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Is 24/7 necessary ?

Is 24/7 necessary ?. Will Orr Royal Berkshire Hospital, Reading Clinical Lead, South Central Cardiovascular Network. NO CONFLICT OF INTEREST TO DECLARE . Is PPCI really so much better than good lysis?. One-year survival in Fast-MI (PPCI v Pharmacoinvasive).

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Is 24/7 necessary ?

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  1. Is 24/7 necessary ? Will Orr Royal Berkshire Hospital, Reading Clinical Lead, South Central Cardiovascular Network

  2. NO CONFLICT OF INTEREST TO DECLARE

  3. Is PPCI really so much better than good lysis? One-year survival in Fast-MI (PPCI v Pharmacoinvasive) Danchin, N. et al. Circulation 2008;118:268-276

  4. 100 miles PCI angiography only no cath lab South Central Cardiovascular Network Is 24/7 necessary ?

  5. Is 24/7 necessary ? • Who is competent to do PPCI? • How important is time? • Who will decide?

  6. Who is competent? Influence of Operator Volume on Outcome Adjusted odds ratios (OR) for major adverse cardiovascular events Moscucci, M. et al. J Am Coll Cardiol 2005;46:625-632

  7. ns Who is competent? OR 0.65 (0.49-0.86) if > 325 PCI per year STEMI & NSTEMI Zahn Heart 2008;94:329–335

  8. ns Who is competent? non-MI PCI Zahn Heart 2008;94:329–335.

  9. South Central Cardiovascular Network * includes transfers from outside Trust sources: MINAP 07-08, Lead Interventionalists’ declared numbers

  10. 80 60 Absolute mortality reduction per 1000 treated patients 40 20 0 0 3 6 9 12 15 18 21 24 Treatment delay (h) Boersma et al : Lancet 1996; 348:771-775 How important is time? Early thrombolysis

  11. How important is time? Primary PCI Time to treatment and 1-year mortality every 30 min delay increases mortality by 7.5% De Luca, G. et al. Circulation 2004;109:1223-1225

  12. How important is time? % Mortality in NIAP

  13. How important is time? % Mortality in NIAP

  14. Potential to worsen outcome How important is time? Pinto Circulation 2006;114:2019-2025

  15. Call-to-Balloon Time How important is time? Target 120 mins Door to balloon Call-to-Depart Travel

  16. Call to Depart-the-scene timesSouth Central -MINAP 2006-2008 median 39 mins range 00:14:00 to 2:39:00 50% < 40 mins 90% < 60 mins 60 39

  17. South Central Median 39:00 Call to Depart-the-scene timesSouth Central -MINAP 2006-2008 n = 333 range 00:14:00 - 02:39:00

  18. Door-to-Balloon times

  19. Call-to-Balloon times

  20. Harefield • median 23 mins • 75% <30 mins • 90% <60 mins • no A&E Door-to Balloon times 30 mins

  21. Call-to-Balloon Time “If we see centres getting >75% patients with PPCI centre D2B times <90 minutes with a median time of, say, 30-40 mins, then almost certainly this will reflect a good system with good outcomes.” “Similarly, if we see centres with >75% getting C2B times <120 mins, this will also represent a good system.”

  22. Call-to-Balloon Time Target >75% C2B <120 mins Travel -10 mins Call-to-Depart >75% <40 mins Door to balloon >75% <90 mins

  23. Call-to-Balloon Time Target >75% C2B <120 mins Travel how much less than 60 mins? Call-to-Depart median 30 mins Travel median 60 mins Door to balloon median 30 mins Similarly, if we see centres with >75% getting C2B times <120 mins, this will also represent a good system.

  24. How important is time? 60 minute Isochrones ORH & SUHT

  25. How important is time? 40 minute Isochrones ORH & SUHT

  26. How important is time? Local service Centre Volume

  27. Local service Centre Volume How important is time?

  28. Who will decide?

  29. Who will decide? sources: MINAP 07-08, Lead Interventionalists’ declared numbers, Health Resource Group

  30. Politicians DOH Acute Trusts Cardiologists BCIS Who will decide? Strategic Health Authority Cardiovascular Network Commissioners Media PPI groups The Public

  31. Politicians DOH Acute Trusts Cardiologists BCIS Who will decide? Strategic Health Authority Cardiovascular Network Commissioners Media PPI groups The Public

  32. Who will decide?

  33. Commissioners will decide • Concerns about Regional Service • significant extra costs • additional ambulance journeys/resources • 18% uplift in tariff at larger centres • unsure of size of health benefits • some areas currently have good outcomes from thrombolysis • areas with longer travel times • reluctant to decommission local services • knock-on effects on local cardiology provision • solution must be acceptable to PPI groups

  34. South Central Cardiovascular Network Rules for Restricted Hours PPCI

  35. Who will decide? X X X X X ? X

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