Hi Adrian,

There will be some evidence presented on urban pre-hosp thrombolysis at the meeting at the Royal College of Physicians on the 15th October.

Anton

In message <009601c387a7$b2ad5ce0$e177fea9@mydell> Adrian Fogarty <[log in to unmask]> writes:
> Thank you for listening, Katherine. Yes, even the cynics like myself =
> agree that it's an important subject, but we're concerned about perverse =
> targets (as you've alluded to), and we're concerned about lack of =
> evidence, for example, is prehospital thrombolysis actually any quicker =
> in the urban environment? I suspect it might be, albeit only marginally, =
> but has anyone actually produced this evidence?
>
> And yes, it certainly has been quite a debate. If the passion of the =
> debate - and hence the diversity of opinion - can be gauged by the =
> length of the ACAD-AE-MED thread, then this debate wins hands down. At =
> over 80 postings, this has certainly been the most hotly debated topic =
> this year, and has probably been the biggest topic in the history of the =
> LIST (although I didn't check beyond January 2003).
>
> Adrian Fogarty
>
>   ----- Original Message -----=20
>   From: Katherine Henderson=20
>   To: [log in to unmask]
>   Sent: Tuesday, September 30, 2003 9:09 PM
>   Subject: Originally ECGs at the scene
>
>
>   Dear List
>
>   Late entry to this discussion but I was keen to read what opinions =
> were out there. It has been very interesting.=20
>
>   There are lots of people out there doing great work in this area but I =
> need to make a declaration of interest for those I have not been in =
> contact with before. I am an A&E Consultant at the Homerton and as such =
> was the local AMI project lead for a first wave Coronary Heart Disease =
> Collaborative site. That led to joining the National team of the CHD =
> Collaborative as one of the 2 doctors on the AMI workstream. I am also =
> the A&E rep on the MINAP steering group at the Royal College of =
> Physicians, am on the DOH CHD Taskforce led by Roger Boyle, was part of =
> the group who wrote the DOH document on Delivering Early Thrombolysis =
> and recently attended a workshop with the Prime Minister's Delivery Unit =
> on Thrombolysis. I recite this not to name drop but to indicate that in =
> some ways I am associated with the DOH targets but also have the =
> potential for influencing strategic thought. There are no other A&E docs =
> on these committees (they keep talking about Casualty!) I know some of =
> you have been involved in the pre hospital arena.
>
>   The one target that has not been mentioned is the 60 minute Call to =
> needle time. This is the main target now - one which your Strategic =
> Health Authority has signed up to agreeing to a 10 percentage point =
> improvement year on year for 3 years. MINAP publishes the Call to needle =
> time data and in this June's report the baseline nationally was 38%. The =
> 30 minute target is part of star ratings. The 20 minute target is now =
> has the status of a local target which it may be appropriate to work =
> towards but not performance manage. Some of your teams may need to know =
> this.=20
>
>   Now some of you will say that these targets are inappropriate =
> government pressure. In particular they are focussing on thrombolysis =
> when we should be concerned with time to reperfusion. I agree with you =
> as did everyone presenting to the Delivery Unit and the DOH Taskforce =
> are well aware of the debate. They argue that everything that they are =
> doing in this area will help set up a system that could deliver Primary =
> angioplasty but that we are nowhere near being able to deliver that =
> service now and it is a 5-10 year project. Training paramedics to make a =
> clinical assessment and do a 12 lead ECG makes prehospital triage to a =
> Cath lab possible in the future. Therefore in the meantime thrombolysis =
> is the treatment for the majority and we should do it as well as we can. =
>
>
>   The 60 minute target is important because it crosses pre hospital and =
> in hospital boundaries and needs both teams to work together to deliver =
> the service. The discussion on this list was rather polarised between =
> paramedics and doctors. Taj is right,in my opinion, that we need =
> multi-disciplinary discussions. We need to be aware of some facts of =
> life. The NHS plan and the NSF encourages pre hospital thrombolysis =
> especially in areas with long journey times but the Ambulance Trusts =
> star rating system scores them on the number of paramedics training to =
> deliver thrombolysis per 100 paramedics in the service. This puts quite =
> a lot of pressure on ambulance trusts to decide to thrombolyse even =
> where this may not be the best way to deliver the 60 minute target. The =
> London Ambulance Service is caught in this situation. Representations =
> have been made to get rid of this perverse incentive in the ratings =
> system. What is important is that we communicate across the boundaries =
> and work together to try and get the patient thrombolysed in 60 minutes.
>
>   On the practical level I do this locally by organising joint training =
> for A&E staff and ambulance crews on ACS recognition. I support ECG =
> training and give lots of positive feedback to crews who do ECGs or =
> 'blue light' in suspected ACS patients. I recognise that giving crews =
> new skills enthuses them and I suspect improves their management of a =
> whole range of patients. Pre hospital thrombolysis will probably have =
> the same effect and additionally aid recruitment to the EMS services. I =
> also make sure that the training mentions primary angioplasty so that =
> staff are aware of the future.=20
>
>   The work on CHD is one of the most successful of the targeted health =
> initiatives. The improvement in getting patients a) thrombolysed b) =
> thrombolysed quickly is documented by MINAP. We should all be proud of =
> ourselves - pre hospital teams and for the majority of patients, A&E =
> teams. But the start of the improvement is the NSF so standards/ targets =
> do have some effect. Have other patients suffered because of the focus =
> on AMI?- personally I doubt it. I suspect all chest pain patients get =
> slicker management because of the CHD efforts.
>
>   Sorry such a long post but I feel honour bound
>
>   Dr Katherine Henderson
>   [log in to unmask]