Pre-hospital thrombolysis by paramedics

This BMJ paper was set up to evaluate a system of pre-hospital thrombolysis, delivered by paramedics, in meeting the national service framework’s targets for the management of acute myocardial infarction.

Evidence of the benefits of early thrombolysis in the context of an acute myocardial infarction is overwhelming.  This is reflected in the national service framework for coronary heart disease in the adoption of a challenging standard “call to needle time” (from the initial call for help to treatment) of less than 60 minutes.

The study was a prospective observational cohort study comparing patients with suspected acute myocardial infarction considered for thrombolysis in the prehospital environment with patients treated in hospital.

The catchment area was a large teaching hospital, including urban and rural areas.

201 patients presenting concurrently over a 12 month period who had changes to the electrocardiogram that were diagnostic of acute myocardial infarction or who received thrombolysis for suspected acute myocardial infarction were studied.

The main outcome measure was the time from first medical contact to initiation of thrombolysis (call to needle time), number of patients given thrombolysis appropriately, and all cause mortality in hospital.

The median call to needle time for patients treated before arriving in hospital (n=28) was 52 minutes.  Patients from similar rural areas who were treated in hospital (n=43) had a median time of 125  minutes.  This represents a median time saved of 73 minutes (P<0.001). 

Sixty minutes after medical contact 64% of patients (18/28) treated before arrival in hospital had received thrombolysis; this compares with 4% of patients (2/43) in a cohort from similar areas.  Median call to needle time for patients from urban areas (n=107) was 80 (78 to 93) minutes.  Myocardial infarction was confirmed in 89% of patients (25/28) who had received prehospital thrombolysis; this compares with 92% (138/150) in the two groups of patients receiving thrombolysis in hospital.

Thrombolysis delivered by paramedics with support from the base hospital can meet the national targets for early thrombolysis.  The system has been shown to work well and can be introduced without delay.

Ref: Web

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Surgeon-Specific Mortality data

There is an unstoppable momentum towards the publication of surgeon specific mortality as part of the initiative to generate greater accountability and transparency in the NHS.  This has been triggered by failures of clinical governance in health care and is tied in with political initiatives about patients’ choice. 

The planned date for publication of surgeon specific data in the United Kingdom is 2004, and although it has been accepted by the secretary of state for health that any such data should be robust, validated, and stratified for case mix to allow meaningful comparisons to be made, this type of dataset does not yet exist for all hospitals and surgeons.

This is a shortened version of a paper published in the BMJ which analysed a database to compare crude mortality after coronary artery bypass surgery with outcomes that were stratified by risk.

It used a retrospective analysis of prospectively collected data. All of the NHS centres in the geographical north west of England that undertake cardiac surgery in adults were included. All patients undergoing isolated bypass graft surgery for the first time between April 1999 and March 2002 were analysed.

Surgeon specific postoperative mortality and predicted mortality by EuroSCORE.

8572 patients were operated on by 23 surgeons.  The overall mortality was 1.7%.  Observed mortality between surgeons ranged from 0% to 3.7%; predicted mortality ranged from 2% to 3.7%.  Eighty five per cent (7286) of the patients had a EuroSCORE of 5 or less; 49% of the deaths were in this lower risk group.  A large proportion of the variability in predicted mortality between surgeons was due to a small but differing number of high-risk patients.

The conclusion of the authors was that it is possible to collect risk stratified data on all patients undergoing coronary bypass surgery.  For most the predicted mortality is low.  The small proportion of high risk patients is responsible for most of the differences in predicted mortality between surgeons.  Crude comparisons of death rates can be misleading and may encourage surgeons to practice risk adverse behaviour.  We recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance.

Ref: Web

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Guidelines to Interventional procedures at NICE

NICE has developed a series of guidelines on interventional procedures. This is the institurtes newest work programme, which develops guidance on whether interventional procedures are safe enough and work well enough for use in the NHS.

By reviewing evidence, facilitating data collection and analysis, and providing guidance on the safety and efficacy of interventions, the interventional procedures programme enables clinical innovation to be responsibly managed. Many of the procedures that the programme investigates are new, but the programme also scrutinises more established procedures if there is uncertainty about it.

NHS healthcare professionals are responsible for notifying procedures to NICE and applying the guidance to meet the needs of individual patients. Although procedures are most commonly notified by clinicians, any individual or organisation may notify procedures that are being performed or are likely to be performed within the NHS.

The first eight subjects are:

·                 Customised titanium implants in orofacial reconstruction

·                 Percutaneous pancreatic necrosectomy

·                 Circular stapled haemorrhoidectomy

·                 Percutaneous intradiscal thermocoagulation for lower back pain

·                 Extracorporeal shockwave therapy for Payronie’s disease

·                 Magnetic resonance image-guided percutaneous laser ablation of uterine fibroids

·                 Endoscopic transsphenoidal pituitary adenoma resection

Training or no training, they all sound horrific to me!

Ref:Web

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