Archived decisions

NHS HAMPSHIRE

DELIVERING AN IMPROVED PRIMARY PERCUTANEOUS CORONARY INTERVENTION SERVICE [PPCI] FOR THE POPULATION OF HAMPSHIRE

1. INTRODUCTION

1.1. This paper has been drafted to provide the Hampshire Overview and Scrutiny Committee with an overview of the way in which NHS Hampshire intends to work with local people and stakeholders to develop and improve the existing provision of primary percutaneous coronary intervention [PPCI] in Hampshire.

2. BACKGROUND

2.1. In October 2008, the Government suggested a rapid expansion of coronary angioplasty (Primary Percutaneous Coronary Intervention or PPCI) for the treatment of heart attack patients in England. Prior to this date NHS Hampshire had established a steering group to look at the provision of Acute Coronary Syndrome patients across Hampshire.

2.2. Evidence suggests that patients who have suffered a heart attack have a greater chance of survival and recovery if they are treated in a specialist centre that provides primary percutaneous coronary intervention (PPCI).

`SHA visions have sent a powerful message that the most effective treatments should be available for all NHS patients. Their plans for transforming treatment for heart attacks vividly illustrate this' (Darzi A (2008) High Quality Care for All)

2.3. The final report of the National Infarct Angioplasty Project (NIAP) was published on 20th October 2008. NIAP was an observational study to test the feasibility of establishing coronary angioplasty (PPCI) as the initial treatment (in place of thrombolysis) for heart attack patients across England. The key findings of the NIAP study were as follows:

· PPCI can be delivered within acceptable treatment times in a variety of settings;

· direct admission to a cardiac catheter laboratory is the preferred route of admission to achieve timely treatment. This shifts the onus of diagnosis onto the ambulance service and away from Accident and Emergency departments.

3. ACUTE CORONARY SYNDROME

3.1. Essentially people with an acute coronary syndrome (heart attack) are divided into two main groups:

Patients with non-ST elevation acute coronary syndrome (NSTEACS)

3.2. These patients are admitted acutely through an Accident and Emergency department into a cardiology (or sometimes general medical) ward. They are treated initially with anti-platelet, anticoagulant and anti-anginal drugs. If they have raised cardiac markers (e.g. troponin), or ongoing symptoms, indicating that they are at high risk of further events, they will usually undergo angiography and be considered for revascularisation, in the form of either PCI or coronary artery bypass graft (CABG). If they have been admitted to a hospital with on-site PCI, the angiogram and PCI will be carried out as a single procedure.

3.3. If admitted to a hospital without onsite PCI, the angiogram may be carried out at the admitting hospital with onward referral to the PCI centre. Alternatively, patients may be transferred to the PCI centre for an angiogram with follow-on PCI if required. Current clinical guidelines suggest that PCI should be performed within 72 hours of admission. NSTEACS patients occasionally require immediate access to a cardiac catheter lab because of haemodynamic instability, ongoing ischaemia or other co-morbidities, but most can be treated during daylight hours.

3.4. These services should and are available in most General Hospitals

Patients with ST segment elevation myocardial infarction (STEMI)

3.5. Immediate PCI is now the preferred treatment (over thrombolysis) for patients presenting with ST segment elevation MI (STEMI) provided it can be delivered within an appropriate timeframe. These patients are taken directly to the PCI centre for primary PCI. This should be performed as soon as possible and preferably within 120 minutes of the patient first summoning medical help. Primary PCI, therefore, mandates 24 hour access to the cardiac catheter lab.

4. NHS HAMPSHIRE APPROACH

4.1. Across South Central, Primary Care Trusts are working with the Cardiac Network to develop improvements in the provision of PPCI, in line with the national steer.

4.2. NHS Hampshire has established a Steering Group charged with developing its approach to PPCI. The Hampshire PPCI Steering Group is chaired by Dr David Balfour of NHS Hampshire and draws representation from a wide range of clinical interests.

4.3. Whilst this paper is focused on the way forward for Hampshire, there have been very positive discussions with partners in Portsmouth, Southampton and the Isle of Wight about taking forward the approach, identified below, collaboratively. This will be confirmed in the next fortnight.

4.4. From its inception, the approach of the Steering Group, in line with recommendations from the Royal College of Physicians, NIAP, NICE, and NHS improvement, was to put forward a case that there should be 24 hour access to PPCI for all its patients.

4.5. The Steering Group felt strongly that patients should not suffer significant risk because their event occurred out of hours or at weekends. Evidence shows clearly that there is a 50% increase in mortality in patients having traditional thrombolysis over those receiving timely PPCI.

4.6. The steering group has therefore drawn up a draft service specification for the delivery of PPCI (see Appendix A). This specifies what good practice looks like and, if implemented, would guarantee equity of access and care for all Hampshire residents.

4.7. It does not dictate which Hospitals should or should not provide the service, although it is likely that some of NHS Hampshire's providers could struggle to meet what are essentially nationally agreed evidence based standards.

5. COMMISSIONING IMPLICATIONS

5.1. In some ways, commissioning of a PPCI service differs from the commissioning of other new clinical services. The procedure (PCI) is already commissioned. Initial fears that commissioning a PPCI service might lead to a substantial growth in total PCI numbers have been unfounded. In West Yorkshire, the introduction and roll-out of PPCI to a population of around three million has led to no increase in absolute PCI numbers, even though PPCI now makes up 30% of the total PCI procedures. The reason for this is clear: when thrombolysis was the standard treatment for STEMI patients, around 60-70% of thrombolysed patients underwent angiography and/or PCI within six months of their initial presentation. Therefore, a policy of PPCI brings forward the PCI procedure to the time when the patient has the most to gain.

