• For use in Frimley Park Hospital only

• To be read by all staff involved with Primary PCI delivery

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

Available in hard copy at CCU front desk.

Activation of the PPCI team during working hours is via the Cath Lab priority (Bat) phone.

Activation of the PPCI team outside working hours, whereby all members of the PPCI team have to be called in, is carried out by CCU only. STEMI patients MUST be referred to CCU by contacting the CCU Priority (Bat) phone.

These referrals may be made by ambulance crews (typically SECAmb or South Central, SCAS), Frimley Park ED (Consultant or SpR only), or RSCH, Guildford (Consultant or SpR only). Occasionally the STEMI patient may be in hospital.

All referrals MUST be discussed with the on call PPCI consultant (by CCU or the referring physician) before activation of the team.

Criteria for PPCI Activation

• ST Elevation in 2 adjacent leads:

  • 1mm in II, III aVF, I, aVL

  • 2mm in V1-V6

• 2mm ST Depression in V1-V3 (Consider posterior STEMI)

• Onset of chest pain <12hrs before presentation

• Ongoing chest pain (please discuss with on call consultant if pain free)

• High risk NSTEMI (see later)

Patients who have had the above changes which have then settled MUST be discussed with the PPCI consultant (and may still activate the PPCI pathway at the discretion of the consultant)

Following features must be highlighted to the PPCI consultant where applicable: systolic BP <90, out of hospital cardiac arrest (see later), patients unable to lie flat or give consent, patients with suspected or known COVID.

Note that RBBB is not an automatic indication for PPCI (but may be a STEMI equivalent, so must be discussed)

Patients with new RBBB or other ECG changes (or even those without ECG changes) may be discussed with interventional cardiology consultant for consideration of emergency PCI (see high risk NSTEMI later)

Patients not considered appropriate for PPCI should be diverted to nearest ED where applicable (see below). This does NOT mean that further cardiology input is not required. Any relevant change in their condition should be communicated to CCU. Details of these patients should be retained for audit purposes.

First Contact (between Ambulance Crew and CCU; 24 Hours)

• Ambulance crew calls CCU Priority (Bat) phone

• CCU nurse takes call and logs patient name and incident number

• Run through CCU Checklist, check type of IV access

• ECG to be sent by LifeNet by SECAmb crews, FastECG by SCAS crews (remember to take down code)

• If ST elevation clear and PPCI indicated (see criteria), instruct to give Aspirin 300mg AND Clopidogrel 600mg or Ticagrelor 180mg (SECAmb crews will only give Ticagrelor as a second antiplatelet agent, as of March 2019)

• CCU nurse-in-charge to give clear instructions: Bring patient to Cath Lab via back entrance (follow PPCI signs).

• All diagnostic ECGs should be transmitted to consultant

Patients NOT accepted may be

1. Diverted to nearest Emergency Dept

2. Brought to Frimley Emergency Dept for further assessment (CCU must alert ED of arriving patient)

OR

3. Brought to Frimley CCU for further assessment

Which of these options is recommended depends on consultant decision.

During Working Hours

CCU to call Cath Lab Priority Phone

Out of Hours

PPCI team to be activated by CCU nurse-in-charge by first calling PPCI consultant, then calling Switchboard on 2222 and stating

Activate Primary PCI team at Frimley Park

Team members are identified clearly on CCU whiteboard

If all team members have not returned calls (to CCU Priority (Bat) phone) within 5 mins, contact directly by mobile phone. If still unable to contact a team member, ask switchboard to keep trying and inform PPCI consultant.

Consultant changeover is 7.30am

If patient critically unwell (systolic BP <90, for example) or there is another patient in Cath Lab, ambulance crew may be diverted to Emergency Department (inform ED).

Waiting for the Patient (Out of hours)

• Medical SpR to be informed

• Site manager to be informed to make bed(s) available

• CCU nurse to change into scrubs

• X-ray equipment switched on by radiographer

• NNP to backfill CCU or assist in lab (NNP will not be available on weekend daytime hours)

Ambulance crew to enter via back entrance and move directly to Cath Lab TWO

See Contact Sheet for key phone numbers/codes (hard copy in CCU)

Ambulance crew to be met at back entrance by CCU nurse out of hours (if possible) and escorted to Cath Lab TWO.

If CCU nurse feels uncomfortable with patient condition (and consultant not in Cath Lab), patient to move to CCU.

CCU nurse to confirm receipt of completed ambulance worksheet

Ambulance crew to remain with CCU nurse where possible

Medical SpR to be contacted unless:

• Patient is stable, AND

• CCU nurse AND one other PPCI team member are present

• OR CCU nurse AND NNP are present

Document CALL TIME and DOOR TIME (to be entered into BCIS dataset).

Patient to be transferred onto Cath Lab table when it is considered safe by team members present (e.g., if 2 out of 4 team members are present, I would consider it appropriate to have the patient on the Cath Lab table for ECG monitoring and draping).

All referrals following out of hospital cardiac arrest including those WITH ST elevation must be discussed with PPCI consultant before PPCI team activation.

CCU to establish type of airway and IV/IO access during first contact.

Patients brought in by ambulance with ROSC, GCS>15, systolic BP>90, not agitated and able to lie flat may go directly to Cath Lab (assuming that patient has been accepted for PPCI and team are present). Anaesthetic team to be made aware of referral.

