Whats Stopping your paramedic thrombolysis

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• Whats Stopping your paramedic thrombolysis?
• Influencing Change
• Mark E Cooke, BMedSci(Hons), MSc
• National Clinical Effectiveness Manager
• The ASA Clinical Effectiveness Programme is
  supported by the Department of Health

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Early Thrombolysis

• Background
• The National Picture
• Barriers to prehospital thrombolysis
• How to overcome these

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Early Thrombolysis The Evidence

• Clinical Trials / Meta-analyses (Morrison et al)
• Greatest benefits are within first 3 hours

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Lives saved per 1000 patients treated(of those
with ST elevation or LBBB)

• 0-1 hour 65
• 1-2 hours 37
• 2-3 hours 26
• Boersma, Lancet 1996
• Every 1 minute delay to thrombolysis equates to
  11 days life lost (when given in first 3 hours)
• Rawles J. J Amer Coll Cardiol, Nov 1997

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Recommendations

• Thrombolysis ideally given prehospital
• Without doctors in ambulances, strategies need to
  allow prehospital treatment if
• Journey time gt 30 minutes
• Journey hospital delay gt 60 minutes
• Ref Task Force Eur Heart J 1998191140
• Resuscitation Aug 1998

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JRCALC Models of Delivery

• Recognition of eligibility for thrombolysis by
  paramedics (based upon the clinical features and
  ECG). No transmission of data, but A/E or CCU
  will be alerted
• As above (model 1), but with the addition of
  transmission of clinical information and ECG so
  that the hospital has all the relevant details
  for clinical decision before patients arrival
• As above (model 2), but with direct contact with
  a physician who might then authorise the
  prehospital administration of a thrombolytic drug
  on a named patient basis
• Cooperation in rural areas with primary care
  physicians who will administer the agents before
  transfer to hospital
• Administration of thrombolytics by trained
  paramedics acting autonomously, using either
  reteplase or tenecteplase under patient group
  directions

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Directed or Autonomous?

• Benefits of Directed PHT
• Double check on appropriate therapy
• Less responsibility for paramedics
• Benefits of Autonomous PHT
• Saves valuable time
• Avoids transmission problems/delays
• Avoids possible misinterpretation/misunderstanding
  
• Avoids risk of no competent hospital advice

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Directed or Autonomous?

• Which way for your ambulance service?
• Too early to tell which model appears to be
  better
• Consultation with partners
• Start with Directed ?
• Confidence grows
• Introduce Autonomous ?
• A multi-disciplinary approach to training is
  essential

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Early ThrombolysisThe National Picture

• 20 Ambulance Trusts now providing PHT
• More than 600 patients have benefited from this
  lifesaving treatment since PHT began in 2002.
  (most of these in the last 12 months)
• A further 8 Trusts plan to introduce PHT during
  2004.
  data obtained from NOF Survey March 2003

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Legislation under POMs order

• Reteplase (Rapilysin/rPA) and Tenecteplase
  (Metalyse/TNK) are now included in the list of
  POMs that can be administered by paramedics
• May 18th 2004
• No longer require a PGD

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Heparin

• No requirement to use heparin with bolus drugs
  provided journey time likely to be less than 20
  minutes (reteplase) or 30 minutes (tenecteplase)
• Heparin may be used using a PGD, where journey
  times exceed this

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Safety

• There have been no reported adverse incidents
  associated with PHT
• It is recognised that bleeds may not be evident
  until after hospital admission, but anonymised
  feedback is expected.
• Re-occlusion rates?

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Perceived Concerns and Difficulties

• Not all paramedics want the responsibility
• Retention of skills with infrequent practice
• Availability of outcome data as feedback to crews
• Multiple ambulance services/hospital (drug
  choice)
• Unpredictability of delays to heparin
• Audit of adverse incidents

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Result

• Speeding thrombolysis and limiting call to needle
  time has been slow and sometimes difficult,
• BUT
• It is a success story and an excellent example of
  how partnership working can save more lives

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Result

• AND
• All ambulance services and acute trusts should be
  working together to develop systems that speed up
  the delivery of thrombolysis, and consider
  alternative approaches to care e.g. Direct
  referral to PCI
• But we need to wait until the London PCI study
  has been evaluated

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Remember

• The small risks associated with thrombolysis
  (whether in or out of hospital) are by far
  outweighed by the benefits
• Lives Saved
• Reduced Morbidity

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Can your health community afford not to provide
pre-hospital thrombolysis

• ?
• mark.cooke_at_asa.uk.net