26th JanuarySESSION XIV DEBATE

DGH vs Tertiary intervention

Is there really a conflict?

Department of Health Perspective

Roger Boyle

No conflict of interest to declare

Cardiology in the district hospital.Report of a working group of the British Cardiac SocietyBr Heart J. 1987; 537-546

The district cardiologist may wish to maintain skills by participating in catheter sessions.

A report of a working group of the British CardiacSociety: cardiology in the district hospital.Br Heart J. 1994; 72: 303-308

It is becoming commonplace for district hospitals to develop their owncatheterisation facilities..

BCS Council Meeting circa 1994

Statement by the Council of the British CardiacSociety. Strategic planning for cardiac servicesand the internal market: role of catheterisationlaboratories in district general hospitals.Br Heart J. 1994; 71: 110-112

DGH cardiologists should be offered specific sessions in tertiary labs

Some DGHs that are geographically disadvantaged might developtheir own labs

Over time, DGH labs would become the norm!!!!!!!!!

BCS Working Group:The changing interface between district hospitalcardiology and the major cardiac centresHeart 1997; 78: 519-523

Main conclusionsThe establishment of new cardiac catheterisation laboratories in DGHs remote from a major centre should be encouraged provided the workload is adequate to ensure efficient use of the facility

Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre

UK Centres - 2005

Revascularisation trends

Angiography waiters from April 2005

PCI waiters by length of wait April 2002 onwards2002/32003/42004/52005/62006/7

Southampton November 2006

8387PCI centresAngiography onlyCentres2005

A discussion of the drugs administered in a case of coronary thrombosis is not relevant here but for pain relief morphine is often given by an attending doctor or on arrival at hospital.the patient should not be questioned unduly or in any way alarmed.

1970

Heart Attack: Progress Since the NSFPercentage of patients treated within 30 minutes of arrival at hospital rose from 38% to 83%Paramedics trained to assess, diagnose and provide thrombolysisPercentage of patients treated within 60 minutes of a call for help rose from 30% to 65%

Pilot schemes set up to test feasibility of primary angioplasty in the NHS

Reperfusion treatment 2003-612.6%14.4%%[plus patients in NIAP not yet transferred~ 2.5%]

Access to PPCI37/68 English & Welsh hospitals with interventional facilities on site perform primary angioplasty14/37 provide an internal service onlyOnly 4 provide 24/7, the rest lab hours or occasional23/37 offered a service to other hospitalsReporting that they provided this to 78 hospitals

NB only 42 non interventional hospitals said they received a routine PPCI service, suggesting that service to other hospitals might be irregular / occasional

James Cook - FriarageLeeds- SJUH- BradfordEast London- R London- Whipps X- King George- Oldchurch- Homerton- NewhamLeeds- SJUH- BradfordSE LondonLewishamBromleySidcupMaydayManchester (2)North McrSalfordStockportTamesideTraffordNW London (3)-Hammersmith-W Middlesex-Ealing-Charing X-St Marys-Northwick-Hillingdon-Harefield-Brompton-HemelExeter

Acute MI CatchmentsTertiary CABG Catchments

Trust Catchment AreasSecondary - Acute MITertiary - CABGNo. of Trusts15328Ave Pop Served321,0001.7 millionLargest787,0003.2 millionSmallest104,000816,000

ConclusionDistrict hospital angiography has improved access to care and the capacity is neededStill a great deal of unmet need particularly in the NorthWe are a long way from providing a comprehensive PPCI service at the presentMany places are dabblingWe need a comprehensive strategy within each network with formal involvement of the ambulance serviceNo reason to exclude DGHs from providing this but the rota requirements are onerous

2006 is ~ of a complete year, with 20,500 patients treated with reperfusion treatment; 15000 in hospital lysis, 2750 prehospital lysis and 2750 PPCI. Lynne and I think 5-700 having PPCI are missing and are in NIAP; perhaps 2%