Dossier n. 196/2010 [Abstract] Evolution of Intensive Cardiac Care Units (ICCUs) in Emilia-Romagna Region. Empirical analysis after the implementation of the integrated network for the management of patients with ST-Elevation Myocardial Infarction

In the last few years, one of the challenges the Emilia-Romagna Region has dealt with is the great transformation process involving cardiac care and, consequently, health services committed to acute and chronic cardiovascular disease treatment.

In particular, the Intensive Cardiac Care Units (ICCUs), set up in the 60s to assure early diagnosis and the complications treatment of Acute Myocardial Infarction (AMI), have deeply changed their profile thanks to two factors:

• the spread of coronary reperfusion therapy (thrombolysis and angioplasty) in routine clinical practice;
• the population ageing that gave rise to the need for multidisciplinary competences and innovative technological approach to chronic disease.

According to the Regional Health Plan 1999-2001, the Emilia-Romagna region has formalized in 2003 the integrated network for the management of patients with ST-Elevation Myocardial Infarction (AMI/STEMI) based on the Hub and Spoke model, with the aim to promote and support evidence-based treatments, timely interventions and mortality reduction (PRIMA-RER project).

Within this network, the ICCU has become the reference framework for acute and chronic coronary heart diseases and, on the basis of the healthcare needs complexity, it has been differentiated in: a) “Hub” ICCU, equipped with catheterization laboratory, primarily devoted to assure reperfusion strategies and AMI complications management, and b) “Spoke” ICCU, covering the role of “junction” within the network, devoted to the management of acute cardiovascular diseases that do not need revascularization.

This report offers a descriptive analysis - based mostly on Hospital Discharge Records (HDR) data -for the years 2002-2009, aimed at assessing the Emilia-Romagna ICCUs reorganization process as a result of the PRIMA-RER project.

The empirical analysis is focused on the trend of admissions to hospitals with an ICCU. Considering both the regional overall volume and each Health Trust and ICCU activity data, the following items have been considered:

• the case study diagnosis composition: STEMI, Non STEMI and Non Acute Coronary Syndromes;
• the care paths: transfer among Hub and/or Spoke hospitals.

These analyses demonstrate the possibility to investigate care paths for selected patients within the Regional Health Service and highlights how the inter-hospital network development has led to relevant clinical outcomes: a significant increase in primary PCI (+51.7%) and in the number of SCA patients entering the network (79%) and a mortality decrease (STEMI - 2.7% on a 30 days period, -3% on a 1 year period). Moreover, they show how this process has influenced the relationship among the network’ junctions and modified the patients’ path within it, resulting in important implications on healthcare organization. As a matter of fact, the “fast” direct access path to the catheterization laboratory for STEMI, has determined an increase in the number of patients admitted (+19.8%) into the “Hub” ICCUs, and a steady decrease in those admitted in the “Spoke” ICCUs (in 2009, 19%).

As these transformations have deeply modified cardiac care, particularly in the “Spoke” ICCUs, it is necessary to redefine both the role and functions of ICCUs and the activities and skills of cardiologists dedicated to.

This report aims to offer to Local Health Trusts stimulus for reflection on the evolution of the cardiology Intensive Care Units following the set up of the STEMI care network and to provide a useful tool to assess the performance of health trusts involved in the process. To sum up, the report contributes to "… reconsider some of the functions and working ways in hospitals, according to the Regional Health Service planning lines for 2009".