Emergency  and  Same  Day  Cases:  Need  for  Regional  24/7  services

Charles  KnightCardiovascular  Clinical  Director  Barts and  

the  London  NHS  Trust

NO  CONFLICT  OF  INTEREST  TO  DECLARE

• Case  for  change  and  rationalisation  of  NSTEMI  management

• London  Cardiovascular  Project• NE  London  experience

Case  for  change

• Improve  clinical  outcomes

• Improve  the  pathway

NEJM  360:2165-­2175  2009

Early  intervention  in  NSTEMI

TIMACS  studyEarly  (24  hour)  versus  Delayed  Invasive  Intervention

Death,  MI,  stroke Death,  MI,  recurrent  ischaemia

TIMACS  NEJM  360:2165-­2175  2009

High  risk  patients  benefit  the  mostStratified  by  GRACE  Risk  Score

(Death,  myocardial  infarction,  or  stroke)

Meta-­‐analysis:  Early  (<24h)  v  delayed

• 4013  patients• Early  =1-­‐14  hours,  Delayed  =  20-­‐86  hours• ABOARD,ELISA,  ISAR-­‐COOL,  TIMACS• No  difference  in  Death/MI• Decreased  recurrent  ischaemia• Decreased  length  of  stay

Katritsis D  G  et  al.  Eur Heart  J  2011;32:32-­‐40

Presumption  in  favour  of  quicker  treatment  if  clinical  equipoise

Case  for  change

• Improve  clinical  outcomes

• Improve  the  pathway

For  patients• The  NSTEMI  Pathway  should  ensure  that:

– Unnecessary  waits  are  abolished  and  the  patient  experience  enhanced

– Interhospital  transfers  and  length  of  stay  are  minimised– Equity  of  care  and  access  is  ensured  

• All  patients  follow  the  same  pathway  regardless  of  time  and  location  of  admission

– Early  access  to  angiogram  +/-­ revasc  for  high  risk  groups  – Patients  at  higher  risk  are  managed  by  specialists  early  in  their  clinical  episode  

– Hospitals  adhere  to  best  practice  guidelines

For  commissioners• Assurance  of  world  class  care  and  efficient  use  of  expensive  

resources• Avoidance  of  double  admission  and  associated  tariffs  (saving  of  

£3841  (EB107)  if  two  admissions  avoided)

Cardiac  surgery

Cardiology

Vascular  services

• Acute  aortic  dissection• Mitral  valve  procedure  • Non-­elective  cardiac  surgery  

• Arrhythmia  • NSTEMI

The  London  Cardiovascular  ProjectKey  elements• Led  by  NHS  London  and  the  Pan-­London  Network• Centralise  services  where  it  would  improve  outcomes• Reduce  LOS• Improve  patient  pathways  and  patient  experiences• Increase  sub  specialisation  of  surgeons  delivering  complex  procedures

NSTEMI  Clinical  Expert  Panel

• Chaired  by  Huon  Gray• Representatives  from  across  London– GP– Patients– Networks– DGH  and  Surgical  centre  Cardiologists  – NHS  London

Key  Recommendations• Diagnose  and  risk  stratify  patients  early• Manage  patients  according  to  their  risk  level  through  the  use  

of  an  agreed,  evidence  based  set  of  criteria• Ensure  “high  risk”  patients  are  offered  angiography  within  

24hours  of  initial  assessment.    If  patient  is  triaged  in  a  hospital  that  cannot  provide  angiography  within  24  hours,  the  patient  should  be  transferred  from  A&E  to  a  unit  that  can  

• Medium  risk  patients  should  be  offered  coronary  angiography  (with  PCI  if  indicated)  within  72-­‐96  hours  of  admission  (LCVP    model  of  care  and  NICE)

• Low  risk  patients  should  be  offered  conservative  management  (NICE) avoiding  hospital  admission  where  possible

Recommendation  1: Recommendation  2:

Patients  clinically  suspected  of  having  NSTEACS  with  ongoing  or  recurrent  chest  pain/discomfort  believed  to  be  of  cardiac  origin,  together  with  at  least  one  of  the  following:

• Persistent  ECG  changes  of  ST  depression  >1mm,  or  transient  ST  elevation  

• Pathological  T-­‐wave  inversion  in  V1-­‐V4  suggesting  an  “LAD  syndrome”

• Dynamic  T-­‐wave  inversion  >2mm  in  two  or  more  contiguous  leads

• Haemodynamic  (e.g.  hypotension,  pulmonary  oedema  or  heart  failure)  or  electrical  instability  (sustained  ventricular  arrhythmias  – VT/VF)  which  are  thought  to  be  due  to  cardiac  ischaemia

• Troponin  ≥  0.1mcg/L

• A  phone  call  should  be  made  to  the  receiving  NSTEACS  centre,  to  allow  discussion  of  appropriateness  of  early  angiography/PCI,  taking  into  account  factors  increasing  the  risk  of  intervention/transfer,  such  as  co-­‐morbidities  and  bleeding  risk

• Once  transfer  agreed:  Referring  A&E  initiates  an  “immediate    transfer”  with  LAS  (i.e.  one  which  arrives  within  the  hour)

Pan-­London  high  risk  NSTEMI  definition

Quality  Standards• Endorsed  by  BCS  and  DoH

• 37  standards– Service  configuration,  support  for  patients  and  carers,  staffing  and  

support  services,  guideline  and  protocols,  service  organisation,  governance,  community  staffing  and  support

• Includes  assessment  of  job  plans,  medical  and  nursing  staffing  levels,  evidence  of  24/7  working,  ICU  support,  audit  data  etc.

• All  centres  externally  assessed  against  standards  with  re-­‐audit

• 10  approved   NSTEMI  centres  signed  off  – (8  of  which  are  HAC’s).    4  remaining  DGH’s  to  come  on  board  before  March  2012

• Ambulance  service  commissioning  agreed  to  provide  transfers

~  1.8  million  population

NE  London  Experience  2010-­‐

24/7  HAC-­‐X  Service    April  2010-­‐ March  2011

Total  Activations  per  MonthTotal  annual  activations:  508

Mean  less  than  2  per  day

HACX  patient  outcomes

• 82%  Patients  met  the  pathway  criteria

• 72%  Patients  had  an  angiogram

• 64%  NSTEMI  discharge  diagnosis

• 46%  revascularised  (PCI/  CABG)

• 79%  Had  a  cardiac  discharge  diagnosis

Pre-­‐HACX/  HACX  audit

• Pre-­‐HACX  391  patients– Retrospective  audit– October  2009  – April  2010

• HACX  311  patients  – April  2010  – October  2010

Impact  of  HACX  service  

• Median  time  delay  for  angiography:  7  days  to  1

• %  receiving  angiogram  within  96  hours:  18%  to  90%

• Median  LOS:  9  days  to  3

• Bed  days  saved:  mean  6  per  patient

• Total  bed  days  over  6  months:  1866

• Savings  for  commissioners  £1.86  million  

Conclusions

• 24/7  urgent  treatment  of  high  risk  NSTEMI  desirable  clinically  and  operationally

• Pathways  can  be  redesigned  to  improve  patient  care  and  use  of  resources  and  reduce  length  of  stay

• Different  models  may  suit  different  locations