Access to Advanced Cardiac Care
Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a treatment available to open blocked arteries in the heart, thereby preventing or treating a heart attack. The procedure may be done on an elective, scheduled basis when the patient is free of symptoms or it may be done on an emergent (primary) basis when the patient is having a heart attack. In either the elective or primary setting, it involves inserting a thin, pliable catheter into a major blood vessel of the arm or leg and manipulating the tip of the catheter to the heart. Then a balloon or mechanical stent at the tip of the catheter is used to reopen blocked or partially blocked arteries and restore blood flow to the heart muscle. When the procedure is done in appropriate patients, the benefit can be great.
Department regulations state that PCI may be performed only in a hospital that has an open heart surgery program onsite. This is a safety measure to deal with possible complications that may be severe enough to require emergency open heart surgery. Over recent years, however, PCI has evolved and improved so that such complications do not occur as frequently as they once did. In any event, Department regulations allow PCI to be done in any hospital without a formal PCI program and open heart surgery program onsite if it is an emergency situation.
Over the years, hospitals have petitioned the Department to waive the regulations requiring onsite open heart surgery as a prerequisite to offering PCI to their patients. The premise is that access to the benefits of PCI should not be denied to patients in as convenient a location as possible. To explore the notion of improving access to care, a decision was made to allow PCI without onsite cardiac surgery as part of a limited program involving a waiver of Department regulations. The Department has issued an exception procedure outling all the requirements for performing this procedure in a facility without a cardiac surgery unit. Participating hospitals must agree to certain operating conditions that are based on the Accreditation for Cardiovascular Excellence Standards. This includes a formal written agreement for immediate (within one hour) transfer of a patient to a cardiac surgical facility should the need arise. Furthermore, the hospitals’ informed consent form must state that the PCI procedure is being done under a waiver from the Department’s regulations and is not completely supported by the ACC guidelines. Patients considered for elective PCI must also undergo careful screening and risk stratification. Those who cannot meet the selection criteria, and may be more likely to have an adverse outcome, are transferred to a cardiac surgical facility for PCI.
Hospitals in the PCI project must report their performance data to the Department through the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). The Department chose to utilize the NCDR because it is a mature system that has been collecting and analyzing PCI data for many years. Member hospitals are required to fill out a standardized record for every patient who undergoes PCI and submit the raw data to the NCDR. As data is analyzed, a member hospital receives a confidential institutional report on a quarterly and annual basis that addresses various outcomes including success, adverse events and mortality. The report compares a hospital’s performance to an NCDR benchmark, to a national average of all member hospitals, and to a comparison group consisting of hospitals that perform a comparable volume of cardiac catheterization procedures. This comparative data is more robust than if the Department had just collected data from participating facilities. Hospitals in the PCI project must share their institutional reports with the Department.
The Department is using the NCDR reports to monitor outcomes to help prevent or minimize harm to patients while permitting the benefits of PCI to become more widely available.
PCI Exception Committee Procedure
As of October 2017, the following facilities currently
perform elective and emergent PCI without onsite surgery. They have met
the Department of Health’s requirements for 28. PA. Code § 138.15 High Risk
Evangelical Community Hospital
Indiana Regional Medical Center
Meadville Medical Center
Memorial Hospital (York)
Monongahela Valley Hospital
Mount Nittany Medical Center
Riddle Memorial Hospital
Luke’s Hospital – Monroe
UPMC Jameson Hospital
Wayne Memorial Hospital
Wellspan Ephrata Community Hospital