Local improvement following
national clinical audit
workshops
Auditing heart
attacks
Saving lives
Dr Andrew Wragg
Barts Health
Overview
• National Audits related to Acute
Coronary syndromes
• What do they involve
• What are our challenges
• How do we use data: how does it
change practice
• What difference has it made
What is a Heart Attack?
What is a STEMI and a
NON STEMI
It is all about ST segment elevation
More than just an
angioplasty
•
•
•
•
•
•
Prompt recognition of symptoms
Heart monitoring and resuscitation
Prevent further coronary thrombosis
Reduce and reverse ischaemia
Prevent future MI
Education
Overview
• National Audits related to Acute Coronary
syndromes
• What do they involve
• What are our challenges
• How do we use data: how does it change
practice
• What difference has it made
NICOR
MINAP (2000)
• Myocardial Ischaemia National Audit project
– All patients presenting with a Acute Coronary Syndromes (ACS)
– Includes STEMI, Non STEMI and non cardiac chest pain
– All hospitals who receive acute admissions
BCIS (1991)
• British Cardiac Intervention Society Audit
– Cover all angioplasty procedures
– All hospitals undertaking angioplasty
MINAP/ BCIS
• National clinical audits of heart attack management
• Hospitals, ambulance services and commissioners have
a record of their management of heart attack patients
• Comparative analysis against nationally agreed
standards
• Allows comparative data between centres and regions
• Clinicians and managers can monitor and improve
quality and outcomes of their local services
Overview
• National Audits related to Acute Coronary
syndromes
• What do they involve?
• What are our challenges?
• How do we use data: how does it change
practice
• What difference has it made
Lots of Data and Manpower
• > 100 questions in each dataset
• Detailed medical and technical information
• Approx 1800 PCI and 1200 MIs at LCH pa
• BCIS done by medics
• MINAP done by specialist nurses
• IT Support needed
BUT huge impact Nationally
Prescription of secondary
prevention medication
• 5 drugs shown to improve
outcome after AMI
• Aspirin/ Statins/ B Blockers/
ACE I and Clopidogrel
Use of secondary prevention post
MI continues to improve
BLT: over 97% for all therapies
MINAP report 2010
30 day mortality post STEMI
continues to decline
MINAP report 2010
Time is muscle!
Relationship between time to treatment and
1-year mortality
De Luca, G. et al. Circulation 2004;109:1223-1225
1791 patients with STEMI in USA
% Mortality
12
10
8
Double
mortality
for delay of
3 hours
6
4
2
60
120
180
240
Ischaemic time (call to balloon)
300
360
Key Performance targets
STEMI (CQC)
• Call-to-balloon (CTB) audit standard 150 mins
• Door-to-balloon (DTB) audit standard 90 mins
Length of stay
Mortality
PCI for Acute Sx
Four admission scenarios
Admitted from
the community
Admission to
Non-PCI centre
D1
CTB
D2
Direct admission
to PCI centre
V
Transfer
to PCI centre
DTB
device
Performance time targets
• Door to balloon: 80% less than 90 mins
• Call to balloon: 75% less than 150 mins
• Direct transfer rate: >80%
How did BLT do!
2009 data
• Door to balloon: 85% < 90 mins
• Call to balloon: 56% < 150 mins
• Direct transfer rate: 50%
• Door to balloon: 80% < 90 mins
• Call to balloon: 75% <150 mins
• Direct transfer rate: >80%
We had to
improve!
Overview
• National Audits related to Acute Coronary
syndromes
• What do they involve
• What are our challenges
• How do we use data: how does it change
practice
• What difference has it made
Monthly call-balloon times <150minutes
April 2009-March 2012
100.0%
90.0%
80.0%
Percentage
70.0%
60.0%
HAC Daily Audit
50.0%
Weekly Report
40.0%
Straight to Lab
30.0%
Internal DTB<60
20.0%
10.0%
Straight to Table
0.0%
Feb 2012
Dec 2011
Oct 2011
Aug 2011
Jun 2011
Apr 2011
Feb 2011
Dec 2010
Oct 2010
Aug 2010
Jun 2010
Apr 2010
Feb 2010
Dec 2009
Oct 2009
Aug 2009
Jun 2009
Apr 2009
Month
Week commencing: 10th – 16th ~February 2012
(Excluding patients who were shocked/ ventilated or initial diagnosis not STEMI)
Patient
Procedure
Date
Admission Route
Call - D1
D1 - D2
1
10/02/2012
2
Call in Hours
Outcome
Direct -
64
0
18
82
In-Hour
No action required
10/02/2012
Direct -
59
0
31
90
In-Hour
No action required
3
10/02/2012
Interhospital
transfer - OLD
71
35
55
161
In-Hour
LAS transfer time under
investigation
4
11/02/2012
Interhospital
transfer - OLD
40
32
60
132
Out-Hour
No action required
5
11/02/2012
Direct -
67
0
41
108
Out-Hour
No action required
6
12/02/2012
Direct -
58
0
41
99
Out-Hour
No action required
7
12/02/2012
Direct -
57
0
59
116
Out-Hour
No action required
8
13/02/2012
Direct -
50
0
32
82
In-Hour
No action required
9
14/02/2012
Direct -
54
0
74
128
Out-Hour
Lab delay under investigation
10
14/02/2012
Direct -
66
0
51
117
Out-Hour
No action required
11
14/02/2012
Direct -
61
0
29
90
Out-Hour
No action required
12
15/02/2012
Interhospital
transfer - WHC
224
47
39
310
In-Hour
Difficulties accessing patient’s
residence
13
16/02/2012
Direct -
51
0
37
88
Out-Hour
No action required
14
16/02/2012
Direct -
42
0
60
102
Out-Hour
No action required
Total pPCI Inc shock
+ ventilated
D2TB
pPCI Exc. shock
+ ventilated
% Indirect Exc.
Shock + ventilated
Self presented
17
14
28.57%
0
537
440
Source: Heart Attack Centre Audit Team
* Excludes patients in Cardiogenic shock, ventilated or already in hospital at time of STEMI
CQC targets: 75% patients call – balloon time should be <150 minutes
These figures may be subject to change pending feedback from LAS and NELN hospitals
Call Balloon
% Direct LAS
Transfers (exc.)
% CTB < 150 mins
(exc.)
% DTB < 90 mins
(exc.)
% DTB <
60 mins
(exc.)
71.43%
85.71%
100.00%
92.86%
72.95%
86.59%
98.86%
88.86%
abcd
What was the impact?
Length of stay post PCI
Conclusion
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•
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•
•
MINAP and BCIS are powerful audits
Great drivers of change
Tool for transforming prognosis
C2B target worthy of its CQC point!
Great resource for local research
• However, not cheap! Significant resource
required to do them well
Local improvement
following national clinical
audit workshop
Dr Andrew Wragg
Barts Health
Acknowledgements: cardiology team/ LAS/
NELCS network/ HAC audit team/ MINAP and BCIS