1. NO CONFLICT OF INTEREST TO DECLARE J.M. McLENACHAN, LEEDS

2. PRIMARY PCI FOR STEMI Is a 24 / 7 service sustainable? Jim McLenachan, Leeds 26 th January, 2006

4. PRIMARY PCI SERVICE AT LEEDS HOW IT WORKS u Commenced 7/3/05 u 24 / 7 service (after much discussion) u Initial phase covering Leeds only (population 800,000) u Plan to roll out to rest of West Yorks over 2 years (total population 3.1 million) u Interventionist on-call 1 in 6 u 2 full-time PPCI nurses and 1 PPCI support officer u Referrals via cath lab scheduler 8 – 4 Mon to Fri and via SpR out of hours

5. PRIMARY PCI SERVICE AT LEEDS TARGETS u DOOR TO BALLOON TIME < 120 MINUTES u CALL TO BALLOON TIME < 90 MINUTES u DOOR TO REFERRAL TIME < 20 MINUTES u HOSPITAL DISCHARGE AT 3 DAYS (achieved in 75%)

6. TOTAL NUMBERS OF PPCI PATIENTS (data for first 10 months) TOTAL NUMBER OF PATIENTS 203 MEDIAN NUMBER OF PATIENTS PER MONTH 20 MEAN NUMBER OF PATIENTS PER MONTH 18

7. MEDIAN DOOR TO BALLOON TIMES MINUTES

8. HOSPITAL MORTALITY MORTALITY % 7/3/05 – 12/1/067/9/04 – 6/3/0528/4/03 – 28/10/03 6.2% 9.1% 9.9%

9. PPCI AT LEEDS DAY OF THE WEEK AND TIME OF THE DAY (first 137 patients) 63%16%21%

11. EXPECTED ANNUAL NO. OF PPCI PATIENTS (population of 3.1 million) 8 am – 8 pm 570 8 pm - midnight 90 midnight – 8 am 190

12. EXTERNAL CHALLENGES u Convincing healthcare commissioners u De-skilling of A and E staff u De-skilling of CCU staff in non-PCI centres u Uncertainty / anxiety among thrombolysis nurses u Ambulance issues : pre-hospital thrombolysis longer transfer times “displaced” ambulances

13. INTERNAL CHALLENGES u WORKING TIME FOR CATH LAB STAFF: finish before midnight - normal hours next day finish after midnight- 11 hours off u WORKING TIME FOR CONSULTANTS: SPA session on morning after on-call

14. ESC GUIDELINES FOR STEMI 2005 PCI STEMITHROMBOLYSIS

15. ESC GUIDELINES FOR STEMI 2005 Consider thrombolysis PCI Contra-indication to thrombolysis or shock ECG resolution thrombolyse No ECG resolution STEMI < 3 hours since onset 3-12 hours since onset salvage PCI within 24 hours

16. IS A 24 / 7 PCI SERVICE SUSTAINABLE? Yes, but………… u Simple guidelines and routes of communication needed u Requires flexibility u ??Easier in a large centre where the frequency of on- call is less but the expectation of being called out-of- hours is higher