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Implementation of 24h PPCI Service in QMH:
Key Determinants to Success & Future Perspectives
Dr Raymond H W Chan, Consultant Cardiologist
Department of Medicine, Queen Mary Hospital
on behalf of the
QMH AMI Clinical Pathway Team 8.5.2012
Chan HWR, Lam L, Lam YM, Choi K, Chan P, Lam S, Chan K, Chan M, Hai JJ,
Wong KLM, Tam F, Yung A, Wong A, Kan A, Tsang YW, Luk WS, Fan L, Lee S,
Wong WF, Ng PS, Tang ML, Wong SM, Tseh E, Tong HK, Tsui SH, Chan C , Lee SWL
Department of Medicine, Central Nursing Department, A& E Department QMH
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
AMI(急性心肌梗塞)& PPCI(通心血管手術) Acute Myocardial Infarction & Primary Percutaneous Coronary Intervention
• When AMI occurs
open up the blocked artery ASAP
• Delay heart muscle
• Medication is inferior to PPCI may fatal brain bleeding
• 24hour PPCI Service
the challenge is Resource & Logistics
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
QMH PPCI Program
part of the QMH AMI Clinical Pathway
(急性心肌梗塞臨床路徑)
Commenced 1.2.2007 – present
The AMI CP is a clearly spelt out management proctocol starting first step at the AED
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
4
AMI Clinical Pathway Management Protocol
(急性心肌梗塞臨床路徑)
AMI CP – Contents
• Evidence Based Medicine
• Multi-departmental collaboration
• AMI CP Protocol - starting at the AED
• Independent audit – Independent Audit Department
• Regular appraisal & Critical Review – System
Interventions
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
EBM – International Benchmarking
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
PPCI SUPERIOR, GIVEN RIGHT TIME , PLACE & PERSON
ACCF/AHA Task Force on Practice Guidelines. http://www.acc.org. Aug 1,2009
ACC/AHA/SCAI 2005 guideline update for PCI. Jacc 2006;47:E1-121
ACC/AHA guidelines for the management of pts w ST elevation MI. JACC 2004;44:e1-e211
Focusses update of the ACC/AHA 2004 Guidelines for the mgt of pts w STEMI. JACC 2008;51:210-47
. . . . .
Timely Management Essential Mortality & Morbidity Door to Needle Time ≤ 30 min D-NT Door to Balloon Time ≤ 90 min D-BT
Lytics Cerebral Bleeding in the followings Female Age>70 SBP>160 M<80kg F<65kg Hx CVA TNK INR> 4 Black race
International Database of AMI Mortality
16.00% 9.80% 7.20%
48.9%
14.5%
49.4%
19.00%22%
0%
20%
40%
60%
80%
100%
AIHW Total
CFR
AIHW hosp
CFR
WHO
MONICA
28d CFR
(Men)
WHO
MONICA
28d CFR
Hosp pts
(Men)
YALE
Medicare
30d, JGIM
2006
Yale 2010
30d RSMR,
Circ Cardio
Outcome
2010
HK HA Ami
Mortality
Study 2009,
in progress
HK QMH
2010 In-
Hosp CFR
Swedish
STEMI
Registry
1996-2007
In-Hosp
Mortality
JAMA 2011
pe
rc
en
ta
ge
Circulation 1997: WHO Project with A population view 1985-1990
Australian Institute of Health & Welfare 9.2002: 1/2 of 48,313 events were fatal (1999-00) & 87% occurred outside hospital
LIMITATIONS: AIHW 2002 WHO 1990 MEDICARE FFS CCU Pt only
½ US AMI Pts
Mortality Trend
Mortality Trend
* * *
AMI CP – Contents
• Evidence Based Medicine
• Multi-departmental collaboration
• AMI CP Protocol - starting at the AED
• Independent audit – Independent Audit Department
• Regular appraisal & Critical Review – System
Interventions
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
Multi-departmental
Collaboration
AED (Made
diagnosis of
AMI)
CCU On
call
(Decision x
PPCI)
Interventional
Cardiologist
Cath Lab Staff
Cath Lab a/v
Cath.
