Safety and efficacy of offsite percutaneous coronary interventions in 1,348 consecutive patients in rural Tasmania

In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites

BACKGROUND

Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery.

METHODS

In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined.

RESULTS

One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630 mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death.

CONCLUSION

This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

Current state of the performance of percutaneous coronary intervention in centres without on-site cardiac surgery

Before the routine use of coronary stents, potential complications of percutaneous coronary interventions required the presence of backup cardiac surgery on-site. Advances in pharmacotherapy and interventional techniques, particularly in the last decade, have significantly decreased the rates of complications requiring emergency cardiac surgery, from approximately 4% to 6% in the balloon angioplasty era to as low as 0.3% to 0.6% in the contemporary era of routine intracoronary stent implantation. An early invasive approach has been shown to improve outcomes among patients with non-ST elevation acute coronary syndromes (NSTEACS), particularly in those at the highest risk, emphasising the importance of early access to revascularisation premises in such patients. Patients with ST-segment elevation myocardial infarction require immediate and sustained recanalisation of the culprit vessel to obtain rapid reperfusion of the threatened myocardium, in order to reduce infarct size and improve outcomes. Primary percutaneous coronary intervention at hospitals without on-site cardiac surgery improves clinical outcomes and reduces length of stay when compared with fibrinolytic therapy. It also significantly reduces door-to-balloon times when compared with transfer for percutaneous coronary interventions at hospitals with on-site surgery. It has been published that risk-adjusted mortality rates for patients undergoing percutaneous coronary interventions in centres without on-site surgical backup are comparable with those of percutaneous coronary intervention facilities that have cardiac surgery on-site, regardless of whether percutaneous coronary intervention was performed as primary therapy for ST-segment elevation myocardial infarction or in a non-primary setting. To achieve these results however, an adequate percutaneous coronary intervention programme is required, including proper hospital infrastructure and appropriately trained interventional cardiologists.

The sustainability of Medical Morning Handover Reporting: adherence in a regional hospital

Background.The Medical Morning Handover Report is a form of clinical handover and is considered to be an essential mechanism for continuity of care and adverse event minimisation within a hospital environment. It is considered a significant Quality of Care activity recommended in Australian Medical Association clinical handover guidelines. The sustainability of such activities has not been reported. Aim.We aimed to assess the sustainability of Medical Morning Handover Reporting (MMHR) in the Department of Medicine at the Launceston General Hospital since its implementation in 2001. Methods.We conducted a quality improvement survey amongst the medical staff (pre-graduate and post graduate medical faculties) to assess its sustainability since implementation in 2001. Results.There were 30 respondents of whom 19 attended MMHR daily, four attended weekly, and only five attended less than weekly. Attendance rates at MMHR were maintained from 2001 to 2009 based on comparisons with previously conducted surveys. Conclusions.This study shows MMHR is sustainable and has evolved in format to incorporate advances in Health Information Technology. We believe adherence is dependent on providing leadership and structure to MMHR. What is known about the topic?Since the mid 2000s, the MMHR has emerged as a significant quality intervention activity in our Department of Medicine, with particular emphasis on the first 12–24 h of a patient's encounter with the hospital with conditions that are considered to be medical diagnoses. When considered relevant follow up feedback on previous admissions is covered by the meeting. What does this paper add?This paper attempts to add measurable end points for the quality of the MMHR meeting, the importance of measuring sustainability and introduce the concepts relating to the use of health information technologies as significant decision support and peer review tools within the meeting. What are the implications for practitioners?This study has several implications for clinicians in hospitals: (1) the Report is an essential component of ongoing quality of care handover to maintain the continuity of care and to apply the necessary variations in care uncovered during the handover process. (2) Strict adherence to the meeting time frame improves the MMHR efficiency. (3) Consultant staff attendance has a strong positive influence on the care and educational benefits of the meeting. (4) The integrated use of e-technologies appears to have a strong positive effect on decision making and education during MMHR.