I disagree with Adrian on this one (oddly enough coming to a totally
different conclusion based on the same facts). If it is considered the
responsibility of both the acute trust and the ambulance service to achieve
the 60 minute call to needle time you might get somewhere (although of
course, ideally emergency ambulances should come under the care of A and E
in any case). The trouble with splitting the times is that it encourages
minor adjustments of the times in one's own favour- for instance here our
ambulances log arrival time as the time when they turn into the road-
whereas I'd like to log them as the time the patient comes through the door.
I've seen 'door to door' times of 5 minutes- a bit of a problem with a 20
minute target.
> Currently ambulance services don't seem to have any targets
> after they've
> reached their patient, and I think that's a pity. They can spend an
> inordinate amount of time doing things that really should wait until
> hospital, especially in cardiac cases, and a prehospital
> target time would
> tighten this up. However I foresee problems with those
> services that, for
> example, do prehospital ECGs. They will be reluctant to do
> these if they
> have a call-to-hospital target time of 30 minutes for
> example.
Yes. I'm unconvinced of the benefits of prehospital ECG unless they can be
done while the ambulance is moving (having a fair amount of prehospital
experience myself I can vouch for the fact that it is quicker to do things
in the hospital). Indeed on prehospital thrombolysis I would refer you back
to the GREAT study. Initially looked as though prehospital thrombolysis
improved outcome (and indeed frequently and wrongly reported as such), but a
lot of selection bias. Reanalyse their results on an intention to treat
basis and you'll find the group in the prehospital arm had a significantly
increased mortality. Boring I know, but that's the facts.
> overall call-to-needle target of 60 minutes. This may be
> relatively easily
> achievable in London, but it will be a lot more difficult in
> Norfolk or
> Northumberland!
Yes, you'd have to make adjustments for areas- as is already done for
ambulance response times.
Possibly a compromise with both targets (maybe slightly relaxed) being
present. I do feel a 20 minute door to needle time to be unreasonable
though- by the time the patient has been undressed and ECG done there is not
really enough time to properly explain what you're doing to them. It may
also encourage thrombolysis in the slightly dubious cases with less
consideration of benefits. Relaxing it to 30 minutes might be safer with
little difference to outcomes. Also, looking at the various studies of ways
to improve door to needle time, the improved times are rarely under 40
minutes. Setting a target that is tighter than any published figures is
unreasonable.
Matt Dunn
Warwick
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