Strategic Context in the NHS
Previous treatment strategy in the NHS
For the past 50 years or so, the main treatment of such an attack has always been based in the hospital, where all the specialist staff, equipment and drugs are available.
However, this has become an inadequate option as the growing body of research evidence has shown that speed is of the essence with regards to thrombolysis, in particular during the "golden hour".(3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18)
This is measured from the time of onset of symptoms of chest pain until the moment when thrombolytic treatment is delivered.
This is the basis for the National Service Framework for Coronary Heart Disease Standard Six, which specifies that "People thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help."(19)
Funding from the central government to achieve this has been earmarked in the NHS Plan.(20)
Progress is being audited in real-time via the Myocardial Infarction National Audit Project (MINAP), which collects data from all hospitals in England and Wales.(21)
Achieving NHS Targets
The National Health Service has set out a target of delivering a 10% increase per year in the proportion of people receiving thrombolytic therapy within 60 minutes of calling for help. The national target set for the year 2004 to 2005 is 58%.(22)
The MINAP report for the corresponding time frame showed that only 55% was achieved in England and only 29% was achieved in Wales.(23) Overall, only 33% of patients achieved this target.
Lengthy ambulance travel times, especially in the rural areas and in the heavily congested urban areas, are the main cause of the delays.
The median time from call for help to arrival in the hospital is 50 minutes in one study. In addition, the median time from arrival to institution of the thrombolytic therapy was 25 minutes.(23)
This "door-to-needle" time is already approaching its maximum potential limit with the implementation of "rapid access pathways" and " dedicated thrombolysis staff" to receive these patients on arrival. In rural areas, transfer time alone from the patients home to the hospital may exceed 30 minutes.(24)
The evidence suggests that thrombolysis within the first 60 minutes halves the subsequent mortality from a heart attack.(3) 65 instead of 37 lives per 1000 may be saved instead. To put this in the UK context, there are up to 110,000 deaths per year from 300,000 heart attacks per year.(19)
In view of the above, pre-hospital thrombolysis appears to be the way forward in other to achieve the 60-minute target. There has been many studies done which has demonstrated its feasibility and capability.(26, 27, 28, 29, 30)
A study carried out in Scotland showed that the median time to treatment with pre-hospital thrombolysis was 52 minutes compared with 125 minutes for patients who was only thrombolysed after arriving in the hospital from a comparable geographic area and distance.(25) This was also better than the median call to needle time of 80 minutes for patients in urban areas, suggesting that the approach would also be of benefit in this setting.(25, 30)
Although there are many models to achieve this end, it has been suggested that paramedics with additional training and telemedicine decision support may best deliver this service.
There is also recent evidence to suggest that pre-hospital thrombolysis may improve the outcome of patients who eventually need mechanical re-perfusion (angioplasty).(31, 32, 33) This would then lead to a seamless management of patient with myocardial infarction in the future.
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17 May, 2017