National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction The Department of Health estimated that it was feasible for PPCI to be rolled out to at least 95% of the population over three about years, but implementation would be for local determination. NHS Improvement was available to support, guide and coordinate the the implementation of PPCI across the 28 Cardiac and Stroke Networks in England. The purpose of this interim report is to document the progress that has been made after 18 months. (Published October 2010).

1. NHS
CANCER NHS Improvement
DIAGNOSTICS
National roll-out of Primary PCI for
patients with ST segment elevation
HEART
myocardial infarction:
An interim report
LUNG
STROKE

2. Contents
Foreword 3
Introduction 4
The national picture 5
The network picture 6
Common themes 35
Conclusion 37
Authors
Dr J M McLenachan
National Clinical Lead, Reperfusion, NHS Improvement,
Consultant Cardiologist, Leeds General Infirmary
Sheelagh Machin
Director, NHS Improvement
Carol Marley
National Improvement Lead, NHS Improvement

3. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 3
Foreword
The introduction and dissemination of primary PCI (PPCI) in England provides a good example of how a nationalised healthcare
system can work at its very best. After randomised trials had established the potential superiority of primary PCI over
thrombolysis for STEMI, the Department of Health and national societies (British Cardiovascular Society, British Cardiovascular
Intervention Society) conducted a feasibility study (National Infarct Angioplasty Project, NIAP), and concluded in its final report
(October 2008) that the roll out of PPCI was both desirable, feasible and cost effective. Taking account of geographical
considerations it was estimated that PPCI could be offered as the treatment of choice to 95% of the STEMI population.
Concerted implementation work then ensued, spearheaded by the cardiac networks and ably supported by NHS Improvement
and its Clinical Lead, Dr Jim McLenachan.
Eighteen months later, more than 70% of STEMIs are now being treated by PPCI (an increase from <10% when the NIAP
started) and with every network having robust plans to achieve 100% coverage for eligible patients. Given the complexity of
delivering a PPCI service, at all hours of the day and night, and for every day of the year, it is remarkable that so much has been
achieved in such a short space of time. We shouldn’t forget that the decision to move to a PPCI dominated strategy was made
on the background of an existing excellent thrombolysis service, which had already delivered improved patient outcomes. It is all
the more remarkable that satisfaction with performance indicators for thrombolysis did not result in any complacency regarding
change. Far from it, as is demonstrated in this report, Ambulance Services, provider Trusts, and management at all levels have
responded with commitment and enthusiasm in implementing a better treatment strategy, to the benefit of patients.
It is a testament to the NHS, and the collaborative working of its multidisciplinary teams, that the national implementation of
PPCI has been so successful, and we have no doubt that the aspiration to achieve near universal coverage will be achieved.
Everyone involved in delivering this service improvement should feel immensely proud of their contribution.
Professor Roger Boyle Professor Huon Gray
National Director for Heart Disease & Stroke Deputy National Director,
Department of Health Consultant Cardiologist, Southampton
Gateway Reference: 14878
www.improvement.nhs.uk/heart

4. 4 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Introduction
The final report of the National Infarct Angioplasty Project (NIAP) was published in October 2008. NIAP was a feasibility
study sponsored jointly by the British Cardiovascular Society and the Department of Health. The NIAP document,
‘Treatment of Heart Attack - National Guidelines’, demonstrated that a strategy of primary percutaneous coronary
intervention (PPCI), as opposed to thrombolysis, as the default treatment for patients presenting with acute ST
segment elevation myocardial infarction, was possible in a UK setting.
The Department of Health estimated that it was feasible for PPCI to be rolled out to at least 95% of the population
over about three years, but implementation would be for local determination. NHS Improvement was available to
support, guide and coordinate the implementation of PPCI across the 28 Cardiac and Stroke Networks in England. The
purpose of this interim report is to document the progress that has been made after 18 months.
The authors gratefully acknowledge the help and cooperation of the staff of the Myocardial Infarction National Audit
Project (MINAP) and of the many hospital staff nationally that input data into MINAP. Without their cooperation, this
report, and the progress described herein, would not have been possible.
www.improvement.nhs.uk/heart

5. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 5
The national picture
The rate of increase in the proportion of eligible patients
receiving PPCI, and the proportionate fall in the use of Figure 1: National MINAP Data
thrombolysis is shown in figure 1. 100
90
In the third quarter of 2008, 58% of those patients who 80
received any reperfusion treatment were treated with 70
thrombolysis and 42% were treated with PPCI. By the end 60
of the first quarter of 2010, the proportion treated with 50
PPCI had risen to 73% and the proportion treated with 40
thrombolysis had fallen to 27%. 30
20
It is important to understand that some patients with ST 10
segment elevation myocardial infarction may receive 0
neither PPCI or thrombolysis, usually for sound clinical 2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
reasons. Review of the numbers of patients not receiving PPCI LYSIS
any form of reperfusion therapy shows no major increase
in this group as a result of the switch from lysis to PPCI
(figure 2).
Figure 2: National MINAP Data - Patients not receiving
reperfusion treatment
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
No Reperfusion Treatment
www.improvement.nhs.uk/heart

6. 6 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
The network picture
Even before the publication of the NIAP report, some areas
of the country had well-established PPCI services. These
areas included all of the London networks, the Black
Country, West Yorkshire and North Yorkshire. Many
hospitals, however, were delivering only ad-hoc PPCI in
small numbers.
The next few pages summarise the progress made
between October 2008 and April 2010 in each of the
28 cardiac and stroke networks in England.
www.improvement.nhs.uk/heart

7. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 7
Anglia
Anglia MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
2.3 million
Hospitals providing 24/7 PPCI
Norfolk and Norwich Hospital, Norwich
Papworth Hospital, Cambridge
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Basildon Hospital, Basildon
Comments
Approximately 87% of the population is now covered by
PPCI service. Pilot study of optimum treatment for East
Suffolk residents is in progress.
www.improvement.nhs.uk/heart

8. 8 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Avon, Gloucestershire, Somerset and Wiltshire
Comments
Avon, Gloucestershire, Somerset and Wiltshire MINAP Data Approximately 56% of the population is now covered by
100 PPCI service.
90
80 Planning to achieve 100% population coverage by
70 November 2011.
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
2.8 million
Hospitals providing 24/7 PPCI
Musgrove Park Hospital, Taunton
Bristol Royal infirmary, Bristol
Hospitals providing limited hours PPCI
Royal United Hospital Bath, Bath
Cheltenham General Hospital, Cheltenham
The Great Western Hospital, Swindon
Neighbouring centres where PPCI patients
may be treated
John Radcliffe Hospital, Oxford
Royal Berkshire Hospital, Reading
Southampton General Hospital, Southampton
Royal Bournemouth General Hospital, Bournemouth
Dorset County Hospital, Dorchester
www.improvement.nhs.uk/heart

9. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 9
Bedfordshire and Hertfordshire
Bedfordshire and Hertfordshire MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.68 million
Hospitals providing 24/7 PPCI
None
Hospitals providing limited hours PPCI
Lister Hospital, Stevenage
Watford General Hospital, Watford
Neighbouring centres where PPCI patients
may be treated
Papworth Hospital, Cambridge
Harefield Hospital, Middlesex
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

10. 10 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Birmingham, Sandwell and Solihull
Neighbouring centres where PPCI patients
Birmingham, Sandwell and Solihull MINAP Data may be treated
100 New Cross Hospital, Wolverhampton
90 University Hospital, Coventry
80
70 Comments
60 100% population
50 coverage achieved.
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.50 million
Hospitals providing 24/7 PPCI
• Heart of England NHS Foundation Trust
• Birmingham Heartlands Hospital, Birmingham
(Covering Good Hope Hospital and Solihull Hospital)
• University Hospitals Birmingham NHS Foundation Trust
• Queen Elizabeth Hospital, Birmingham
• Sandwell and West Birmingham Hospitals NHS Trust –
• Sandwell District Hospital, West Bromwich
• City Hospital, Dudley Road, Birmingham
(Out of hours one on call team – attending the trust where
the patient presents)
Hospitals providing limited hours PPCI
None
www.improvement.nhs.uk/heart

11. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 11
Black Country
Black Country MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1 million
Hospitals providing 24/7 PPCI
New Cross Hospital, Wolverhampton
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Birmingham Hospitals
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

