implementation of 24h ppci service in qmh · 2012. 5. 29. · qmh ppci program part of the qmh ami...

Implementation of 24h PPCI Service in QMH:

Key Determinants to Success & Future Perspectives

Dr Raymond H W Chan, Consultant Cardiologist

Department of Medicine, Queen Mary Hospital

on behalf of the

QMH AMI Clinical Pathway Team 8.5.2012

Chan HWR, Lam L, Lam YM, Choi K, Chan P, Lam S, Chan K, Chan M, Hai JJ,

Wong KLM, Tam F, Yung A, Wong A, Kan A, Tsang YW, Luk WS, Fan L, Lee S,

Wong WF, Ng PS, Tang ML, Wong SM, Tseh E, Tong HK, Tsui SH, Chan C , Lee SWL

Department of Medicine, Central Nursing Department, A& E Department QMH

急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH

AMI(急性心肌梗塞)& PPCI(通心血管手術) Acute Myocardial Infarction & Primary Percutaneous Coronary Intervention

• When AMI occurs

open up the blocked artery ASAP

• Delay heart muscle

• Medication is inferior to PPCI may fatal brain bleeding

• 24hour PPCI Service

the challenge is Resource & Logistics


QMH PPCI Program

part of the QMH AMI Clinical Pathway

(急性心肌梗塞臨床路徑)

Commenced 1.2.2007 – present

The AMI CP is a clearly spelt out management proctocol starting first step at the AED


4

AMI Clinical Pathway Management Protocol

(急性心肌梗塞臨床路徑)

AMI CP – Contents

• Evidence Based Medicine

• Multi-departmental collaboration

• AMI CP Protocol - starting at the AED

• Independent audit – Independent Audit Department

• Regular appraisal & Critical Review – System

Interventions


EBM – International Benchmarking


PPCI SUPERIOR, GIVEN RIGHT TIME , PLACE & PERSON

ACCF/AHA Task Force on Practice Guidelines. http://www.acc.org. Aug 1,2009

ACC/AHA/SCAI 2005 guideline update for PCI. Jacc 2006;47:E1-121

ACC/AHA guidelines for the management of pts w ST elevation MI. JACC 2004;44:e1-e211

Focusses update of the ACC/AHA 2004 Guidelines for the mgt of pts w STEMI. JACC 2008;51:210-47

. . . . .

Timely Management Essential Mortality & Morbidity Door to Needle Time ≤ 30 min D-NT Door to Balloon Time ≤ 90 min D-BT

Lytics Cerebral Bleeding in the followings Female Age>70 SBP>160 M<80kg F<65kg Hx CVA TNK INR> 4 Black race

http://www.acc.org/

International Database of AMI Mortality

16.00% 9.80% 7.20%

48.9%

14.5%

49.4%

19.00%22%

0%

20%

40%

60%

80%

100%

AIHW Total

CFR

AIHW hosp

CFR

WHO

MONICA

28d CFR

(Men)

WHO

MONICA

28d CFR

Hosp pts

(Men)

YALE

Medicare

30d, JGIM

2006

Yale 2010

30d RSMR,

Circ Cardio

Outcome

2010

HK HA Ami

Mortality

Study 2009,

in progress

HK QMH

2010 In-

Hosp CFR

Swedish

STEMI

Registry

1996-2007

In-Hosp

Mortality

JAMA 2011

pe

rc

en

ta

ge

Circulation 1997: WHO Project with A population view 1985-1990

Australian Institute of Health & Welfare 9.2002: 1/2 of 48,313 events were fatal (1999-00) & 87% occurred outside hospital

LIMITATIONS: AIHW 2002 WHO 1990 MEDICARE FFS CCU Pt only

½ US AMI Pts

Mortality Trend

Mortality Trend

* * *

AMI CP – Contents






Interventions


Multi-departmental

Collaboration

AED (Made

diagnosis of

AMI)

CCU On

call

(Decision x

PPCI)

Interventional

Cardiologist

Cath Lab Staff

Cath Lab a/v

Cath.

Lab

CCU

Multi-dept


CCU & CW Nursing Team

Occupational Therapist

MSW

Dietitian

Physiotherapist


AMI CP – Contents






Interventions


AED

• AED physicians elective to CCU for 3 months

for conjoint management on AMI

• AMI CP care protocol facilitated AED nursing staffs at triage level

• AMI CP clear-cut flow-chart Rx protocol


AMI CP – Contents




• Independent audit – CND QMH


Interventions


Central Nursing Division & Quality &

Risk Management Team

•Review & develop SOP & Care Maps

•Root cause analysis of variances ( DNT, DBT, LOS, Mortality)

•Monitor patient delivery logistic (the AED → CCU / CCL Transit)

•Re-engineer PCI booking mechanisms

•Case manager : data acquisition, analysis, variance audit & health

education & assessment


AMI CP – Contents





• Regular appraisal & Critical Review –

System Interventions


System Intervention

• 4 Cardiology specialty trainees were recruited into the team since 1 Jul 2007 A B C

• With effect from 31 Aug 07, we re-rectify the practice to administer Lytics in AED; Cardiology Consult was carried out only if essential. A • W.e.f. 1 July 2007, AED sent an Emergency Medicine Fellow for elective to CCU for 3m A B

