LAUSR

Introduction Primary PCI (PPCI) is the recommended treatment for patients presenting with ST-elevation myocardial infarction (STEMI). The catheterisation laboratory in the Royal Victoria Hospital in Belfast is activated when a diagnostic STEMI ECG is received from an ambulance crew or emergency department. The decision to activate is taken by CCU nurses. The aim of this study was to assess the numbers, sources, appropriateness and clinical outcomes of patients turned down for PPCI by this process and to assess the diagnostic accuracy of nurse-delivered ECG interpretation. Methods The Belfast PPCI pathway is activated by trained nurses who act according to a regionally agreed protocol. Electrocardiograms (ECG) are transmitted by email or fax to a central hub and considered along with a focused telephone conversation. If the laboratory team is not activated, the referral is deemed a turndown. Clinical information and a record of the ECG is kept for each case and logged on a database. All turndowns between the beginning of April 2017 and the end of September 2017 were reviewed. A turndown was deemed inappropriate if retrospective review of the history and ECG demonstrated diagnostic features within PPCI pathway criteria. Results Between 1st April 2017 and 30th September 2017 there were 957 referrals to the PPCI service. 595 (62.2%) were turned down and in 362 (37.8%) cases the laboratory team was activated. 15 (1.6%) turndowns were deemed inappropriate of which 12 cases were due to inappropriate interpretation of the ECG and 3 cases were due to inaccurate interpretation of the clinical history. 51 cases were re-referred to the service a second time and of these 3 cases were identified as having been inappropriately turndown on first referral. In 2014, the inappropriate turndown rate had been 3.1% 322 (76.1%) patients in the turndown population required hospital admission and 290 (48.7%) were admitted to a Cardiology service. The six-month mortality in the turndown population was 17% with a cardiac cause of death in 5.7% of cases. There were 2 (13.3%) deaths in the inappropriate turndown group at six months, both due to cardiac causes. The sensitivity, specificity positive and negative predictive values are shown in the Table. They indicate a high level of diagnostic accuracy for nurse-delivered ECG interpretation, and show that the system inclines towards greater sensitivity to miss as few patients as possible. Abstract 166 Table 1 Conclusion In this PPCI service, the majority of patients referred are turned down appropriately. Clinical outcomes were similar among patients in the appropriate and inappropriate groups in the turndown cohort and the mortality rate in this group as a whole is relatively high. The rate of inappropriate turndown has decreased since 2014. Conflict of Interest Nil