Interesting points from Charles there, but everyone is consistently missing the point. I don't
give a stuff what the door to needle time is - my CCU measures the time from the door to their
unit not the front door! Except for patients sent up untreated from A&E where our audit
shows there to be a consistent added delay of 40 minutes or so.
What matters as a measure of the system response is the CALL to needle time, and what
matters to the patient is the PAIN to needle time. So those need to be measured, and steps
taken to minimise them. We have just completed an audit of chest pain and advice given on
discharge as one of the main delays we found was a delay in seeking help. Therefore a key
message on the card is, "if the pain lasts more than 15 minutes dial 999."
This will start to address the pain to call time and we are going to re-assess this after the
leaflets have been put out - the paper from Brighton suggested it would help. We are routinely
seeing call to needle times around 60 to 90 minutes (providing the patient receives
thrombolysis in A&E) and I do not think that empowering the prehospital carers further to
treat in our environment will improve that.
However, the evidence is that pre-hospital ECG transmitted to the A&E unit to allow them to
confirm the diagnosis, prepare thrombolytics and set up everything for the patient is good,
and I think it represents the next (albeit very expensive) step. Something needs to be done
about the machines our paramedics use locally, though - as Gautam points out in another
posting there seem to be some very marked differences in ECG tracings as the machines are
calibrated for different purposes.
Different environments (especially those with long transport times) may require different
solutions, but Brault needs to remember that there is no medical control in the UK at present
(As far as I know - there was a pilot study in Maidstone that has folded, I think) and if a
patient is thrombolysed who has not had a myocardial infarction but something else like a
dissecting thoracic aneurysm that the paramedic had not detected there may be quite a lot of
problems.
Each provider unit (and none of this pre-hospital versus hospital stuff, please; it's irrelevant to
the patient) should decide how it can most quickly and safely administer thrombolysis and
use that. It can then audit that system to see if the postulate is satisfied. The evidence and
informed opinion suggests that a pain to needle time of one hour in 90% of patients is a
suitable standard for general audit.
Best wishes,
Rowley Cottingham
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