HSIB: Emergency response to heart attack. Summary report (March 2021)

Summary

This Healthcare Safety Investigation Branch (HSIB) investigation explores the impact of ambulance delays on the emergency treatment of heart attack.

The current preferred model of care in the NHS in England is for patients to receive primary percutaneous coronary intervention (PPCI), a procedure which involves widening a blocked artery and inserting a stent to keep the artery open. The effectiveness of PPCI is dependent on the timescale in which it can be carried out. National figures have identified increasing delays in ambulances taking people with a type of heart attack known as ST-elevation myocardial infarction (STEMI) to hospital so that PPCI can be provided within target timescales. This may lead to worse outcomes for these patients. Alternative treatment using thrombolytic medicine (medicines used to dissolve blood clots) is advised where specific timescales for providing PPCI may not be met.

This investigation started after a patient notified HSIB of a delay in an ambulance attending him after suffering a heart attack (STEMI).

Content

HSIB recommendations

• HSIB recommends that NHS England and NHS Improvement revise the Ambulance Clinical Quality Indicator: Clinical Outcomes for ST-elevation myocardial infarction to reflect each element of the call to balloon response and review this indicator alongside the critical time standards workstream.
• HSIB recommends that the Association of Ambulance Chief Executives, working with the College of Paramedics and cardiology specialists, produces a position statement on the use of pre-hospital thrombolysis by paramedics.
• HSIB recommends that NHS England and NHS Improvement support the Joint Ambulance Improvement Programme to respond to emerging risks and research highlighting factors impacting on effective ambulance response.

Safety observations

• It may be beneficial if NHS emergency call handling triage systems consider how intelligent analytics or increased clinical oversight may be enhanced to assist in the early identification of STelevation myocardial infarction calls.
• It may be beneficial if current guidance on the use of thrombolysis as an alternative to primary percutaneous coronary intervention in England is reviewed to consider the challenges posed in safely administering thrombolysis in the pre-hospital setting.
• It may be beneficial if further work was conducted to identify the impact of delays in primary percutaneous coronary intervention on the morbidity of patients, and longer-term mortality of patients, suffering from ST-elevation myocardial infarction.