Implementing a Primary PCI Urgent Transfer Process as First Line Management of STEMI at a Non-PCI Hospital in a Large Regional Area

Abstract

Introduction: Primary PCI (pPCI) has been demonstrated to be superior to fibrinolysis therapy in reducing mortality, recurrent MI and stroke but benefits are lost if the delay to PCI is >121 mins (1). ESC recommends pPCI as the preferred reperfusion strategy provided PCI can be performed within 120mins from STEMI diagnosis. (2). CSANZ guidelines recommend PCI if a “Door in-Door Out time” (DI-DO) of ≤30mins can be achieved. Wollongong Hospital (WH) is the PCI-capable centre for the ISLHD. Bulli District Hospital (BDH) and Shellharbour Hospital (SHH) are a short drive to WH (18 and 34 minutes respectively). Aim: To develop a process to Transfer for pPCI if a DO in-DO time of ≤30mins can be achieved Treat with fibrinolysis if this time cannot be achieved. Methods: NSWA and the departments of Cardiology and ED at BH, SHH and WH developed a system of patient review, cardiac consultation and expedited ambulance booking and transfer. Data was collected looking specifically at key times for example DI-DO, ECG to ambulance booking, ambulance arrival and departure, arrival to PCI Hospital and time to device. Results:Tabled 1SHH pPCI transfersSHH FibrinolysisTotal number STEMI treated (Nov 2016-Dec 2018)15 (1 patient angiogram normal coronary arteries)12 (1 patient angiogram normal coronary arteries)Angiogram- normal coronary artery11Mean length of stay3 days4 daysNov-Dec 2016Jan-Dec 2017Jan-Dec 2018Total pPCI transfers437Mean ECG to NSWA booking19.5 mins25 mins14 minsMean ECG to device112.5 mins125.5 mins106 mins Open table in a new tab Conclusion: Urgent transfer for pPCI is achievable for non-PCI hospitals within a short driving distance to a PCI centre. Biggest predictor of achieving a STEMI diagnosis to device time of <120mins is the time from STEMI diagnosis to NSWA booking. This system also resulted in a decreased LOS of 1 day. National Heart Foundation of Australia & Cardiac Society of Australia New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. 2017 ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation