1. BCIS Annual Meeting London January 2006 Dr Bernard Prendergast DM FRCP Wythenshawe Hospital Manchester UK Primary Angioplasty for Acute MI Who are the Stakeholders? NO CONFLICT OF INTEREST TO DECLARE

2. Manchester Cardiac Services 2001

4. PCI projections Greater Manchester 2005-6 Population 3.8 million PCI @ 1050/million: 4000/annum Wythenshawe 1500 MRI 1750 DGH (250x3) 750

5. ● February ● February: MRI commences 8am – 4pm primary PCI service for A&E patients. ● June: ● June: Greater Manchester Cardiac Board allows PCI Group to consider provision of a city wide service. ● September ● September: Multidisciplinary process mapping meeting. ● October ● October: Two day Network meeting attended by DOH representatives to establish a network PCI programme. ● November ● November: “Primary PCI: The Challenge” – national UK conference (193 delegates). ● December ● December: Invitation to submit a NIAP proposal. 2 year phased proposal signed by chief Executives of the two PCI centres, the Ambulance Trust and the Cardiac Network. ● February: ● February: Successful NIAP bid with six other UK centres. ● March / April: ● March / April: Meetings to discuss implementation of primary PCI proposals. ● April: ● April: Wythenshawe commences 8am – 4pm primary PCI service for A&E patients. ● June: ● June: A&E Consultants meeting. ● July: ● July: NMGH & Hope meeting. ● August: ● August: Stepping Hill Hospital meeting. ● September: ● September: Greater Manchester Ambulance Service commissioning meeting. ● October: ● October: Appointment of PCI Project Manager and Clinical Audit/Information Officer. ● November: 3 initial pilot sites confirmed 2004 2005

6. Primary PCI Stakeholders The Patient ● Local vs. specialist care ● Inequity of access to PPCI ● When for my DGH? ● Informed consent ● Relatives ● Confusion/bewilderment

7. Primary PCI Stakeholders The Ambulance Service Thrombolysis in Greater Manchester 2005 ● CTS < 8 min75% ● CTD < 30 min55%< 40 min89% ● CCG86% ● DTN < 20 min 64%< 30 min88% ● CTN < 60 min82% Outstanding Issues Skills in ECG interpretation Impact on other emergency services Geographical imbalance of ambulance pool Alternative strategies for urban and rural populations

8. Primary PCI Stakeholders The Referring DGH A&E Department ● “Why should we replace optimal thrombolysis with an experimental PPCI service” ● “What about our stars – we’re about to bid for foundation status, you know!” ● “We’re not going back to the dark ages of assessment in the back of ambulances” ● “Who’s responsible if the patient dies in transit?” ● “We will need informed consent for transfer” ● “This clinical trial – what about ethical approval?”

9. Primary PCI Stakeholders The Catheter Lab Team Nurses, Radiographers, Technicians, Audit Team, Activity Managers

10. Primary PCI Stakeholders The DGH Cardiac Team The backlog of ACS transfers is a greater day- to-day headache Guaranteed repatriation at 24 hrs (and perhaps sooner) and need for altered nursing skill mix Abbreviated IP stay diminishes time for Phase 1 rehabilitation and education GPs may be unprepared or unwilling to cope Limited exposure to AMI for doctors in training

11. Primary PCI Stakeholders The Bed Manager Time spent in A&E Locker, T. E et al. BMJ 2005;330:1188-9.

12. Primary PCI Stakeholders Tertiary Centre NHS Trusts The clinical/political conflict ● 3/12 waiting list target met as a priority ● Current mean wait 7-10 days (range 2-21 days) ● Constant pool of 40-50 patients awaiting transfer to tertiary care ElectiveNon-elective (ACS) 

13. Primary PCI Stakeholders Healthcare commissioners/Cardiac Network ● Current activity projections are conservative and account only for elective and ACS work ● In 2005-2006, a 40% reduced rate non-elective short stay tariff will apply for in-patient stays <48hrs* ● Only in the NHS could attempts at increased efficiency be rewarded by diminished reimbursement!! ● Who pays for: – Ambulance activity – Clopidogrel – Abciximab – etc, etc * Currently being addressed by DOH/BCS

14. Primary PCI Stakeholders The Government/Department of Health To address: ● Logistic difficulties of providing a PPCI service ● Challenges in different geographical settings ● Robust data collection and audit ● Costs of service provision ● Patient’s experience of such a service ● Detailed outcome analysis ● Patient and carer experience ● Workforce implications ● Outcome using different models of service delivery ● Implementation and feasibility issues ● Economic evaluation THE NATIONAL INFARCT ANGIOPLASTY PROJECT British Cardiac Society and Department of Health - a joint project. AIMS OUTCOMES “Ultimately, a hybrid model of PPCI and pre-hospital thrombolysis seems likely.” Sue Dodd, DOH, Manchester November 2005.

15. Primary angioplasty is arriving!

16. Primary PCI in the UK Evolution not REvolution