Local improvement following national clinical audit workshops Auditing heart attacks Saving lives Dr Andrew Wragg Barts Health

Overview National Audits related to Acute Coronary syndromes What do they involve What are our challenges How do we use data: how does it change practice What difference has it made

What is a Heart Attack?

What is a STEMI and a NON STEMI It is all about ST segment elevation

More than just an angioplasty Prompt recognition of symptoms Heart monitoring and resuscitation Prevent further coronary thrombosis Reduce and reverse ischaemia Prevent future MI Education

Overview National Audits related to Acute Coronary syndromes What do they involve What are our challenges How do we use data: how does it change practice What difference has it made

NICOR MINAP (2000) Myocardial Ischaemia National Audit project –All patients presenting with a Acute Coronary Syndromes (ACS) –Includes STEMI, Non STEMI and non cardiac chest pain –All hospitals who receive acute admissions BCIS (1991) British Cardiac Intervention Society Audit –Cover all angioplasty procedures –All hospitals undertaking angioplasty

MINAP/ BCIS National clinical audits of heart attack management Hospitals, ambulance services and commissioners have a record of their management of heart attack patients Comparative analysis against nationally agreed standards Allows comparative data between centres and regions Clinicians and managers can monitor and improve quality and outcomes of their local services

Overview National Audits related to Acute Coronary syndromes What do they involve? What are our challenges? How do we use data: how does it change practice What difference has it made

Lots of Data and Manpower > 100 questions in each dataset Detailed medical and technical information Approx 1800 PCI and 1200 MIs at LCH pa BCIS done by medics MINAP done by specialist nurses IT Support needed BUT huge impact Nationally

Prescription of secondary prevention medication 5 drugs shown to improve outcome after AMI Aspirin/ Statins/ B Blockers/ ACE I and Clopidogrel

Use of secondary prevention post MI continues to improve MINAP report 2010 BLT: over 97% for all therapies

30 day mortality post STEMI continues to decline MINAP report 2010

Time is muscle!

% Mortality Ischaemic time (call to balloon) De Luca, G. et al. Circulation 2004;109: patients with STEMI in USA Relationship between time to treatment and 1-year mortality Double mortality for delay of 3 hours

Key Performance targets STEMI (CQC) Call-to-balloon (CTB) audit standard 150 mins Door-to-balloon (DTB) audit standard 90 mins Length of stay Mortality

Admitted from the community Direct admission to PCI centre Transfer to PCI centre Admission to Non-PCI centre PCI for Acute Sx Four admission scenarios device D1 D2 V CTB DTB

Performance time targets Door to balloon: 80% less than 90 mins Call to balloon: 75% less than 150 mins Direct transfer rate: >80%

How did BLT do! 2009 data Door to balloon: 80% < 90 mins Call to balloon: 75% <150 mins Direct transfer rate: >80% Door to balloon: 85% < 90 mins Call to balloon: 56% < 150 mins Direct transfer rate: 50% We had to improve!

Overview National Audits related to Acute Coronary syndromes What do they involve What are our challenges How do we use data: how does it change practice What difference has it made

HAC Daily Audit Weekly Report Straight to Lab Internal DTB<60 Straight to Table

Week commencing: 10 th – 16 th ~February 2012 (Excluding patients who were shocked/ ventilated or initial diagnosis not STEMI) abcd Source: Heart Attack Centre Audit Team * Excludes patients in Cardiogenic shock, ventilated or already in hospital at time of STEMI CQC targets: 75% patients call – balloon time should be <150 minutes These figures may be subject to change pending feedback from LAS and NELN hospitals PatientProcedure Date Admission RouteCall - D1D1 - D2D2TBCall - Balloon Call in HoursOutcome 110/02/2012Direct In-Hour No action required 210/02/2012Direct In-HourNo action required 310/02/2012Interhospital transfer - OLD In-Hour LAS transfer time under investigation 411/02/2012Interhospital transfer - OLD Out-HourNo action required 511/02/2012Direct Out-HourNo action required 612/02/2012Direct Out-HourNo action required 712/02/2012Direct Out-HourNo action required 813/02/2012Direct In-HourNo action required 914/02/2012Direct Out-Hour Lab delay under investigation 10 14/02/2012Direct Out-HourNo action required 1114/02/2012Direct Out-HourNo action required 1215/02/2012Interhospital transfer - WHC In-Hour Difficulties accessing patient’s residence 1316/02/2012Direct Out-HourNo action required 1416/02/2012Direct Out-HourNo action required Total pPCI Inc shock + ventilated pPCI Exc. shock + ventilated % Indirect Exc. Shock + ventilated Self presented% Direct LAS Transfers (exc.) % CTB < 150 mins (exc.) % DTB < 90 mins (exc.) % DTB < 60 mins (exc.) % %85.71%100.00%92.86% %86.59%98.86%88.86%

What was the impact?

Length of stay post PCI

Conclusion MINAP and BCIS are powerful audits Great drivers of change Tool for transforming prognosis C2B target worthy of its CQC point! Great resource for local research However, not cheap! Significant resource required to do them well

Local improvement following national clinical audit workshop Dr Andrew Wragg Barts Health Acknowledgements: cardiology team/ LAS/ NELCS network/ HAC audit team/ MINAP and BCIS