12. 12 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Cheshire and Merseyside
Cheshire and Merseyside MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
2.0 million
Hospitals providing 24/7 PPCI
Liverpool Heart and Chest Hospital, Liverpool
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
None
Comments
Approximately 46% population coverage on1 April 2010.
Coverage then increased to 100% on 1 June 2010.
www.improvement.nhs.uk/heart

13. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 13
Coventry and Warwickshire
Coventry and Warwickshire MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
0.88 million
Hospitals providing 24/7 PPCI
University Hospital, Coventry
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Birmingham Heartlands Hospital, Birmingham
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

14. 14 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Dorset
Comments
Dorset MINAP Data Daytime PPCI provided at Dorset and Bournemouth with
100 thrombolysis for out-of-hours presenters. Planning to
90 achieve 100% population coverage by November 2011.
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
0.78 million
Hospitals providing 24/7 PPCI
None
Hospitals providing limited hours PPCI
Royal Bournemouth Hospital, Bournemouth
Dorset County Hospital, Dorchester
Neighbouring centres where PPCI patients
may be treated
Southampton General Hospital, Southampton
Royal Devon and Exeter Hospital, Exeter
Musgrove Park Hospital, Taunton
www.improvement.nhs.uk/heart

15. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 15
East Midlands
Comments
East Midlands MINAP Data Extensive consultation process over last 18 months. Plans
100 now in place to have 100% population coverage by
90 November 2011.
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
3.8 million
Hospitals providing 24/7 PPCI
Glenfield Hospital, Leicester
Hospitals providing limited hours PPCI
Royal Derby Hospital, Derby
Kettering General Hospital, Kettering
Northampton General Hospital, Northampton
Nottingham City Hospital, Nottingham
Neighbouring centres where PPCI patients
may be treated
Northern General Hospital, Sheffield
John Radcliffe Hospital, Oxford
University Hospital, Coventry
www.improvement.nhs.uk/heart

16. 16 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Essex
Essex MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.7 million
Hospitals providing 24/7 PPCI
Essex Cardiothoracic Centre, Basildon
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Bart’s and the London NHS Trust, London
Harefield Hospital, Middlesex
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

17. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 17
Greater Manchester and Cheshire
Comments
Greater Manchester and Cheshire MINAP Data 50% population coverage on 1 April 2010. This increased
100 to 80% on 6 September 2010 with plans to go to full
90 100% coverage in March 2011.
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
3.2 million
Hospitals providing 24/7 PPCI
Manchester Royal Infirmary, Manchester
Wythenshawe Hospital, Manchester
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
University Hospital of North Staffordshire, Stoke on Trent
www.improvement.nhs.uk/heart

18. 18 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Hereford and Worcester
Pre hospital thrombolysis with immediate transport to a
Hereford and Worcester MINAP Data PCI centre will be the treatment of choice for areas with
100 long travel times.
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
0.8 million
Hospitals providing 24/7 PPCI
None
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
New Cross Hospital, Wolverhampton
Queen Elizabeth Hospital, Birmingham
University Hospital, Coventry
Comments
Plans to introduce daytime access to PPCI at Worcester
Royal Hospital with out of hours transfer to existing
PPCI services in Birmingham are in progress.
www.improvement.nhs.uk/heart

19. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 19
Kent
Kent MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.6 million
Hospitals providing 24/7 PPCI
None
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Guys and St Thomas’s, London
King’s College Hospital, London
Comments
Kent now has 100% population coverage for PPCI based
at The William Harvey Hospital, Ashford. The service
commenced on 12 April 2010.
www.improvement.nhs.uk/heart

20. 20 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Lancashire and Cumbria
There are plans to roll out PPCI to 75% of the population
Lancashire and Cumbria MINAP Data over the next 12 months. Cumbria will continue with
100 thrombolysis because of the long travel times from this
90 area pending the development of a PCI / PPCI centre at
80 Carlisle.
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.9 million
Hospitals providing 24/7 PPCI
Victoria Hospital, Blackpool
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
None
Comments
The current service covers only the Blackpool catchment
area (approximately 17% of the network population).
www.improvement.nhs.uk/heart

21. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 21
North & East Yorkshire and Northern Lincolnshire
North & East Yorkshire and Northern Lincolnshire MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.3 million
Hospitals providing 24/7 PPCI
Castle Hill Hospital, Hull
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Leeds General Infirmary, Leeds
James Cook University Hospital, Middlesbrough
Comments
PPCI currently covers 60% of the population. Planning to
roll out to 100% by November 2011.
www.improvement.nhs.uk/heart

22. 22 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
North Central London
North Central London MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.2 million
Hospitals providing 24/7 PPCI
Royal Free Hospital, London
The Heart Hospital, London
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Any other London hospital
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

23. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 23
North East London
North East London MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.5 million
Hospitals providing 24/7 PPCI
Barts and the London Hospital
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Essex Cardiothoracic Centre, Basildon
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

24. 24 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
North Trent
North Trent MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.75 million
Hospitals providing 24/7 PPCI
Northern General Hospital, Sheffield
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
None
Comments
79% population coverage on 1 April 2010. Coverage
increased to 100% on 6 April 2010.
www.improvement.nhs.uk/heart

25. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 25
North West London
North West London MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.8 million
Hospitals providing 24/7 PPCI
Hammersmith Hospital, London
Harefield Hospital, Middlesex
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
St George’s Hospital, London
Bart’s and the London, London
London Chest Hospital, London
The Heart Hospital, London
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

26. 26 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
North of England
North of England MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
2.8 million
Hospitals providing 24/7 PPCI
James Cook University Hospital, Middlesbrough
Freeman Hospital, Newcastle
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Leeds General Infirmary, Leeds
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

27. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 27
Peninsula
Cornwall patients may receive thrombolysis because of longer travel
Peninsula MINAP Data times to the PPCI centre. At present South Devon patients receive
100 thrombolysis out of hours. Referral pathways to Derriford and Royal
90 Devon and Exeter NHS Foundation Trust are in discussion to ensure
80 a 24/7 service is provided for South Devon patients.
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.6 million
Hospitals providing 24/7 PPCI
Royal Devon and Exeter Hospital, Exeter
Derriford Hospital, Plymouth
Hospitals providing limited hours PPCI
Torbay Hospital, Torbay (24/5)
Neighbouring centres where PPCI patients may be treated
A small number of patients from North Devon may be transferred
to Musgrove Park Hospital, Taunton due to exceptional
circumstances. A PPCI service is being established for North Devon
patients with the Royal Devon and Exeter NHS Foundation Trust.
This service is hoping to commence formally in October 2010.
Comments
Royal Cornwall Hospitals NHS Trust is keen to commence
a PPCI service but there have been difficulties in recruiting
a cardiologist. A small number of North Devon and
www.improvement.nhs.uk/heart

28. 28 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Shropshire and Staffordshire
Shropshire and Staffordshire MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.5 million
Hospitals providing 24/7 PPCI
University Hospital of North Staffordshire, Stoke on Trent
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
New Cross Hospital, Wolverhampton
Heart of England NHS Foundations Trust
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

29. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 29
South Central
PPCI from their nearest 24/7 centre from 14 April 2010 onwards
South Central MINAP Data and Buckinghamshire patients have had access to PPCI from their
100 nearest 24/7 centre since 26 May 2010. Portsmouth have provided
90 a 24/7 service since 1 September 2010. Population coverage of
80 97% has now been achieved.
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
4.2 million
Hospitals providing 24/7 PPCI
John Radcliffe Hospital, Oxford
Southampton General Hospital, Southampton
Royal Berkshire Hospital, Reading
North Hampshire Hospital, Basingstoke
Hospitals providing limited hours PPCI
Wycombe General Hospital, High Wycombe
Queen Alexandra Hospital, Portsmouth
Neighbouring centres where PPCI patients may be treated
Harefield Hospital, Middlesex
Frimley Park Hospital, Surrey
Comments
Coverage was 83% on 1 April 2010. This included all
areas except Portsmouth, East Berkshire and the Isle of
Wight. East Berkshire patients have had access to 24/7
www.improvement.nhs.uk/heart

30. 30 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
South East London
South East London MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.3 million
Hospitals providing 24/7 PPCI
Guy’s and St Thomas’s Hospital, London
Kings College Hospital, London
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
None
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

31. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 31
South West London
South West London MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.4 million
Hospitals providing 24/7 PPCI
St George’s Hospital, London
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
None
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

32. 32 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Surrey
Comments
Surrey MINAP Data Current population coverage is around 85-90% for
100 daytime presenters and 20% for out-of-hour’s presenters.
90 Planning to achieve 100% population coverage by
80 November 2011.
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.1 million
Hospitals providing 24/7 PPCI
Frimley Park Hospital, Frimley
Hospitals providing limited hours PPCI
St Peters Hospital, Chertsey
East Surrey Hospital, Redhill
Neighbouring centres where PPCI patients
may be treated
St George’s Hospital, London
www.improvement.nhs.uk/heart

33. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 33
Sussex
Comments
Sussex MINAP Data 75% population coverage on 1 April 2010. Planning to achieve
100 100% by March 2011.
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
1.6 million
Hospitals providing 24/7 PPCI
Royal Sussex County Hospital, Brighton
Eastbourne District General Hospital, Eastbourne
Conquest Hospital, St Leonards on Sea
Hospitals providing limited hours PPCI
Worthing Hospital, Worthing
Neighbouring centres where PPCI patients
may be treated
Southampton General Hospital, Southampton
East Surrey Hospital, Redhill
William Harvey Hospital, Ashford
Frimley Park Hospital, Frimley
www.improvement.nhs.uk/heart

34. 34 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
West Yorkshire
West Yorkshire MINAP Data
100
90
80
70
60
50
40
30
20
10
0
2008/2 2008/3 2008/4 2009/1 2009/2 2009/3 2009/4 2010/1
PPCI LYSIS
Population
2.2 million
Hospitals providing 24/7 PPCI
Leeds General infirmary, Leeds
Hospitals providing limited hours PPCI
None
Neighbouring centres where PPCI patients
may be treated
Northern General Hospital, Sheffield
Castle Hill Hospital, Hull
James Cook University Hospital, Middlesbrough
Comments
100% population coverage achieved.
www.improvement.nhs.uk/heart

35. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 35
Common themes
While formulating and implementing the individual The PCI-related delay is made up mainly of the travel time
network plans for the delivery of PPCI, a number of to the PCI centre and the so called ‘door-to-balloon’ time
common themes emerged. at the PCI centre. For patients with longer travel times,
there is evidence that the ‘door-to-balloon’ time can be
Local politics shortened to around 30 minutes because the PCI centre is
Cardiology has seen considerable decentralisation over the ready and prepared for the patient’s arrival. This allows a
last two decades with many procedures that were once the travel time of 70-90 minutes. In some rural areas of
preserve of tertiary referral centres now being performed England, a travel time of 90 minutes may still not be
in large numbers in district general hospitals. A primary enough to reach a PCI centre (eg. Cumbria, East Suffolk,
PCI service requires 24/7 catheter lab availability, a service Isle of Wight). This should apply to less than 5% of the
not available in many district hospitals. In some areas, the English population. If patients from these areas cannot
development of a PPCI service has been perceived as a receive PPCI, it is very important that they receive the next
‘centralisation’ process which threatens some district best standard of care. This involves pre-hospital
general hospitals. This has occasionally led to a desire to thrombolysis followed by immediate transfer to a PCI
retain local thrombolysis over what is seen as a distant centre. It is well established that 25%-35% of these
PPCI service. It is very important that the needs of the patients will fail to reperfuse following thrombolysis; if this
patient, rather than the needs of the hospital, dictate how happens, then the patient should receive rescue PCI as
the service is organised. This is vital during patient and quickly as possible. This cannot happen if the patient has
public engagement; the setting up of a PPCI service should been given pre-hospital thrombolysis and has then been
be seen as something to reduce the rate of death and taken to a hospital without PCI facilities.
stroke in local patients, based on the best available
scientific evidence, and not as something being taken Call-to-balloon time of 150 minutes
away from the local hospital. For the reasons outlined above, it has been proposed that
the threshold used to assess the performance of a PPCI
Long travel times service should be the proportion of patients in whom a
The time delay between the patient (or relative) first calling call-to-balloon time of less than 150 minutes is achieved.
for medical help and the patient later receiving reperfusion Experience has shown that this time is readily achievable in
treatment will almost always be longer for PPCI than for most parts of the country where diagnosis of ST segment
thrombolysis. There has been much debate about what is elevation MI is made by the ambulance service and the
an ‘acceptable’ PCI-related delay. In other words, at what patient is taken directly to the PPCI centre. In contrast,
length of PCI-related delay are the clear benefits of PPCI it is much harder to achieve if the patient is taken initially
over thrombolysis lost? There is some consensus that the to a non-PPCI hospital. Call-to-balloon time (like
benefits of PPCI are retained unless the PCI related delay ‘call-to-needle’ time) measures performance across the
exceeds 120 minutes. whole patient pathway which will include the ambulance
service, the non-PPCI hospital and the PPCI centre.
www.improvement.nhs.uk/heart