Lab
CCU
Multi-dept
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
CCU & CW Nursing Team
Occupational Therapist
MSW
Dietitian
Physiotherapist
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
AMI CP – Contents
• Evidence Based Medicine
• Multi-departmental collaboration
• AMI CP Protocol - starting at the AED
• Independent audit – Independent Audit Department
• Regular appraisal & Critical Review – System
Interventions
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
AED
• AED physicians elective to CCU for 3 months
for conjoint management on AMI
• AMI CP care protocol facilitated AED nursing staffs at triage level
• AMI CP clear-cut flow-chart Rx protocol
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
AMI CP – Contents
• Evidence Based Medicine
• Multi-departmental collaboration
• AMI CP Protocol - starting at the AED
• Independent audit – CND QMH
• Regular appraisal & Critical Review – System
Interventions
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
Central Nursing Division & Quality &
Risk Management Team
•Review & develop SOP & Care Maps
•Root cause analysis of variances ( DNT, DBT, LOS, Mortality)
•Monitor patient delivery logistic (the AED → CCU / CCL Transit)
•Re-engineer PCI booking mechanisms
•Case manager : data acquisition, analysis, variance audit & health
education & assessment
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
AMI CP – Contents
• Evidence Based Medicine
• Multi-departmental collaboration
• AMI CP Protocol - starting at the AED
• Independent audit – Independent Audit Department
• Regular appraisal & Critical Review –
System Interventions
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
System Intervention
• 4 Cardiology specialty trainees were recruited into the team since 1 Jul 2007 A B C
• With effect from 31 Aug 07, we re-rectify the practice to administer Lytics in AED; Cardiology Consult was carried out only if essential. A • W.e.f. 1 July 2007, AED sent an Emergency Medicine Fellow for elective to CCU for 3m A B
• Enhanced Division communication by weekly frontline team meeting in CCU A B C
• Regular case review meetings with AED A B
• Case Manager involvement in patient education & risk factors identification C
A. Shorten DN-T B. Shorten DB-T C. Shorten LOS
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
HIGHLIGHTS
1. Strategy of Extension of Cardiac Catherization Laboratory hours
2. 3 Nurses Deficient, How to sustain 24h PPCI - Manpower Logistics
System Intervention – Strategy of Extension
of Cardiac Catherization Laboratory hours
24 hour Emergent Cath Lab Service for PPCI 01/02/2007 9A – 5P
01/08/2008 8A – 8P
15/04/2009 24h PPCI for patients ≥ 2 Risk Factors for ICH
07/11/2010 24h PPCI for all eligible patients
24h PPCI Service_AMI Same Manpower
• Insights - 2 Strategic Actions
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
STRATEGIC ACTION 1
Case Admission Pattern Analysis
• 53.61 % (CP89); 52.24 % (non-CP105) of patients admitted 8a-6p
• 26.51 % (CP44); 25.87 % (non-CP52) of patients admitted 6p-12mn
• 19.88 % (CP33); 21.89 % (non-CP44) of patients admitted 12mn–8a
53.61
26.51
19.88
0
10
20
30
40
50
60
08:00 - 18:00 18:01 - 00:00 00:01 - 08:00
Time
Percentages (%)
