Letters

Call to needle times after acute myocardial infarction

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7197.1553a (Published 05 June 1999) Cite this as: BMJ 1999;318:1553

Paramedics in Derbyshire can admit direct to coronary care unit when they diagnose myocardial infarction

  1. David A Sandler, Consultant physician (DoctorDAS{at}aol.com)
  1. Chesterfield and North Derbyshire Royal Hospital, Chesterfield S44 5BL
  2. Gipping Valley Practice, Barham, Ipswich IP6 0AS
  3. Medicines Assessment Research Unit, University of Aberdeen, Royal Infirmary, Aberdeen AB25 2ZN

    EDITOR—Edhouse et al have shown that in an urban area such as Sheffield the optimum method of hastening thrombolytic treatment for acute myocardial infarction is for patients to dial 999 and be brought to the casualty department and for the thrombolytic treatment to be given there.1 This reduced the door to needle time to a median of 41.5 minutes.

    In North Derbyshire, a mix of urban and rural areas adjacent to Sheffield, we have a system of direct admission to the Chesterfield and North Derbyshire Royal Hospital coronary care unit by paramedics (bypassing the accident and emergency department) when the paramedics diagnose an acute myocardial infarction from a 12 lead electrocardiogram obtained at the patient's home.2 In the 21 months since the system was introduced in May 1997 I have collected data on all admissions to the coronary care unit.

    The unit has received 889 patients with myocardial infarction, of whom 159 have been delivered directly by paramedics. Altogether 495 of the patients have received thrombolytic treatment, including 131 of those delivered by the paramedics. The mean (median) times from arrival in hospital to thrombolysis (door to needle times) were 89 (107) minutes for all patients with acute myocardial infarction yet only 42 (43) minutes for those delivered by paramedics. Altogether 171 patients given thrombolysis who were admitted to the coronary care unit direct from the accident and emergency department had mean door to needle times of 80 (76) minutes.

    At present we do not give thrombolysis in the accident and emergency department, although this policy is under review. The door to needle time that we achieve with our paramedic direct admission service is similar to the Sheffield model of thrombolysis in the accident and emergency department. This model should also be considered as a means of delivering thrombolysis more quickly than traditional methods of admission to hospital. If thrombolysis starts to be given in the accident and emergency department in Chesterfield we will have to compare this service with the existing paramedic service and determine if the model proposed by Edhouse et al is even quicker.

    References

    GPs are encouraged to rely on ambulance service

    1. P D Thomas, General practitioner. (pault{at}gippingvalley.demon.co.uk)
    1. Chesterfield and North Derbyshire Royal Hospital, Chesterfield S44 5BL
    2. Gipping Valley Practice, Barham, Ipswich IP6 0AS
    3. Medicines Assessment Research Unit, University of Aberdeen, Royal Infirmary, Aberdeen AB25 2ZN

      EDITOR—I was interested to see that the letters criticising the paper by Rawles et al on call to needle times after acute myocardial infarction were written by trust employees. 1 2 As a general practitioner practising immediate care and offering domiciliary thrombolysis I wonder whether they have a genuine wish to improve patient care, or are they influenced by a powerful conflict of interest?3

      As Edhouse et al and Ahmad et al confirm,1 in an emergency most patients make a 999 call for an ambulance in the belief that an ambulance offers the quickest route to hospital care and therefore the best outcome. This need not be the case. As Rawles et al show, at least in the case of acute myocardial infarction, general practitioners can offer an improved clinical outcome but only if they are adequately equipped, readily available, and mobilised in time.2

      Few general practitioners currently offer domiciliary thrombolysis or indeed any other emergency medical care. Most receive financial inducements to delegate out of hours care to the cooperative deputising services. Unfortunately, this means that in many cases a doctor cannot be provided in time to influence the clinical outcome when one is genuinely needed. Delays in visiting of more than an hour are now common, so it is no surprise to learn that the corporatist NHS hierarchy, in the form of the Sandwell NHS Trust, encourages acutely ill patients to bypass their general practitioner and dial 999 instead.1

      Although official ambulance response times in Suffolk often exceed 30 minutes and the trust is under investigation by the region for its poor performance, local general practitioners are encouraged to rely on the ambulance service in all acute cases rather than provide a comprehensive service themselves. On one occasion the ambulance trust initially refused to contact me for a patient in pulseless ventricular tachycardia after its receipt of a 999 call, although I had been asked for by name and was readily available. In fact, I arrived well before the ambulance and initiated treatment and the patient survived. In a more recent but identical case I was called belatedly, only to confirm death.

      The provision of quality medical care by general practitioners is greatly hampered by unreasonable patient demand and trust corporate philosophy. In consequence there has been a reduction in general practitioners' involvement and an increase in the use of the ambulance service and accident and emergency departments. I have yet to be convinced, however, that patients receive better treatment in consequence.

      References

      New standard of 60 minutes has been proposed but may be too rigorou

      1. John Rawles, Honorary senior lecturer in medicine.
      1. Chesterfield and North Derbyshire Royal Hospital, Chesterfield S44 5BL
      2. Gipping Valley Practice, Barham, Ipswich IP6 0AS
      3. Medicines Assessment Research Unit, University of Aberdeen, Royal Infirmary, Aberdeen AB25 2ZN

        EDITOR—Since our paper was published1 and the responses to it were written,2 a new standard call to needle time of 60 minutes has been proposed.3 This supersedes the 90 minute standard set by the British Heart Foundation.

        Audit of call to needle times after acute myocardial infarction in Grampian in relation to proposed standard of ≤60 minutes3 and British Heart Foundation's standard of ≤90 minutes

        View this table:

        In relation to these standards the table shows up to date call to needle times from the Grampian audit, comparing prehospital thrombolysis by general practitioners in rural areas with scoop and run in the city and suburbs of Aberdeen and in rural areas 25 km or more from Aberdeen. In the scoop and run cases, patients taken to hospital after a 999 call were given thrombolytic treatment either in the accident and emergency department or in the coronary care unit to which they were directly admitted. No doctor to doctor referrals occurred in these cases, so these times are about the shortest that are achievable with this approach.

        These results suggest that the rigorous 60 minute call to needle standard is unlikely to be achieved in most cases unless thrombolysis is initiated in the community before patients are transported to hospital.

        References

        View Abstract

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