All out of hospital cardiac arrests brought in by ambulance crews requiring anaesthetic input on arrival (i.e., intubated patients or agitated patients or GCS<15) MUST be taken to the ED for assessment before coming to the cath lab. This applies during working hours and out of hours.

CCU nurse-in-charge to inform ED and ITU

Decision to take OOHCA patients to the lab is made by PPCI consultant. The MIRACLE 2 score which may be used to guide this decision is attached at the end for reference (Appendix One). Patients with a low MIRACLE 2 score (0 to 3) and ST elevation on their ECG are more likely to have a favourable outcome, for example.

In patients unable to take medication by mouth (intubated, agitated etc), please consider Aspirin 300 mg by rectum and IV Cangrelor (see appropriate guidelines).

See Contact Sheet for key phone numbers/codes (hard copy in CCU)

Emergency Dept (Consultant or SpR only) to phone CCU Priority (Bat) phone if criteria for PPCI have been satisfied (or Cath Lab priority (Bat) phone during working hours)

PPCI team to be activated by CCU staff (Not Emergency Dept)

Once accepted by CCU or Cath Lab, patient to be transferred to Cath Lab ASAP (and ED staff to remain with patient out of hours until at least 2 members of PPCI team have arrived).

Please do NOT perform ABGs (radial arteries will need to be used for arterial access during PPCI). Do not delay for paperwork, CXR etc if following PPCI pathway.

If the diagnosis is in doubt, the interventional cardiology consultant on call may be contacted directly (by an ED consultant or SpR only). Note that cardiology problems unrelated to PCI should be discussed with the non-interventional cardiology consultant on call (between 9AM and 2 PM Saturday, Sunday, and bank holidays).

ECGs have to be transmitted by CCU to the mobile phone of the PPCI consultant. ECGs are not always visible on Haiku (Epic) and not all consultants have the Haiku app on their phones.

High Risk NSTEMI patients meeting both the following criteria MUST be discussed with interventional cardiology consultant on call:

• ECG Criteria: 2mm ST Depression in any leads OR T wave inversion, RBBB

• Patient unwell (ongoing chest pain, cardiogenic shock, acute heart failure, ventricular arrhythmias)

Referrals from RSCH must be by a consultant or SpR, and to be accepted by CCU in the same way as we would from an ambulance crew.

If PPCI criteria are met and the decision to transfer patient has been made by a consultant or SpR (at RSCH), discuss with Frimley interventional cardiology consultant on call before activating PPCI team (or accepting on to CCU for further assessment).

Guildford ECGs to be emailed to: fhft.ccufph@nhs.net

Guildford CCU or ED should request a Level One or Time Critical Transfer via 999 using the phrase “Primary PCI” as reason for transfer when asked by the call operator.

Frimley CCU to make a note of the name of the referring RSCH doctor and ask for transferring ambulance crew to contact Frimley CCU.

Refer to separate STEMI Guidelines in the COVID era (see Chart 2).

Where patients are NOT taken to Cath Lab, considered inappropriate for PPCI, OR do NOT require PCI, please document reasons clearly for audit purposes.

BALLOON TIME to be clearly documented.

Any cause for delay in transfer or intervention to be recorded in procedure report

Cardiac Arrests in the Cath Lab if Anaesthetic Team not already present

For cardiac arrests, put out a crash call.

For Cath Lab emergencies (low blood pressure, agitated patient, possible imminent cardiac arrest, and so on) and for an immediate anaesthetic response with ODP and outreach to the Cath Lab, the call to switchboard should say, CATH LAB EMERGENCY. Do NOT ask for anaesthetic emergency. If there is no support after an appropriate time (this will vary depending on the situation), put out a crash call (if immediate anaesthetic support still required).

As a rule, do NOT put out a crash call for Cath Lab emergencies unless it is a cardiac arrest and you want the full medical team as well.

If GP IIb/IIIa inhibitor must be given, give Tirofiban (as per Appendix 2) or Eptifibatide (Integrilin; see separate guideline). Abciximab (Reopro) is no longer available.

Patient to be admitted by on call SpR or SHO

Zwolle Risk Score (ZRS) to be assessed on CCU ward round following morning. Patients with a ZRS of 3 or less (< 4) are considered low risk and may be discharged at 48 hours if appropriate. Patients with ZRS of 4 or greater (> 3) are considered to be at high risk and may be discharged at 72 hours (see Appendix Three).

Patient to receive information on cardiac rehabilitation (including contact details and rehab goals) and Patient Satisfaction Questionnaire

Referring hospital to be sent a copy of discharge summary (where required)

Discharge summary should make duration of dual antiplatelet therapy (DAPT) or triple therapy (DOAC + DAPT) clear. If there has been a change in antiplatelet therapy during admission (e.g., Ticagrelor to Clopidogrel), please make sure the patient has been reloaded with second antiplatelet agent.

Patient to be given copy of discharge ECG.

Presentation: Pre-diluted (ready to use) 250ml bag containing Tirofiban 50mcg per ml.

Dosage in PPCI patients:

25 micrograms/kg, to be given over 3 minutes at start of PCI, then (by intravenous infusion) 150 nanograms/kg/minute for 12–24 hours, maximum duration of treatment 48 hours.

Patients with a ZRS of 3 or less (< 4) are considered low risk and may be discharged at 48 hours if appropriate. Patients with ZRS of 4 or greater (> 3) are considered to be at high risk and may be discharged at 72 hours.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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