36. 36 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
Cross-boundary working Workforce and training issues
There are well established routes of referral between PPCI involves a major shift towards out-of-hours working. For
general practitioners and local hospitals and between many centres, this has involved employing and training
district hospitals and tertiary centres. These have evolved additional nursing, physiology and radiography staff. For
largely for elective and urgent care. Because time delays existing catheter lab staff, the move towards more frequent
are critical when setting up a PPCI Service, networks have night time and weekend working has sometimes been
had to consider where patients might receive PPCI with the difficult to manage. Whatever local arrangements are made,
minimum time delay. For some patients, the nearest PPCI it is clearly important that the PPCI service is sustainable in the
centre may not be within the cardiac network, or even long term.
within the Strategic Health Authority, in which they live. All
networks, therefore, have had to consider where patients, Response from the networks
particularly those patients close to the network As part of this survey, cardiac networks were asked whether
boundaries, are likely to receive the speediest care. any specific issues had delayed their plans to implement PPCI.
Three networks reported that discussion over the funding of
Limited hours and 24/7 centres the necessary additional ambulance activity had led to delays
Most PPCI centres in England operate 24 hours per day, in implementing the service. Three networks cited delays in
seven days per week. Some smaller hospitals operate a recruiting interventional cardiologists and two mentioned
PCI service which includes treating ST segment elevation delays in recruiting nursing and other cardiac catheter lab
MI patients during working hours (9am to 5pm, or 7am to staff.
7pm Monday to Friday). Patients outside of these times
are then taken to the nearest 24/7 Centre. This requires
careful planning between the limited hours centre, the
24/7 centre and the ambulance service. The service should
be centred around what is best for the patient; there is
little point in having a 9-5 service if the busiest times on
the roads (and hence the longest transfer times) are 8-9am
and 5-6pm.
www.improvement.nhs.uk/heart

37. National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report 37
Conclusion
Considerable progress has been made over the period
October 2008 to April 2010. All 28 cardiac and stroke
networks now have a strategy to deliver PPCI to most of
the population by October 2011. Increasingly, the focus
will be on outcomes. All centres delivering primary PCI
should strive to deliver the best possible quality of PPCI to
all eligible patients. Factors that will help to improve
outcomes will include the following:
1. Minimising the call-to-balloon time by ensuring that as
many patients as possible are diagnosed by the
ambulance service and taken directly to the PPCI centre,
avoiding accident and emergency units and coronary
care units.
2. Minimising door-to-balloon times at PPCI centres.
3. Developing strategies for dealing with simultaneous
referrals. Most PPCI centres can only treat one patient
at a time, particularly out-of-hours. If two or more
referrals are made to the same centre within a few
minutes, then it clearly benefits the second patient if
they can be taken to an alternative PPCI centre which is
not already treating a STEMI patient provided the
procedure is still carried out within an acceptable time
frame. In urban areas, this will involve cooperation
between neighbouring PPCI centres.
www.improvement.nhs.uk/heart

38. 38 National roll-out of Primary PCI for patients with ST segment elevation myocardial infarction: Interim report
www.improvement.nhs.uk/heart

39. Contacts
Carol Marley
National Improvement Lead, Reperfusion, NHS Improvement
email: carol.marley@improvement.nhs.uk
Sheelagh Machin
Director, Heart, NHS Improvement
email: sheelagh.machin@improvement.nhs.uk

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