Introduction Our centre operates a 24/7 primary PCI (PPCI) service delivering coronary reperfusion to a population of 1.2 million, accessed via a centralised pre-alert call system managed by coronary care nurses. Our aim was to audit PPCI pre-alerts and patient discharge diagnoses to assess the appropriateness of referrals and ensure that referrals are being correctly accepted/declined.
Methods All pre-alert calls received in 2013 were recorded on a standardised proforma and included in the study. Discharge diagnosis was retrieved from hospital case records, both locally and at district hospitals. In 52 cases this information was not recoverable.
Results 1343 pre-alert calls were received, 1227 (91%) were received directly from paramedics. The mean age was 68 ± 15 years. 586 (44%) of referrals were accepted for PPCI.
701 (52%) of the referrals had chest pain and satisfied ECG criteria (ST elevation/LBBB). 137 (10%) had neither chest pain nor met ECG criteria.
508 patients had a diagnosis of STEMI at discharge and 454 were accepted directly. 54 cases with a final diagnosis of STEMI were initially declined: 14 in cardiac arrest were directed to their local ED as policy; 18 had documented clinical reasons for declining; 7 did not meet criteria. 15 patients (3%) with chest pain and ECG criteria were declined without a documented reason; 3 were subsequently accepted after assessment at a local hospital.
Of those accepted by the pre-alert pathway: 454 (77%) were discharged with a diagnosis of STEMI; 86 (15%) had an alternative cardiac diagnosis; and 46 (8%) had a non-cardiac diagnosis.
LBBB accounted for 258 pre-alert calls. Of these, 29 (12%) were accepted for PPCI but only 3 had a discharge diagnosis of STEMI: 2 received PCI but did not have an acute coronary occlusion at angiography, and 1 incorrectly labelled as LBBB.
372 patients referred were aged >80 years, of which 119 (32%) had LBBB on ECG. 89 (24%) of patients aged >80 years were accepted for PPCI, compared to 497 (52%) of <80 years. 21% of patients >80 years had a final diagnosis of STEMI but were declined from the pre-alert pathway, compared to 5% of patients <80 years.
430 of referrals were female. 167 (39%) were accepted for PPCI, compared to 417 (49%) of males. 50% of those declined and subsequently discharged with STEMI diagnosis were female, which is disproportionate compared to the referral numbers.
Conclusion Patients are frequently referred who do not meet symptom/ECG criteria; however the pre-alert system correctly identifies the majority of appropriate STEMI patients without burdening the service with non-cardiac patients. Females and patients aged >80 years are more likely to be declined for PPCI due to atypical presentation and co-morbidity. Regular audit of pre-alert services is mandatory to ensure delivery of timely and appropriate PPCI in the management of STEMI.
- Primary Percutaneous Coronary Intervention
- ST Elevation Myocardial Infarction
- Acute Coronary Syndrome
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