The Lincolnshire Heart Centre (LHC) came into existence in 2012 following a strategic review by the East Midlands Heart and Stroke Network. At this time, less than 5% of patients having a heart attack were treated with Percutaneous Primary Coronary Intervention (PPCI). This treatment involves opening a blocked artery in the heart (the cause of most heart attacks!) with a balloon followed by insertion of a metal scaffold or stent.
PPCI has been shown to be superior to using ‘clot busting’ drugs and is the preferred treatment if it can be delivered in a timely fashion. Minutes means muscle and every second really does count! The devolved rural demography of Lincolnshire coupled with a poor road infrastructure meant that patients could not be easily treated within strict time constraints at other previously established ‘Heart Attack Centres’ within the East Midlands.
Five years have now passed since the LHC was opened and now 99.9% of eligible patients with an ST elevation heart attack are treated with PPCI.
How have we achieved this? Via perseverance, innovation and teamwork.
Delivering PPCI in a District General Hospital requires a different mind-set to delivery in a tertiary centre. It is well-recognised that the most successful PPCI services have the provision to directly admit the patient to the cardiac catheter laboratory without entering the Emergency Department. When we designed and built our heart attack centre (HAC) this was a mandatory requirement. The physical distance between our ambulance arrival bay and the Catheter laboratory is just a few metres, and results in some of the most rapid times from hospital door to balloon inflation in the coronary artery of any Heart Attack Centre nationally. We knew that we would not have 24/7 junior doctor support within cardiology, and the evidence suggested that lack of expert knowledge at the front door would delay decision making and impact on patient care. We also identified that as cardiology becomes more specialised there was a need to have specialist knowledge out of hours. Hence, we developed a team of Advanced Clinical Practitioners (ACPs), who are nurses trained to Band 7 level (most of whom now have or are working towards a master’s degree). The team are all non-medical prescribers, able to request investigations and essentially function as a middle grade doctor equivalent within cardiology. The ACP team case manages the patient with a heart attack from when they are identified by the ambulance service, into the cardiac catheter laboratory (where they act as a circulating nurse if required) and then onwards to the coronary care unit (CCU). The ACP will perform the medical admission clerking, prescribe all necessary medications and request any immediate post-intervention investigations. If the patient requires surgical intervention they will also accompany the patient to the surgical centre.
Patient Recorded Outcome Measures (PROM) data indicates that patients feel very reassured having one person overseeing their pathway and they particular like the fact that they don’t have to give multiple histories to multiple health care professionals. Reduction of complicated clinical hand forwards has also reduced the risk of communication errors. Pre-hospital colleagues report that having a senior decision maker who can offer decision making support and offer direct admission as extremely clinically desirable. In addition to supporting the PPCI pathway the ACP team help deliver acute and chronic heart failure services, decision making support to the ED, DC cardioversions, implantable loop recorders insertion and undertake rapid access chest pain assessment clinics on all of the Trusts 3 hospital sites. Our PPCI ACP model was shortlisted for a national patient safety award, received a HSJ Value ‘Highly Commended’ and previously show-cased as part of the national Myocardial Ischemia National Audit Project (MINAP) publication. Following its success it has also been mirrored at other NHS Trusts in the UK.
As the service developed it was very clear we needed to grow a special relationship with our local Ambulance Service (East Midlands Ambulance Service ) and also our local helicopter ambulance charity (Lincolnshire and Nottingham Air Ambulance) given the poor road infrastructure and long traveling times. Thus, we needed to reduce pre-hospital transfer times as much as we were able. We agree joint pathways with our pre-hospital colleagues and implemented the pre-hospital STEMI pathway to reduce time on scene. Other innovations included shared governance, shared training days, FAQs posted on the ambulance intranet, shared research and the development of new advanced skills i.e. Rapid Sequence Induction (RSI) and Pacing by delivering medial staff to the patient by Ambucopter. We undertake bi-annual ‘surgeries’ in all ambulance stations in Lincolnshire to improve communication with paramedics and ambulance technicians and share new knowledge and skills.
Our governance process means we review the outcome of every one of our patients and learn from their experience. We observed a strong correlation with lack of ‘out of hours’ specialist cardiology support and clinical outcomes. As a result we combined cardiologists from our 3 sites into a single rota across the county. This ensures that is a non-interventional consultant and an interventional consultant available 24/7. As part of this service review we also made the decision set up diverts with our local ambulance service to ensure that patients with other high risk cardiac conditions (such as extremely slow heart rates and who would need urgent cardiac pacing) would also bypass our other sites in the same way that patients do when suffering a heart attack. This has improved the outcome in these patients also and reduced the need for subsequent onward inter-hospital transfers later on in the admission. Thus, making more 999 ambulances available. We also agreed to transfer all patients who became unwell or unstable from our ‘spoke’ sites to the ‘hub’ at the Lincolnshire Heart Centre as priority transfers so they could be managed appropriately with the minimum delay.
Nowhere was the safety implication of this ‘centralisation’ more apparent than in patients who had suffered a non-traumatic out of hospital cardiac arrest (OOHCA). We developed a seamless pathway with the Intensive Care Medicine (ICM) team such that when cardiology accept a patient the ICM team guarantee advanced airway support and an ITU bed without prior arrangement . We believe this joint working to be virtually unique and has removed all of the delays associated with intra specialty communication/ working. Despite the longer transfer times as patients now bypass their local hospital and go directly to the HAC survival to discharge for patients whose heart has stopped in the community, who required CPR, defibrillation and airway support on a ventilator has improved from 8% to 51%. This massive improvement in patient outcome was achieved purely via pathway re-design, team and multi-agency working and innovation with no additional funding.
By utilizing our resources better we have seen other significant improvements in the patients experience and clinical outcomes. Median length of stay for heart attack (STEMI and nSTEMI) is now below the national average as is our length of stay for heart failure. In 2015-16 100% of our non ST elevation heart attack patients had a specialist review compared to 96% nationally and only 34% when we started. In reality this reduction in length of stay means that annually our hospital has the equivalent of a 30 bedded medical ward available for other patients.
30-day mortality for patients who have suffered a heart attack (STEMI/ nSTEMI combined) has fallen from 13.8% to 5.4%.
Prescription of the 5 medications used in secondary prevention to reduce the likelihood of another heart attack has risen from 63% to 100% (9% higher than the 2015-16 national average).
We have come a long way in a very short space of time, defying our critics that it would be impossible to deliver such good outcomes in such a challenging geographical area. Our PPCI service has grown from strength to strength due to the hard work and dedication of everyone involved in the care of the patient from pre-hospital to discharge and beyond. We are always striving to better our performance and feel there is always something to improve.
We hope that our positive outcomes and patient feedback are testament to the teams’ determination to be FAB!
In summary, team working, shared values, innovation and a willingness to think we can always improve has resulted in...
Shorter length of stay
Less readmissions
Improved prescribing
Lower mortality
High patient experience
Mr Alun Roebuck – Consultant Nurse in Cardiology and Associate Chief Nurse Lincolnshire Heart Centre/ United Lincolnshire Hospitals NHS Trust [email protected]
Dr David O’Brien – Consultant Interventional Cardiologist and Clinical Director Lincolnshire Heart Centre/ United Lincolnshire Hospitals NHS Trust David.o’[email protected]