PPCI: WHY I CAN’T SUSTAIN A 1:6 ON-CALL …...JAH PCI audit data total acute STEMI PPCI rota • 1994 107 6 0 • 1995 123 23 1 1:2 • 1996 143 22 0 • 1997 191 36 0 Arthur •

PPCI:WHYICAN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!

DRJIMHALLJAMESCOOKUNIVERSITYHOSPITAL

MIDDLESBROUGH

NOCONFLICTOFINTERESTTODECLARE


• Background


• Background–Whyme?


Appointedconsultant1993

MIDDLESBROUGH

MAPSHOWINGNATIONALPARKSINTHEUK


Appointedconsultant1993>1000emergencySTEMIcasesØ outofhours~66%

Middlesbrough STEMI protocol

1993♦ Thrombolysis first line therapy ♦ PCI if

ØContraindication to thrombolysisØCardiogenic shock ØRe-infarction (failed thrombolysis)ØRescue

JAHPCIauditdata

total acuteSTEMIPPCI rota• 1994 107 6 0• 1995 123 23 1 1:2• 1996 143 22 0• 1997 191 36 0Arthur• 1998 204 48 9 1:3• 1999 227 75 10 Merlin• 2000 273 87 9• 2001 205 79 4 1:4• 2002 160 20 6• 2003 230 40 9Prague

JAHPCIauditdata

total PPCI rota• 2004 239 20 MiddlesbroughPPCI• 2005 259 32 1:5• 2006 250 43 +NYorks• 2007 215 47 1:6• 2008 240 92 +regionalroll-out• 2009 228 89 1:7• 2010 205 73• 2011 180 84• 2012 177 62• 2013 143 60 1:8

1:2ROTA36

1:2ROTA36

1:5ROTA47

1:2ROTA36

1:5ROTA47

1:7ROTA57


• Whyme• Issues– 1:6rota– Impactof‘on-callduties’– Influenceofincreasingage– Implicationsforservicemodels

– Can’torwon’torneedn’torshouldn’t?

– RecommendationsallwillbeLEVEL1C


• Issues– 1:6rota

PPCI:WHYIWON’TDOA1:6ON-CALLSERVICEUNTILI’M65!

• Issues– 1:6rota

PPCI:WHYIWON’TDOA1:6ON-CALLSERVICEUNTILI’M65!

• Issues– 1:6rota– whenI’m65nolongernecessaryinEngland

EFFECTIVE PATHWAY FOR STEMI PATIENTS

STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HRdeLuca et al Circ 2004:109;1223-25

RIGHT PATIENTRIGHT PLACERIGHT TIME

5NV Craven

5NV Harrogate

5KF Gateshead

5D7 New castle 5D8 North Tyneside

5KL Sunderland

5KG South Tyneside

5NV Hambleton

5NV Scarborough

5NV Ryedale

5QR Redcar and Cleveland

5KM Middlesbrough

5D9 Hartlepool

5E1 Stockton-on-Tees

5J9 Darlington

5NV Richmondshire

TAC Tynedale

TAC Castle Morpeth

TAC Wansbeck

TAC Blyth Valley

5ND Teesdale

5ND Wear Valley

5ND Derw entside

5ND Chester-le-Street

5ND Durham

5ND Sedgefield

5ND Easington

A 1(M )

A 1(M )

A 64 (M )

25 km

5NE Carlisle

5NE Eden

5NE South Lakeland and Barrow

5NV Craven

5NV Harrogate

5KF Gateshead

5D8 North Tyneside

5KL Sunderland

5KG South Tyneside

5NV Hambleton

5NV Scarborough

5NV Ryedale

5QR Redcar and Cleveland

5KM Middlesbrough

5D9 Hartlepool

5E1 Stockton-on-Tees

5J9 Darlington

5NV Richmondshire

TAC Tynedale

5ND Teesdale

5ND Wear Valley

5ND Derwentside

5ND Chester-le-Street

5ND Durham

5ND Sedgefield

5ND Easington

A 1(M)

15 km

A: <=5 minB: <=10 minC: <= 15 minD: <= 20 minE: <= 30 minF: <= 45 minF: <= 60 minG: > 60 min

Drive-time zones to JCUH Middlesbrough

Primary angioplasty within 150 minutes of call for help

MINAP public report 2009

WYT

AMG WAL

VICSTO

UCL

TOR

STHSTM

GEO

SGH

SAN

RSC

RFHRDE

BOU

BHR

QEB

QAP

PAPNGS

NCR

MRIBHL

LIS

LGI

KCH

RAD

JCUH

HH

HAM

GRL

FRE

ESU

DUD

BRI

EBH

BAL

30%

40%

50%

60%

70%

80%

90%

100%

0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 800 850 900 950 1000

Number of cases

Perc

enta

ge m

eetin

g do

or to

bal

loon

90

min

utes

(%)

England average = 79%

Primary angioplasty within 150 minutes of Call for HelpMINAP Public report 2009

Primary angioplasty within 150 minutes of Call for HelpMINAP Public report 2014

PPCI:WHYIWON’TNEEDTOSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!

• Issues– 1:6rotas– whenI’m65nolongernecessaryinEngland

– Largerinstitutionalvolumes– Biggerteams– Lessonerousrotas–Morereliableprocesses– Betterperformancemetrics

PPCI:WHYISHOULDN’TSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!

• Issues– Impactof‘on-callduties’– Atthetime?– Thenextday?– Thenextweek?– Influenceofincreasingage?– Lessonsfromotherprofessions?


ONCALLDUTIES=SLEEPDEPRIVATION• Sleepdeprivationisreducedtotalsleeptime(decreased

quantity)orfragmentationofsleep(decreasedquality).• Acutesleepdeprivation

– measurablechangesincognitiveperformance,alertness,andneurobehavioralfunction.Susceptibilitytosuchchangesvariesamongindividuals.

