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Abstract
Introduction Recent Department of Health guidance suggests primary percutaneous coronary intervention (PCI) should be the default reperfusion strategy for patients with ST elevetion myocardial infarction (STEMI). In 2005, Leeds Teaching Hospitals (LTHT) became one of the first centres in the UK to implement a 24 h primary PCI service. The programme expanded to include the catchment area of Bradford Teaching Hospitals Trust (BTHT) in May 2006. Since then an additional four trusts (nine hospitals) across Yorkshire have joined the service and the population served has increased from 700 000 to 3.1 million. Now all patients presenting with STEMI in the region are transferred to LTHT for primary PCI unless there are contra-indications or the catheter laboratory is unavailable, in which case thrombolysis is given. We sought to determine whether expansion had a detrimental effect on the number of patients given thrombolysis in Leeds and Bradford and on the door-to-balloon time (DTB) for those receiving primary PCI.
Median door-to-balloon time for direct admissions to Leeds: May 2006–April 2008.
Thrombolysis cases due to catheter laboratory unavailability at Bradford (2006–8).
Methods The Myocardial Infarction National Audit Project (MINAP) databases at LTHT and BTHT were used along with patient records to determine the numbers and reasons for patients receiving thrombolysis for STEMI and DTB times for all direct admissions (ie, those brought directly to LTHT by paramedics rather than via emergency departments) from May 2006 to April 2008. The median DTB time was calculated for working hours (09:00–17:00 hours, Monday–Friday), out of hours (17:00–09:00 hours and weekends) and all hours. Median DTB times for each month, quarter and 12-month period were compared. For thrombolysis cases the numbers per quarter were plotted.
Results 472 patients from Leeds or Bradford were directly admitted to LTHT for primary PCI. The median DTB was consistently longer out of hours than during the working day (median DTB 64 vs 48 minutes, p<0.001) but the overall DTB time for direct admissions remained constant (fig 1) and within the 90-minute target during the 2-year period (56 vs 58 minutes, p = ns). 76 patients were thrombolysed. In 39 of 59 cases in which the reason for thrombolysis was recorded the cause was unavailability of the catheter laboratory at LTHT. As a percentage of total eligible patients, thrombolysis cases increased from 4.5% to 6.4% from 2006 to 2008. There is a small upward trend during 2007–8 almost entirely due to BTHT cases (fig 2) in which there is a clear adverse impact of expansion on catheter laboratory availability for primary PCI.
Conclusion The median DTB time for direct admissions did not increase significantly over the 2 years. The number of thrombolysis cases has increased as the primary PCI service has expanded, with catheter laboratory unavailability being the main cause. This figure may rise further if the service expands without a corresponding increase in resources. Centres expanding their primary PCI programme should consider the impact of this on the need for thrombolysis and possible rescue PCI for failed thrombolysis throughout their referring network.