theheart.org blogger finally gets go-ahead for PCI without surgical backup

December 08, 2009

Glasgow, KY - After seven years of campaigning, much of it on the pages of theheart.org, forum moderator and "Heartfelt" blogger Dr Melissa Walton-Shirley (TJ Samson Hospital, Glasgow, KY) and her colleagues have finally achieved their goal of getting their rural hospital certified by the state of Kentucky to perform PCI without on-site surgical backup.

The cath lab team at TJ Samson Hospital

TJ Samson Community Hospital, along with Ephraim McDowell Regional Medical Center, in Danville, KY, had just come to the end of a three-year pilot project on primary PCI for acute MI and, prior to this decision, which goes into effect on December 24, were unsure as to whether they would be able to continue to offer this treatment. Laura Belcher, director of planning, development, and marketing at TJ Samson Community Hospital, told heart wire that the two hospitals were allowed to proceed in the certificate-of-need (CON) application due to "the impeccable service and outcomes achieved during the pilot project."

Almost nine out of 10 STEMI patients now get a PCI in less than 90 minutes at TJ Samson, says Walton-Shirley. "Six years ago, that number was around six out of 100. I don't think there is anything more pressing than this in intervention today. I don't know why we don't have more support from our guideline writers on this issue. When you look at other countries—for instance, Poland, which has AMI centers and boasts door-to-balloon times in some instances as short as 12 minutes—you see how far they have come, but how much farther we really have to go.

 
No one seemed to believe us when we told them that PCI without surgery on-site was the norm in Europe.
 

"At our early meetings, I remember surgeons accusing us of wanting to place patients at risk," she recalls. "They thought it was going to be one disaster after another, and they were vocal about it. No one seemed to believe us when we told them that PCI without surgery on-site was the norm in Europe. They seemed to want data from the US experience. Four years later, we've not had to transfer one single patient for an 'accident' in the cath lab. We've [treated] over 300 AMIs with 0% mortality."

Walton-Shirley is also ecstatic that the new state certification will allow her institution to perform both elective and emergent PCIs. The pilot project covered only primary PCI, so they had to turn away patients with nonurgent symptoms, resulting in transfer costs of $500 to $700 per patient.

Bill Kindred, chief executive officer at TJ Samson Community Hospital, said, "Since the inception of our primary angioplasty program, we have saved lives. Expanding this to include elective angioplasty will allow us to prevent a possible MI from happening. Also, our patients will no longer have to travel to a second facility and undergo an additional invasive cardiac cath.  I am so pleased that the Commonwealth of Kentucky has the vision to provide the same access . . . to rural patients as they do in urban areas."

Allowing elective PCIs will also enable the hospital to keep up with ACC guidelines that stipulate operators should perform 75 PCIs a year, says Belcher. Because this is an ACC recommendation, Kentucky also made this a requirement for the primary-angioplasty pilot project, she notes. So prior to offering the elective service at TJ Samson, "our interventionalist Dr Venkata Reddy would often travel for up to 45 minutes to perform these procedures to keep up his skills and volumes."

More than 30 US states allow some form of PCI without surgical backup

Belcher says decisions about whether to allow angioplasty without surgical backup are made on a state-by-state basis in the US, with well over 30 out of 50 allowing it currently. "Some of these states limit the service only to emergency patients, while others have no distinction. And it's interesting to note," she adds, "that the Veterans Administration hospital system—which is above state jurisdiction—has been performing these procedures unsupported for years.

 
The Veterans Administration hospital system—which is above state jurisdiction—has been performing these procedures unsupported for years.
 

"It is critical to raise the level of care patients receive in the more rural areas to be equal to care provided at larger and more urban facilities," Belcher stresses. "Making the standard of care for heart attack available to residents, regardless of their demographic, should be a priority. It will take hospitals, physicians, patients, hospital associations, local officials, and others to bring this issue to the attention of their law-makers. Not only is this service great for improving health of the patients, it's also a way to reduce healthcare costs."

Walton-Shirley is already planning the next phase of AMI care at TJ Samson: "We'll look at long-term planning, like putting cath labs down on the ground floor with our own ambulance bay so we can mirror the successes of the European AMI centers. Little things like avoiding the ER and elevators will go a long way toward reducing door-to-balloon times."

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