This document discusses clinical governance practices regarding primary percutaneous coronary intervention (PPCI) and direct admission of high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients. It outlines some recurrent issues like monitoring, medications, communication, and delays. It also describes opportunities to learn from past cases without blame. Meeting and feedback structures are in place between teams. Referral processes and decision making are important, and several case studies illustrate lessons learned from reviews of past patient transfers and treatments. Open communication between ambulance and hospital staff is encouraged.

1. Clinical Governance
PPCI and Direct Admission of High Risk NSTEMI
Frank Hearl Claire Ferguson
Senior Charge Nurse Charge Nurse
Coronary Care Unit
Golden Jubilee National Hospital

2. • To err is human (to forgive devine)
• Insanity…..... doing the same thing over and over & expecting a diiferent
outcome
'Clinical governance is the system through which NHS organisations are
accountable for continuously monitoring and improving the quality of their
care and services, and safeguarding high standards of care and services'
Clinical governance is everyone's responsibility:
’The standard you walk past is the standard you accept’
David Morrison
PPCI and Direct Admission of High Risk NSTEMI

3. Recurrent issues
• Cardiac monitoring
• Pharmacology: interactions and contraindications- DAPT & TNK
• Communication
• ECG labelling: patient demographics
• Delays in decision making
• Transportation
PPCI and Direct Admission of High Risk NSTEMI
- resolved

4. Opportunities to Learn
(not to blame)
PPCI and Direct Admission of High Risk NSTEMI

5. Meetings & Feedback
• Collaborative working.
• Long standing links with SAS governance teams
• Monthly meetings scheduled to discuss operational & governance issues
• Monthly Morbidity & Mortality meetings
PPCI and Direct Admission of High Risk NSTEMI

6. Information Exchange
• Good communication throughout any organisation or system is vital.
• Referral process
• Originates with the referrer
• Transmit the ECG then call to discuss
• Responsibility of referrer to make contact with PCI centre
PPCI and Direct Admission of High Risk NSTEMI

7. Referral Process
• Critical information exchange
• More than just an ECG (although this is important!!)
• Haemodynamics, neurological & functional status
• PMHx / co-morbidity
• Resuscitation status
PPCI and Direct Admission of High Risk NSTEMI

8. Decision Making
• Consideration of the big picture.
• Equivocal ECG- check clinical portal or SCI Store for previous ECGs
• Complex presentations
• Perceived delays
Aim to get all patients to the right destination for the right treatment first time
PPCI and Direct Admission of High Risk NSTEMI

9. CaTHi

10. SCI Store

11. PPCI and Direct Admission of High Risk NSTEMI
Clinical Portal

12. PPCI and Direct Admission of High Risk NSTEMI
ECS

13. Case Studies
PPCI and Direct Admission of High Risk NSTEMI

14. Case Study 1
Unannounced arrival of pPCI patient by ambulance from A&E department.
• Patient taken to local A&E department by SAS.
• STEMI diagnosis. Quickly turned around and transferred to GJNH
• No referral from either A&E or SAS
• Patient arrived unannounced
• Cath Lab available- direct admission to lab
• Uneventful procedure without complication
Learning point: Communication is vital to ensure availability of cath lab team
PPCI and Direct Admission of High Risk NSTEMI

16. Case Study 2
Thrombolysis for acute inferior STEMI
• Presentation to A&E department. STEMI criteria on clinical
presentation, history & ECG
• pPCI not feasible in current time window of 120 minutes from diagnosis
• ACS management initiated
• DAPT (Ticagrelor), Heparin, Tenecteplase and LMWH
• Transfer to GJNH
• Reperfused and pain free on arrival
• Planned convalescent PCI (4-24 hours)
PPCI and Direct Admission of High Risk NSTEMI

18. Case Study 2
• Sudden reduced conscious level
• Left hemiparesis
• Catastrophic intracerebral haemorrhage
• Discussion with neurosurgical team
• No intervention
• Thrombolysis??. Thrombolysis +/- DAPT?? Ticagrelor unlicenced
PPCI and Direct Admission of High Risk NSTEMI

19. Case Study 3
ECG transmission from SAS to GJNH CCU
• ECG reviewed and clinical discussion between SAS and nursing staff.
• No name on ECG. Age and gender only.
• Clinical presentation consistent with ACS
• ECG reviewed consistent with STEMI
• Direct transfer to GJNH cath lab. DAPT & UFH pre-hospital
• Diagnostic angiography. No culprit lesion identified. No complications.
• Repeat ECG not diagnostic of major vessel occlusion.
PPCI and Direct Admission of High Risk NSTEMI

21. Case Study 3
• Reflection and consideration by CCU staff
• ECG receiving station reviewed. Multiple ECGs in in-box.
• The ECG belonged to a patient of similar age and gender, referred and
successfully treated 24 hours previously.
• The patients ECG was not diagnostic of STEMI. No name on this ECG either
Learning points identified after review process:
• Management & storage of ECG transmission revised
• Patient identifier should be mandatory on all ECGs
This issue still happens ….....
PPCI and Direct Admission of High Risk NSTEMI

22. Case Study 4
Proposed Heli-med transfer of acute STEMI to GJNH
• SAS crew attend patient having acute anterior STEMI in Killin
• On scene at 22:30. Diagnostic ECG received at GJNH at 22:45
• Accepted for Optimal Reperfusion- pPCI
• Unsuitable for thrombolysis due to hypertension
• Attempt to arrange transfer by Heli-med
• Job cancelled due to weather after 60 minutes
• Road transfer undertaken
• Arrival at GJNH 00:50- 80 minute transfer time.
PPCI and Direct Admission of High Risk NSTEMI

23. PPCI and Direct Admission of High Risk NSTEMI

24. Case Study 4
Learning points identified after review process:
• Heli-med is a fast means of transport
• Availability is limited
• 3 Helicopters. 2 Fixed wing.
• Time critical treatment. Delays can lead to adverse outcomes
• Consider road transfer unless assurance Heli-med is immediately available
• Activation and attendance on scene takes time.
PPCI and Direct Admission of High Risk NSTEMI

25. Open Door
• We would like to extend an open door to all ambulance personnel to
come and discuss cases with GJNH staff if they have concerns or to
seek clarification.
• An open invitation to all to visit the GJNH to see first hand the PCI
service as it operates.
By arrangement, we prefer you don’t just pop up unannounced!!
PPCI and Direct Admission of High Risk NSTEMI

26. Thank you
frank.hearl@gjnh.scot.nhs.uk
claire.ferguson@gjnh.scot.nhs.uk
PPCI and Direct Admission of High Risk NSTEMI