• Enhanced Division communication by weekly frontline team meeting in CCU A B C

• Regular case review meetings with AED A B

• Case Manager involvement in patient education & risk factors identification C

A. Shorten DN-T B. Shorten DB-T C. Shorten LOS


HIGHLIGHTS

1. Strategy of Extension of Cardiac Catherization Laboratory hours

2. 3 Nurses Deficient, How to sustain 24h PPCI - Manpower Logistics

System Intervention – Strategy of Extension

of Cardiac Catherization Laboratory hours

24 hour Emergent Cath Lab Service for PPCI 01/02/2007 9A – 5P

01/08/2008 8A – 8P

15/04/2009 24h PPCI for patients ≥ 2 Risk Factors for ICH

07/11/2010 24h PPCI for all eligible patients

24h PPCI Service_AMI Same Manpower

• Insights - 2 Strategic Actions


STRATEGIC ACTION 1

Case Admission Pattern Analysis

• 53.61 % (CP89); 52.24 % (non-CP105) of patients admitted 8a-6p

• 26.51 % (CP44); 25.87 % (non-CP52) of patients admitted 6p-12mn

• 19.88 % (CP33); 21.89 % (non-CP44) of patients admitted 12mn–8a

53.61

26.51

19.88

0

10

20

30

40

50

60

08:00 - 18:00 18:01 - 00:00 00:01 - 08:00

Time

Percentages (%)

2007, 2008 CCU Admission Time: AMI Pts

52.24

25.8721.89

0

10

20

30

40

50

60

08:00 - 18:00 18:01 - 00:00 00:01 - 08:00

Time

Percentages (%)

AMI (Clinical Pathway Pts) AMI (Non- Clinical Pathway Pts)

- with complications

STRATEGIC ACTION 2

Pressure Testing

PPCI 2007

(No. of Patients)

2008

(No. of Patients)

2009

(No. of Patients)

2010

(No. of Patients)

08:00 – 08:59 1 2 2 5

09:00 – 17:00 17 23 34 32

17:01 – 20:00 3 10 9 8

20:01 – 07:59 1 1 12 15

Lytics 2007

(No. of Patients)

2008

(No. of Patients)

2009

(No. of Patients)

2010

(No. of Patients)

08:00 – 08:59 0 1 0 0

09:00 – 17:00 11 8 1 1

17:01 – 20:00 7 5 2 0

20:01 – 07:59 20 22 13 5

E-PPCI System Pressure Testing & Contextualization

1.2.2007

PPCI 9a-5p

1.8.08

PPCI 8a-8p

15.4.09

PPCI

8a-8p: all ami

8p-8a: 2 Risks

7.11.2010

24h PPCI

All STEMI

` 1.8.2008 15.4.2009 7.11.2010

* Figures: AMI pts recruited into AMICP

System Intervention – Manpower Logistics

2 Cardiac Catherization Laboratories 3 Interv Cardiologists

5 Full-time Cath Lab Nurses (no technician) 6 Cardiac Fellows

(very “average” Hardware & Software strength)

3 RN Deficient, how to sustain 24 PPCI ? QMCC-DNR (Doctor-Nurse-Runner)-

Doctors acting as Cath Lab nurses in Nurses Call list as back-up

QMH is the only HK Hospital offering 24h PPCI since 2010


RULE: Cath Lab Nurse on Call not >1:3

* * Staff Motivation & Commitment * *

2007 2008 2009 2010 1-4/2011 International

Benchmark

CP no.Recruited 201 160 174 119

CP no.Completed 166 123 113 89

Age (mean) 68.1 65.8 63 65.3

Lytics no.(CP) 38 (22.9%) 36(29%) 16(14%) 5 (5.6%) x

D-N-T (mean) 86

42 40 43 x 30

PPCI no.(CP) 23(13.9 %) 36(29%) 57(50%) 60(67.4%)

D-B-T (mean) 277 113 101 96 90

LOS (mean) 5.2 4.2 3.9 4

Readmission

Rate

6.6 4.1 4.4 5.6

Hosp Mortality

(All AMI) 13.2 10.5 10.2 9.8

See Chart

RESULTS: AMI 2007 - 2011

QMH : 5y Trend of ↑E-PCI & AMI Mortality

*

∑ 6.8% ∑ 7.9%

0% 0%

367

65

4430

361

104

63

25

465

64

96

10

476

36

87

5

570

37

126

0

2007 2008 2009 2010 2011

ELECTIVE

URGENT

EMERGENCY

LYTICS

Overall

AMI Mortality

EMERGENT PCI :

Procedure be

performed ASAP/

within 24h

(Maj = PrimaryPCI)

URGENT PCI :

Procedure be

performed within

index hospitalisation

13.2% 10.5% 10.2% 9.8%

0%

24 Hour PPCI

7.11.2010

∑ 4.3% (4/93)

2.8% (2/72)

9.5% (2/21)

0%

E-PCI : ∑ Mort Rate

Non UR ( =NON ULTRA RISK)

UR (Shock, Post Arrest, Intub, VT)

Elective PCI : 0%

∑ 8.1% (7/87)

0% (0/66)

33.3 % (7/21)

0%

Dr Wong Ka Lam et al_HA Convention 2012 e Abstract

“Reduction of Mortality with implementation of AMICP in QMH”

2029 AMI patients ( 7 year analysis 2004 – 2011)

AMI Mortality after Implementation of AMICP ( PPCI)

p<0.05

CONCLUSION:

Key Determinants to Success of the Program: • Staff Commitment & Dedication

• Well planned and Mutidepartmental Collaboration

• Independent Audit

• Mandatory Regular Critical Review & Reappraisals

Future Perspectives: • Power Analysis on Outcome Determinants

• Training to all CCU Nurses so that they will be competent

Cath Lab Staff in the near future in support of the

24 PPCI Service


Queen Mary Hospital

瑪麗醫院

Queen Mary Hospital

瑪麗醫院

THANK YOU !

AMI CP

TEAM


implementation of 24h ppci service in qmh · 2012. 5. 29. · qmh ppci program part of the qmh ami...

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