Response from the networks As part of this survey, cardiac networks were asked whether any specific issues had delayed their plans to implement PPCI. Three networks reported that discussion over the funding of the necessary additional ambulance activity had led to delays in implementing the service. Three networks cited delays in recruiting interventional cardiologists and two mentioned delays in recruiting nursing and other cardiac catheter lab staff.

www.improvement.nhs.uk/heart

National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 37

Conclusion
Considerable progress has been made over the period October 2008 to April 2010. All 28 cardiac and stroke networks now have a strategy to deliver PPCI to most of the population by October 2011. Increasingly, the focus will be on outcomes. All centres delivering primary PCI should strive to deliver the best possible quality of PPCI to all eligible patients. Factors that will help to improve outcomes 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 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report

www.improvement.nhs.uk/heart

Contacts
Carol Marley National Improvement Lead, Reperfusion, NHS Improvement email: carol.marley@improvement.nhs.uk Sheelagh Machin Director, Heart, NHS Improvement email: sheelagh.machin@improvement.nhs.uk

NHS
CANCER

NHS Improvement

DIAGNOSTICS

HEART

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 to 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.

LUNG

STROKE

NHS Improvement
3rd Floor | St Johns House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

Delivering tomorrows improvement agenda for the NHS

NHS Improvement 2010 | All Rights Reserved Publication Ref: IMP/comms002 - October 2010