South Africa Early Reperfusion Project

Transcription

1 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T South Africa Early Reperfusion Project Dr Adriaan Snyders MMed FACC FESC Chairman SA Heart STEMI Early Reperfusion Project President SA Heart Association

2 Key Worldwide Challenges Despite guidelines recommending primary angioplasty, the adoption of these guidelines has been very slow due to: Skepticism as to the true advantage of the treatment proposed, Financial concerns Organizational difficulties. Initially none of the European Stent For Life (SFL) countries have primary angioplasty rate greater than 50% Initially no data could be obtained from many interested SFL countries. UK moved from an angioplasty rate of < 40% in 2006 to > 90% in Many countries do not have a unified emergency telephone number. Education of the public is necessary throughout the world. Educational programs need to be organized and repeated!

3 South African Healthcare Challenges Public (Government) Sector: 70% of South African patients cared for by 30% of doctors Four out of 11 provinces do not have one registered cardiologist in publick health service Private Sector: Treats 30% of South African patients 20% of these patients have varying levels of medical insurance Cardiologists tend to work as individuals and not as a team in hospitals that belong to one of four major private groups South Africa aiming for National Health Insurance (NHI) but currently struggling to deliver healthcare

4 The South African Heart Association SA Heart Association: Working towards best healthcare practices Exco consists of cardiologists who contribute their time and enthusiasm outside of their practices with no remuneration Objectives are to promote: And develop the life sciences pertaining to the cardiovascular system in health and disease. Good fellowship among those involved in the treatment of patients with cardiovascular disease or with research interest involving the cardiovascular system. Public welfare by education directed towards the prevention and treatment of diseases of the cardiovascular system

5 The South African Heart Association cont. SA Heart supports and advocates practicing ESC guidelines To address the frustrations experienced by cardiologists regarding STEMI patient care, SA Heart took on the SA Heart STEMI Early Reperfusion Project: To run a small scale survey in Tshwane and surrounding areas Results demonstrated that South Africa is far behind the ideal

6 Stent For Life Our Mission. The Stent for Life Initiative aims to improve the delivery of care and patient access to the life saving indications of primary percutaneous coronary intervention (p-pci), thereby reducing mortality and morbidity in patients suffering from acute coronary syndromes (ACS). Our Purpose. The Stent for Life Initiative is a unique European platform for interventional cardiologists, government representatives, industry partners, patient groups and patients to work together to help shape health care systems and medical practices and ensure that the majority of ST elevation myocardial infarction (STEMI) patients have equal access to the life saving indication of p-pci. The purpose of the Stent for Life Initiative is to: Support the implementation of ESC guidelines on management of acute myocardial infarction in patients presenting with persistent ST-segment elevation Help identify specific barriers to the implementation of guidelines Define actions to make sure that the majority of STEMI patients in Europe have access to p-pci Our Aims. The Stent for Life Initiative has two key objectives to be achieved: Define the regions/countries with an unmet medical need in the optimal treatment of ACS Implement an action programme to increase patient access to p-pci where indicated We are working to: Increase the use of p-pci to more than 70% among all STEMI patients Achieve p-pci rates of more than 600 per one million inhabitants per year Offer 24/7 service for p-pci procedures at invasive facilities to cover the country STEMI population need

7 SA Heart STEMI Early Reperfusion Objectives Stent for Life Key Objectives: Support the implementation of ESC guidelines on the management of acute myocardial infarction in patients presenting with persistent ST-segment elevation Help identify specific barriers to the implementation of guidelines Define key actions to make sure that the majority of STEMI patients in Europe have access to PCI. SA Heart STEMI Early Reperfusion Project Key Objectives: Improve quality of AMI care Improve the network of care in order to give more patients access to reperfusion therapy Decrease AMI mortality

8 SA Heart STEMI Early Reperfusion Project Strategy: Select a limited geographical area for a pilot study Undertake a survey to measure the timeline of STEMI patients pathway to the cathlab. This data forms a baseline measurement. Develop a strategy for the removal of barriers in the pathway including education and training of key players Repeat the survey to measure results, which hopefully shows an improvement in patient access to primary PCI. Roll-out the strategy in other areas. The attention is focused on STEMI patients only but, if the project results are in an improved pathway for STEMI patients, all ACS patients will benefit.

