Redefining the NSTEACS pathway in London

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1 Redefining the NSTEACS pathway in London Sotiris Antoniou Consultant Pharmacist, Cardiovascular Medicine, Barts and The London NHS Trust and Project Lead, North East London Cardiovascular and Stroke Network Nick Bunce Consultant Cardiologist, St George s Healthcare NHS Trust, Cardiac Clinical Lead for South London Cardiac and Stroke Network (South West London) Russell Don Assistant Director, Cardiac, South London Cardiac and Stroke Network

2 1. London Cardiovascular Project 2. NSTEACS 3. The North East London experience 4. Implementation

3 The London Cardiovascular Project Key elements Centralise services where it would improve outcomes Reduce LOS Improve patient pathways and patient experiences Increase sub specialisation of surgeons delivering complex procedures Vascular services Cardiac surgery Cardiology Acute aortic dissection Mitral valve procedure Non-elective cardiac surgery Arrhythmia NSTEACS

4 Developing the model of care 2009 Mar 2010 Aug 2010 Oct 2010 Dec 2010 Review begins 2010/11 commissioning intentions developed Patient perspective Engagement Proposed model of care Case for change Engagement report Review of current services Clinical lead and clinical expert panel (CEP) Patient panel Clinical evidence National and international best practice Model of care The London Cardiac Networks were directed by NHS London to support local implementation across the capital.

5 Project structure

6 Cardiology Death from heart disease remains the biggest killer in the UK and London. After one year, patients with NSTEACS have the same likelihood of death as patients who have suffered a STEMI. Treatment practices for these patients need to change to reduce mortality. The model of care focused on two areas: Services for patients with NSTEACS Patients with heart rhythm defects

7 1. London Cardiovascular Project 2. NSTEACS 3. The North East London experience 4. Implementation

8 NSTEACS model of care Diagnose and risk stratify patients early Manage patients according to their risk level through the use of an agreed, evidence based set of criteria Ensure high risk patients are offered angiography within 24hours of initial assessment. If patient is triaged in a hospital that cannot provide angiography within 24 hours, the patient should be transferred to a unit that can Medium risk patients should be offered coronary angiography (with PCI if indicated) within hours of admission (LCVP model of care and NICE) Low risk patients should be offered conservative management (NICE) avoiding hospital admission where possible

9 Proposed outcomes For patients A standardised system for diagnosing and managing suspected NSTEACS patient ensures that: All patients follow the same pathway, thus ensuring equity of care and access Early access to angiogram and possible PCI is offered therefore, earlier access to specialist care is achieved best practice is encouraged Patients at higher risk are managed in specialist centres early in their clinical episode For commissioners Assurance of world class care and efficient use of resources Avoidance of double admission and associated tariffs

10 Process so far Quality standards have been developed and agreed with the involvement of London clinicians and patient representatives (These are now endorsed by BCS and the DH. Awaiting comments from BCIS before final version released.) Clinical Expert Panel (CEP) has reconvened to define high risk NSTEACS Negotiations with LAS commissioners and operational leads ongoing Working with commissioners (e.g. around emergency activity threshold, patient flows and potential activity shifts)

11 Quality standards Aims Improve access Improve the patient experience Improve clinical outcomes What they cover Best practice for centres that will deliver care to high risk NSTEACS patients in line with the London model Relevant to all cardiology inpatient services Development process Pan-London clinicians group, network revascularisation workstreams and patient representatives BCS / DH / BCIS Watch this space! Structure / contents Service configuration Support for patients and carers Staffing and Support services Accepting centre (service organisation, governance, guidelines and policies) Outcome indicators How they will be used Assessment process A1, A2

12 Pan-London high risk NSTEACS definition Recommendation 1: Recommendation 2: Patients clinically suspected of having NSTEACS with ongoing or recurrent chest pain/discomfort believed to be of cardiac origin, together with at least one of the following: Persistent ECG changes of ST depression >1mm, or transient ST elevation Pathological T-wave inversion in V1-V4 suggesting an LAD syndrome Dynamic T-wave inversion >2mm in two or more contiguous leads Haemodynamic (e.g. hypotension, pulmonary oedema or heart failure) or electrical instability (sustained ventricular arrhythmias VT/VF) which are thought to be due to cardiac ischaemia Troponin 0.1mcg/L A phone call should be made to the receiving NSTEACS centre, to allow discussion of appropriateness of early angiography/pci, taking into account factors increasing the risk of intervention/transfer, such as co-morbidities and bleeding risk Once transfer agreed: Referring A&E initiates an immediate transfer with LAS (i.e. one which arrives within the hour)

13 High risk NSTEACS definition: comments The CEP stressed that the recommendations should not override clinical judgement Any high risk NSTEACS patient, who would potentially benefit from early angiography/pci should be discussed with local cardiologist and / or regional cardiac centre A formal risk scoring assessment (e.g. GRACE score) should still be part of all assessments on patients admitted with UA/NSTEACS, in line with NICE guidance

14 1. London Cardiovascular Project 2. NSTEACS 3. The North East London experience 4. Implementation

15 North East London experience

16 North East London experience Risk stratification approach The clinical and risk assessment criteria used to diagnose suspected NSTEACS patients: Chest pain that was thought to be due to myocardial ischaemia, plus at least one of the following: ECG changes of myocardial ischaemia defined as ST depression >1 mm in > 2 contiguous leads or an LAD syndrome Raised blood troponin concentration determined by point of care testing on presentation or two hours later

17

18 Clinical dx unstable angina / GRACE > 88 / acute symptoms (e.g. ongoing pain, SOB), <6/52 post cardiac intervention +/- Dynamic ST in 2 or > contiguous leads >1mm, OR Pathological T wave inversion in V1-V4 suggesting LAD syndrome, OR Dynamic T wave inversion >2mm in two or more other contiguous leads NSTEMI Pathway Clopidogrel 600mg. Fondaparinux 2.5mg S/C unless contraindicated First Triple Panel Test, FBC, VBG, ABG if hypoxic TNI <0.05 TNI >0.05 MONITOR PATIENT IN RESUS for ongoing ischaemia After 120 mins repeat Triple Panel Test and ECG TNI >0.05 NO ST Depression LAD syndrome T wave inversion >2mm in >2 leads GRACE SCORE >88 Discuss with Senior A&E Dr. before contacting re: possible transfer or admission YES YES Call LAS to transfer patient to LCH as IMMEDIATE TRANSFER Excluding patients: -Shock - Anaemia -Hypoxia -Cardiac arrest -ARF -LOC -Trauma (not CPR) If no exclusions: Give Eptifibatide (180mcg/kg) bolus. Unless contraindicated (see bleeding chart)

19 1. London Cardiovascular Project 2. NSTEACS 3. North East London experience 4. Implementation

20 Proposed timescales for Implementation Full implementation across London by the end of March 2012 NSTEACS centre assessments (July/early August 2011) Training and support for A&E teams (over a 1-2 month period prior to go live) Go live (early implementers in September 2011, with roll-out across referring centres following this) with LAS agreement Post go-live review meeting

21 A joint approach for implementation Pathway / protocols Risk stratification Troponin Prescribing Transfer Training and education

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