2007, 2008 CCU Admission Time: AMI Pts
52.24
25.8721.89
0
10
20
30
40
50
60
08:00 - 18:00 18:01 - 00:00 00:01 - 08:00
Time
Percentages (%)
AMI (Clinical Pathway Pts) AMI (Non- Clinical Pathway Pts)
- with complications
STRATEGIC ACTION 2
Pressure Testing
PPCI 2007
(No. of Patients)
2008
(No. of Patients)
2009
(No. of Patients)
2010
(No. of Patients)
08:00 – 08:59 1 2 2 5
09:00 – 17:00 17 23 34 32
17:01 – 20:00 3 10 9 8
20:01 – 07:59 1 1 12 15
Lytics 2007
(No. of Patients)
2008
(No. of Patients)
2009
(No. of Patients)
2010
(No. of Patients)
08:00 – 08:59 0 1 0 0
09:00 – 17:00 11 8 1 1
17:01 – 20:00 7 5 2 0
20:01 – 07:59 20 22 13 5
E-PPCI System Pressure Testing & Contextualization
1.2.2007
PPCI 9a-5p
1.8.08
PPCI 8a-8p
15.4.09
PPCI
8a-8p: all ami
8p-8a: 2 Risks
7.11.2010
24h PPCI
All STEMI
` 1.8.2008 15.4.2009 7.11.2010
* Figures: AMI pts recruited into AMICP
System Intervention – Manpower Logistics
2 Cardiac Catherization Laboratories 3 Interv Cardiologists
5 Full-time Cath Lab Nurses (no technician) 6 Cardiac Fellows
(very “average” Hardware & Software strength)
3 RN Deficient, how to sustain 24 PPCI ? QMCC-DNR (Doctor-Nurse-Runner)-
Doctors acting as Cath Lab nurses in Nurses Call list as back-up
QMH is the only HK Hospital offering 24h PPCI since 2010
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
RULE: Cath Lab Nurse on Call not >1:3
* * Staff Motivation & Commitment * *
2007 2008 2009 2010 1-4/2011 International
Benchmark
CP no.Recruited 201 160 174 119
CP no.Completed 166 123 113 89
Age (mean) 68.1 65.8 63 65.3
Lytics no.(CP) 38 (22.9%) 36(29%) 16(14%) 5 (5.6%) x
D-N-T (mean) 86
42 40 43 x 30
PPCI no.(CP) 23(13.9 %) 36(29%) 57(50%) 60(67.4%)
D-B-T (mean) 277 113 101 96 90
LOS (mean) 5.2 4.2 3.9 4
Readmission
Rate
6.6 4.1 4.4 5.6
Hosp Mortality
(All AMI) 13.2 10.5 10.2 9.8
See Chart
RESULTS: AMI 2007 - 2011
QMH : 5y Trend of ↑E-PCI & AMI Mortality
*
∑ 6.8% ∑ 7.9%
0% 0%
367
65
4430
361
104
63
25
465
64
96
10
476
36
87
5
570
37
126
0
2007 2008 2009 2010 2011
ELECTIVE
URGENT
EMERGENCY
LYTICS
Overall
AMI Mortality
EMERGENT PCI :
Procedure be
performed ASAP/
within 24h
(Maj = PrimaryPCI)
URGENT PCI :
Procedure be
performed within
index hospitalisation
13.2% 10.5% 10.2% 9.8%
0%
24 Hour PPCI
7.11.2010
∑ 4.3% (4/93)
2.8% (2/72)
9.5% (2/21)
0%
E-PCI : ∑ Mort Rate
Non UR ( =NON ULTRA RISK)
UR (Shock, Post Arrest, Intub, VT)
Elective PCI : 0%
∑ 8.1% (7/87)
0% (0/66)
33.3 % (7/21)
0%
Dr Wong Ka Lam et al_HA Convention 2012 e Abstract
“Reduction of Mortality with implementation of AMICP in QMH”
2029 AMI patients ( 7 year analysis 2004 – 2011)
AMI Mortality after Implementation of AMICP ( PPCI)
p<0.05
CONCLUSION:
Key Determinants to Success of the Program: • Staff Commitment & Dedication
• Well planned and Mutidepartmental Collaboration
• Independent Audit
• Mandatory Regular Critical Review & Reappraisals
Future Perspectives: • Power Analysis on Outcome Determinants
• Training to all CCU Nurses so that they will be competent
Cath Lab Staff in the near future in support of the
24 PPCI Service
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH
Queen Mary Hospital
瑪 麗 醫 院
Queen Mary Hospital
瑪 麗 醫 院
THANK YOU !
AMI CP
TEAM
急性心肌梗塞24小時通心血管手術 24h PPCI Service QMH