6. PROPOSED WAY FORWARD

6.1. The next phase of the development will be to work with the local community, service users and carers in the development and commissioning of an appropriate PPCI service across Hampshire.

6.2. The key audiences for this phase will be:

· Staff

· Public

· Service users

· Carers

· Local clinicians

· Local politicians

· Local voluntary and community groups

· Media

Objectives

6.3. The objectives of this phase of the process will be to:

· listen to the views of services users and their carers and ensure and develop a service specification which reflects their views;

· involve local service users, carers in the commissioning of local services to deliver this specification;

· inform and involve local NHS staff, local partner organisations and the local community in the development of a PPCI service specification and the commissioning of a local service to deliver this specification;

· provide accurate and timely information on the current and future plans for the delivery of PPCI across the county.

Methods of communication and engagement

· Face to face: staff and stakeholder meetings, discussion and briefings

· Publications: targeted bulletins; staff newsletters; community groups', charitable organisations', local authority and parish magazines

· Media: print and broadcast media via media releases and interviews

· Opinion research: targeted research into service user and carer views

· Web: NHS Trust websites, Community Voices online, partner websites

Approach

6.4. It is anticipated that three main approaches will be used during this phase:

a) to proactively undertake opinion research into service user and carer views to inform the service specification

b) to undertake face to face briefings and discussion with interested parties by mapping existing meetings and key contacts and proactively attending stakeholder meetings to listen and respond to local views

c) to develop greater interaction with, and information for, local community groups, voluntary organisations, service user/carer groups and faith groups in order to listen and respond to local views.

Tactics, implementation and measurement

6.5. The outline implementation plan is set out at Appendix B

7. OUTCOME

7.1. Following this period of involvement, it is anticipated that NHS Hampshire will have finalised a PPCI service specification for subsequent implementation. An update on this work will be presented, if required, to the HOSC in November 2009. The Steering Group will be broadened to ensure service user / carer representation as the specification moves forward for implementation.

7.2. In the light of the challenge that some providers may face in meeting the proposed quality standards, NHS Hampshire and the Steering Group will continue to work with the HOSC around the next steps.

APPENDIX A

SERVICE REQUIREMENTS 1

General

· Minimum of 400 PCI procedures per annum

· Minimum of 75 PCI procedures per operator

· Minimum of 2 cardiac catheterisation laboratories (see below)

· Cath lab available to reopen for minimum of 6 hours post procedure

PPCI Specific

· In the first year a minimum of 50 PPCI procedures per annum, working towards a target of 80 PPCI¹.

SERVICE REQUIREMENTS 2:

· Provide 24/7 PPCI service (in house or agreed networked solution) throughout year

· PPCI patients to be admitted directly to cath lab or cath lab reception area (bypassing A&E)

· Achieve Care Quality Commission targets. Initial target of call to reperfusion time of 150mins in 75% of patients

· Target of call to reperfusion time of 120mins achieved in 75% of cases irrespective of time of day/night (NHS Hants target)

SERVICE REQUIREMENT 3:

· Must have a defined clinical lead

· Must submit complete validated data electronically to MINAP and BCIS datasets

· Must achieve all PCI related Care Quality Commission standards

· Must agree, measure and report against a set of quality and patient experience metrics

SERVICE REQUIREMENT 4:

Service Specific

· Facility for Ambulance service to pre-alert staff of patient arrival at all times

· Cardiology staff to manage patient throughout hospital stay from point of entry

· Sufficient cardiology staff with European Working Time Directive compliant rota to support a service 24/7 including holiday cover

· Emergency cath lab available for PPCI at all times within the time frame for PPCI - either within provider or within network

· Door to balloon times of <90mins in 75% of patients

· Door to balloon times of <60mins in 50% of patients

· Facility for Intra Aortic Balloon Pumping and Temporary Pacing at all times

· Dedicated cardiac care beds for PPCI patients

· Availability of echocardiography 24/7 in all centres

· Integrated Care Pathway for PPCI patients with expected date of discharge <72 hours post PPCI

· Multi-vessel disease - Revascularisation of all culprit lesions on same admission in >90% of cases

· Discharge medication

o Aspirin >95%

o ACE I, β-blocker, statin, Clopidogrel, all >90%

· Final discharge information to Primary Care within 24 hours of discharge in 100% of cases

· Provision of phase 1 cardiac rehabilitation in all patients at PPCI centre

· Link to and transfer of information at discharge to providers of phase 2 & 3 cardiac rehabilitation

SERVICE REQUIREMENT 5:

Annual 30-day mortality for PPCI >8% triggers service review by British Cardiovascular Intervention Society on behalf of NHS Hants

SERVICE REQUIREMENT 6:

· Full cover between the hours of 8am and 6pm Monday to Friday excluding Bank Holidays (it is further suggested that non 24/7 units should have staff available to accept calls from 7.30 a.m. so that the catheter lab can be prepared for a patient arriving at 8.00 a.m.)

· Receipt of a call from SCAS at 17:59 reporting a STEMI patient en route activates the cath lab, without exception

· The service will run every week of the year and include cover for staff holidays

· The ability to deliver this will be evidenced by:

o Written submission of proposed cath lab staffing levels

o Written submissions of consultant job plans

o Written submissions of arrangements for holiday cover

o Audit by the network in collaboration the SCAS

· Daytimes centres must commit to reopening the cath lab for up to 6 hours post PPCI to deal with any daytime procedures that subsequently need further attention

Appendix B

PPCI OUTLINE IMPLEMENTATION PLAN