Practical upgrade quality and quantity of PCI service in acute myocardial infarction

Dr Lam Ho
Consultant (Medicine and Geriatrics)
Tuen Mun Hospital

Acute myocardial infarction (AMI) service demand is increasing in New Territories West Cluster (NTWC). There is an ultimate need to AMI percutaneous coronary intervention (PCI) service to increase quality and quantity simultaneously. However, how to do it under limited resources and manpower? “The success of a reform depends on correct direction of pursuit and right strategy in execution,” says Dr Lam Ho, Consultant (Medicine and Geriatrics) of Tuen Mun Hospital (TMH).

He stresses two directions must be fulfilled in a successful AMI service reform. One is handling ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) cases at the same time as both have same mortality risk. Two is to face reality by designing a tailor‑made system based on current available manpower and resources.

In terms of execution, he used ‘system and skill’ dual approach to improve current service. He prioritised and listed problems of NTWC AMI service in the system and settled them one by one. An inter‑departmental team which involved healthcare staff from Accident and Emergency Department (AED) and Department of Cardiology was formed and mapped out a practical, efficient and safe service model which included reforms on diagnosis, treatment, patient transfer, complication management and post-operative care. To ensure the quality and sustainability of the new service model, together with his team, they built an effective feedback system to monitor patient care. If there is any modifiable problem found, the team will investigate at once and solve it in 24 hours.

Regarding skill, Dr Lam continuously improves PCI approach in the whole team from nursing to fellows. He believes AMI PCI is teamwork and PCI approach should be individualised based on patient. His most memorable experience was a cardiac arrest patient who had been resuscitated in AED for 1.5 hours. He performed PCI to revascularise the coronary vessel by an innovative thrombus management method. The patient was saved and survived till now. In recent few years, TMH cardiac team has been awarded with numerous Best Case Awards in various international case competitions.

In the new AMI service model, TMH transformed to AMI PCI centre in last year smoothly. Both STEMI and NSTEMI patients received evidence and guideline based PCI service even under limited resources. There were minimal impact on general medical duties and a rapid development in complex PCI, such as CTO and left main intervention. Last year, over 60% PCI in TMH were urgent PCI, rescue PCI, pharmacoinvasive PCI, primary PCI (PPCI) for NSTEMI, STEMI and cardiac arrest. Despite more than 10 times increase in PCI for AMI and cardiac arrest, the overall PCI 30 days mortality last year was around 0.95%. Quality Transfer PPCI system was also established in NTWC to support sister hospitals.