• Chronicsleepdeprivation– associatedwithavarietyofadverseoutcomesinobservational

studies– reducedperformance,increasedriskforaccidentsanddeath,and

detrimentaleffectsonbothpsychologicalandphysicalhealth.


Impactof‘on-callduties’– Atthetime?physiciancrossoverstudyof24hrworkingtest– reducedconcentrationendurancePsychoneuroendocrinology 2014;47:221-31

poston-calltestingofconcentration<4hourssleepincreasederrorsJBoneJSurg 2012;94:1975-81

physiciancrossoverstudyof24hrworkingIncreasedVPBsandBPEur HeartJ2009;30:2606-13


Impactof‘on-callduties’– Thenextday?– Thenextweek?

RecoveryfromsleepdeprivationMeanage25Largeinter-individualvariabilityinrecoveryØSleepiness ~1.1dayØLapses ~3.2daysØReactiontime ~6.6days

Chronobiol Int 2008;25:297-308


Impactof‘oncallduties’- lessonsfromotherprofessions?

– USFighterPilots3hrlyflightsimulatortestsover35hrs

performancesignificantlydeclinedafter20hrsJAppResearchMemoryandCognition2012127-33


Impactof‘on-callduties’– ThenextdayPCI?PCIperformed11pmto7amPCIthenextday“sleepdeprivedcases”

Singlecentredata- 5years167“sleepdeprivedcases”MortalityRR6.8(0.7-39)

Cath Cardiovasc Interv 2012:80;1149-54

Registrydata- 3years36,049“sleepderivedcases”MortalityRR1.02(0.94– 1.12)

JACC:CardiovascularInterventions2015;8:49-56



Sonoproblem?

– .



Sonoproblem?But… 1945of5014interventionistsdon’tdo

“sleepdeprivedcases”97.6%ofcasesperformedwerenot“sleepdeprivedcases”

– Resipsa loquitor

PPCI:WHYIMIGHTSUSTAINA1:6ON-CALLSERVICEUNTILI’M65!

Influenceofincreasingage?Age22v68– 26hourwakeperiodbettertoleratedbyoldersubjects!

JAmGS2009;57:1245-51

– Sleepresistancenotrelatedtoage– Sleepresistanceafeatureofgreaterprefrontal/executivefunctioning

Aviat SpaceEnvironM2009;80:81-7


Impactofincreasingage- lessonsfromotherprofessions?– Upperagelimitforcommercialpilots

1919- 45yearsagelimit1963- ICAO 60yearsagelimit2007- ICAO 65yearsagelimit

Mainissue-suddenincapacitatingdiseases•Coronaryheartdisease•Stroke•Seizure

••••

DrAnthonyEvansofInternationalCivilAviationOrganization


Impactofincreasingage- lessonsfromotherprofessions?– Upperagelimitforcommercialpilots

1919- 45yearsagelimit1963- ICAO 60yearsagelimit2007- ICAO 65yearsagelimit

Mainissue-suddenincapacitatingdiseases•Coronaryheartdisease•Stroke•Seizure

otherissue- gradualperformancedegradation•Reactiontime•Shorttermmemory•Flexibility•Physicaldegradation– Vision– Hearing

Performancedegradationriskincreaseswithincreasingage•Simulationchecks+peerreviewwilldetectmostcasesofsignificantdeterioration

DrAnthonyEvansofInternationalCivilAviationOrganization


AgeisnotaparticularlyinterestingsubjectAnyonecangetold

Allyouhavetodoislivelongenough

GrouchoMarx(1890– 1977)


Impactof‘on-callduties’Nextday-PCIthenextday?OPDclinicdecisions?Managementdecisions?Behaviour?Cardriving?


Impactof‘on-callduties’Longertermavailabilityforotheractivities?ResearchTAVICTOetc.Teaching/trainingLeadershipManagement


• Issues– 1:6rotas

– Impactof‘on-callduties’

– Impactofincreasingage

– Implicationsforservicemodelse.g.dutiesafteron-call?

e.g.oncallafterlabdays?e.g.12hourw/eshifts?


Conclusions1– Beawareofthisasanissue– IntegrateintoplanningaPCIservice– Integrateintoplanningacardiologyservice– Nosimplerules- pragmaticflexibleapproach– Teamdecisions


Conclusions2• CouldI?• ShouldI?

• WillIhaveto?


Conclusions2• CouldI– yes• ShouldI– no– Notnecessary– Nothealthy– Notsafe– Notsustainable

• WillIhaveto?


Conclusions2• CouldI– yes• ShouldI– no– Notnecessary– Nothealthy– Notsafe– Notsustainable

• WillIhaveto– no– thankstomycolleagues

JAHPCIauditdata

total PPCI rota• 2004 239 20 MiddlesbroughPPCI• 2005 259 32 1:5• 2006 250 43 +NYorks• 2007 215 47 1:6• 2008 240 92 +regionalroll-out• 2009 228 89 1:7• 2010 205 73• 2011 180 84• 2012 177 62• 2013 143 60 1:8• 2014 149 401:17

1:2ROTA36

1:5ROTA47

1:17ROTA58

DRJIMHALLJAMESCOOKUNIVERSITYHOSPITAL

MIDDLESBROUGH

WHYIDON’TNEEDTOSUSTAINA1:6ONCALLSERVICEUNTILI’M65!

Documents

PPCI: WHY I CAN’T SUSTAIN A 1:6 ON-CALL …...JAH PCI audit data total acute STEMI PPCI rota • 1994 107 6 0 • 1995 123 23 1 1:2 • 1996 143 22 0 • 1997 191 36 0 Arthur •