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Impact of PPCI on the DGH

How shall I explore this?. Personal ? anecdotal ? unashamedly!Situation before PPCI widely used in NECVNNumerical impacts?What other changes have been occurring?What has gone?What are impacts on staff: doctors and nurses?. Acute cardiology - the problem. Formerly part of GIMRapid change in management protocols (esp ACS)Difficult to manage as general physicianGood evidence that cardiologists provide more complete process of care.

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Impact of PPCI on the DGH

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    1. Impact of PPCI on the DGH Phil Adams Newcastle upon Tyne Hospitals Foundation NHS Trust

    2. How shall I explore this? Personal – anecdotal – unashamedly! Situation before PPCI widely used in NECVN Numerical impacts? What other changes have been occurring? What has gone? What are impacts on staff: doctors and nurses?

    3. Acute cardiology - the problem Formerly part of GIM Rapid change in management protocols (esp ACS) Difficult to manage as general physician Good evidence that cardiologists provide more complete process of care

    4. CPAU at the RVI

    5. Role of consultant cardiologist Daily take rounds 08:00 & 16:30 CCU round daily Rapid Access Angina Service weekdays Weekends the same PLUS: visit ward to troubleshoot, see recent admissions etc

    6. Acute anterior MI with marked ST elevation I well remember the inferior young woman, CHB – wait until tlysis has time to work!I well remember the inferior young woman, CHB – wait until tlysis has time to work!

    7. Percent pts receiving thrombolysis within 60mins call for help

    8. 30 day mortality: STEMI

    9. Change in reperfusion treatment

    10. Final Diagnosis – CPAU audit of 50pts 2006 STEMI small numerically

    11. Daily admissions to CPAU RVI

    12. Nursing staff “Discovery interviews” “Lost the buzz” core role gone change to “HDU patients” recruitment training experience still needed but not gained thrombolysis nurses

    13. Junior medical staff training – recognition of ECG abnormalities team-working with nursing staff involvement in cardiology hurly burly timely, urgent care less arrhythmias more complex patients, harder to manage to protocol

    14. Effects at tertiary centre lab needed for PPCI – no pacemakers out of hours delay to transfer, temporary wires considerable increased work load on call rotas bed pressures delay to transfer of ACS patients increased opportunity for PCI trainees

    15. Technical issues discharge and rehab echo & DVLA guidelines coronary disease identified, not dealt with stress testing when we know anatomy secondary prevention: choices of drugs MINAP financial hit: Ł1 million lost in typical DGH

    16. Consultants a major function gone: pivotal function of CCU “less interesting”, “excitement” of thrombolysis disagreement with tertiary centre – stressful less protocol driven care more direct consultant involvement discharge arrangements

    17. Part of a pattern? Acute MI – PPCI at tertiary centre ACS – angiography ą PCI at tertiary centre Angina – debate between PCI and CABG at tertiary centre angio ?proceed Heart failure – CRT at tertiary centre specialist heart failure team Sudden death risk – ICD at tertiary centre Valve disease – surgery at tertiary centre TAVI (or not?) Genetic conditions – special clinic at tertiary centre Arrhythmias – ablation at tertiary centre

    18. Perhaps not woken as much!

    19. Conclusions Excellent service before PPCI Impact numerically small at DGH but large at tertiary centre with some knock-on effects Background of major changes in practice One of the core roles of DGH cardiology unit gone Significant impact on clinical staff; nurses, junior doctors and consultants

    20. But remember… PPCI means more like this!

    21. Doig Numbers down overall (trend anyway?) Nature of pts changed, acute medical bed, HDU type work (F1s cannot do it as can’t protocolize) Nursing: decline in morale, future vacancies hard to fill, lower grades used. More variation in workload, so seemingly overstaffed at times. Financial: North Tyne 1million loss. Transfers to DGH/RVI

    22. El-Harari CCU not less busy, diferent case mix less interesting: excitement of thrombolysis (QWERTY – MInAP data, arrhythmias) beds used for non-cardiac, HDU, inotrope CPAP issue of disagreement – stress ++ more work to do with pts, less straightforward

    23. RVI training less ill and more ill less protocol driven, F1 cannot do so well less straightforward cardiac, more GIM component ?not so good at arrhythmias, less pacing echo more important effects on A&E recruitment to nurse & consultant posts impact on role of dGH cardiologist in decision making what happens afterwards? Rehab issues. we gote mis back so we don’t lose out altogether. staffing on CCU means difficulties with training as they don’t have opportunity to accrete the appropriate skills. Where are the CP assessment coming from in the furture. stopped doingg pacemakers at weekends etc

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