9 18 24 months S A H E A R T E A R L Y R E P E R F U S I O N P R O J E C T Key factors to set up a successful region One key cardiologist per region to drive the program All relevant stakeholders need to be contacted, advised of the project and invited to join the project Once buy in has been received, start the Early Reperfusion Project training in the following order: 1. Hospitals with a cathlab (ICU, Emergency department, hospital manager, nursing manager ) 2. Hospitals without cathlabs (Emergency department, physicians, GPs based at the hospital) 3. Referring GPs and physicians 4. Ambulance services 5. Patient awareness 6. Medical insurance and funders

10 SA Heart STEMI Early Reperfusion Project Our Slogans Time Is Muscle This Must Never Happen Again Correct Diagnosis Appropriate Therapy

11 SA Heart STEMI Early Reperfusion Project Buy In Collaboration Education Crucial elements to avoid unnecessary delays involve: PPCI inhibited by a perception of anticipated transport delays. Even Drip & Ship requires effective networks. Fibrinolysis is not the final step in therapy Drip & Ship with PCI within 24 hours Direct transfers from ambulance to cathlab.

12 SA Heart STEMI Early Reperfusion Project Tshwane Pilot Project Highlights Progress we have made so far: The Spin-Offs STEMI PPCI = Well defined diagnoses and treatment strategy relevant to < 20% of patients in need of appropriate cardiac care but this is manageable. Project dragging along Getting all patients with chest pain/angina to appropriate care to avoid STEMI Developing networks to assist in other projects while taking into account the fragmentation of the South African healthcare system Contributing/assisting in the National Health Insurance (NHI) mission

13 SA Heart STEMI Early Reperfusion Project Tshwane Pilot Project Highlights Challenges we have encountered so far: Identification and by in of stakeholders Emotions have ranged from apathy to obstruction to enthusiasm from healthcare professionals State hospital inertia = denial 14 Emergency medical services Fragmentation of healthcare Crucial to develop the Team

14 SA Heart STEMI Early Reperfusion Project Pilot project Implemented to: Assess Learn Test our perception Guide action Survey followed by education BUT maybe it should be the other way round? Buy In Partnering = Crucial Development of key tools Educational slide set with ESC guidelines Defining steps to set up network

15 Time Delay from Onset of Symptoms to Treatment

16 Time Delay from Onset of Symptoms to Treatment

17 Key Lessons Learnt from the Pilot Survey Symptoms: Patients tend to ignore or dismiss their symptoms Patients may consult a referring general practitioner, prior to going to a cathlab hospital. Some patients are sent home with incorrect diagnoses but others are sent to hospital directly. Transport to cathlab hospital: Patients do not trust an ambulance to arrive quickly and rather use their own transport. It is usually a family member who takes the patient to hospital. Patients may go to a hospital without a cathlab first both in Tshwane and in outlying areas

18 Key Lessons Learnt from the Pilot Survey cont. Emergency Medical Services (EMS): Many ambulances do have an ECG on board. Authorization for treatment can delay interventions. Most ambulances do not carry thrombolysis on board in some cases this is due to financial challenges Majority of EMS personnel are not qualified to give thrombolysis EMS personnel qualified to give thrombolysis tend to live outside South Africa or aren t on call

19 Key Lessons Learnt from the Pilot Survey cont. Time to treatment: Often a considerable delay before even arriving at a cathlab hospital Even patients that go directly to a cathlab hospital wait too long (on average) for diagnosis and start of treatment First medical contact may not be able to make a diagnosis on patient history and ECG alone First medical contact may then wait and rely on further special investigations.

20 Key Lessons Learnt from the Pilot Survey cont. Fragmentation Of Medical Services: Different hospitals belong to different hospital groups Separation between private and public sector No coherence of ambulance service in Tshwane. Public Hospitals Extremely slow in contributing to and participating in pilot project Comments. It is impossible and of no use. Lack of 24/7 Service Even at cathlab hospitals personnel have to drive from home to provide a 24/7 service 30+ minutes delay. Progress is however being made!

21 How do we intend rolling out nationally? Phase 1a Key driving cardiologist identified in each region Stakeholders identified and their buy in is confirmed Phase 1b General meeting is held with all stakeholders to run through roll out process PHASE 1 Roll out (no data collection) Phase 1c ISCAP driven All relevant staff in cathlab hospitals are trained on Early Reperfusion Project by hospital cardiologist Phase 1d Hospitals without cathlabs/referring hospitals are targeted Local cardiologist conducts Early Reperfusion Project and ECG training Early Reperfusion Project champions meet with medical aids to advocate and endorse best MI management practice Approximately 12 months

22 How do we intend rolling out nationally? Phase 2 CME started for all GPs and ambulance staff who refer to cathlab and non cathlab hospitals (CPD accredited) Training to include basic refresher ECG module Local cardiologist to conduct training supported by local ISCAP chapter and events management company PHASE 2 4: Roll out cont. (Comprehensive data collection process is initiated) Phase 3 Data collection to demonstrate effectiveness of Early Reperfusion Project initiated (region by region basis) Dr Snyders, Prof Delport and project coordinator driven Phase 4 Patient awareness program started with Heart and Stroke Foundation Early Reperfusion Project champions continue to meet with medical aids to advocate and endorse best MI management practice Approximately 6-12 months but data collection ongoing Back to Phase 1c

23 Our Next Steps for National Roll Out Finalizing the expanded survey protocol to obtain ethics approval: First roll out in Tshwane Propose to run expanded survey annually for 2 months in every region Finalizing the budget for 2014 Identify champions (cardiologists) in each region to assist and monitor the roll out in the region Host a roll out meeting for champions and industry March 2014 Approach industry for logistical and financial support Compile a national roll out package containing: Guidelines to ensure the project runs smoothly Educational materials and documents Look into the possibility of affiliating with the Stent for Life program

24 Questions? Thank You

25

26

27 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T Symptoms of a heart attack Most typical discomfort/pain zones Other possible discomfort/pain zones Heavy pressure, tightness, crushing pain or unusual discomfort in the centre of the chest Sweating, sickness, faintness or shortness of breath may be experienced This may feel like indigestion, spread to shoulders, arms, neck or jaw and/or last for more than 15 minutes. It may stop or weaken and then return There may be a rapid, weak pulse Sharp stabbing pain in the left side of the chest is usually NOT heart pain (accessed on 7 Feb 2013

28 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T Ischemic Symptoms - Explained Discomfort or Pain in the Center of the Chest that lasts >20 minutes (MI), or that goes away and comes back (Crescendo Angina/UAP). Feels like an Uncomfortable Pressure, Squeezing or Burning. It often spreads to the neck/jaw, arms or the abdomen and is not respiratory dependant. Chest pain may also include back pain. Sublingual (oral) Nitroglycerine has minimal or no effect. Common accompanying symptoms are Nausea, Dizziness, Vomiting, Cold sweat, Anxiety and possibly Dyspnea. Symptoms in women are often different than in men. Women are more likely to experience nausea, dizziness, and anxiety.

29

30

31 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T What do I do? Reperfuse now! Immediate PCI (< 120 mins) OR Thrombolysis (> 120 mins) Reperfuse how? Ship immediately to closest cathlab (< 120 mins) OR Drip and then ship to closest cathlab (> 120 mins) Reperfuse where? Closest cathlab location 1 st 1 st

32 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T Treatment Choice Conclusions During first 2-3 hours after symptom-onset, time to treatment is critical After 3 hours, PPCI is preferred if it can be done within 2 hours of first medical contact. If not, then a pharmacoinvasive strategy with thrombolysis followed by immediate transfer for PCI within next 3-24 hours may improve myocardial salvage and survival. Immediate or rescue PCI for failed thrombolysis

33 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T Where is my nearest cathlab in Pretoria & Centurion Dr George Mukhari Montana Eugene Marais Steve Biko Academic Pretoria Heart 1 Military Zuid Afrikaans Wilgers Unitas

34 S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T Summary of common pitfalls Not obtaining a history of cardiac chest pain Not performing immediate ECG on all patients triaged as possible cardiac chest pain Not performing serial ECG when appropriate Repeated ECGs when diagnosis is clear Lack of knowledge regarding closest cathlab Administering drugs before activating EMS Rotating and temporary staff unaware of protocol Thrombolytics not being carried on board ambulance Lack of beds available at hospital with a cathlab (call to check!) Possible medical aid authorisation delays

35 What is a regional ppci service? EMS PPCI team Healthcare planners Patient Emergency Rooms CICU team