Dr. Niall Herity:

Towards the end of May 2016, I was asked by the Minister for Health to undertake an independent clinical review of provision of a second cardiac catheterisation laboratory, also known as a cath lab, at University Hospital Waterford, UHW. The terms of reference were as listed in the published final report, which the committee has received. Following preparatory work, I visited UHW on 7 June, Cork on 16 June and had separate detailed meetings with representatives of the acute coronary syndrome, ACS, programme, the Department of Health, the national ambulance service and the Health Service Executive.

I applied the following principles to the work: the primary concern is the quality of care that patients receive; conclusions and recommendations will be driven by data; and conclusions and recommendations will reflect scientific evidence as summarised in the published guidelines of relevant professional bodies. The terms of reference required me to assess the needs of two distinct groups of patients, those undergoing planned, non-emergency procedures - approximately 96% of the patients - and those undergoing an emergency procedure called primary PCI, amounting to approximately 4% of the patients. Regarding the 96% of patients who required planned, non-emergency procedures, my analysis indicated that the effective catchment population for the UHW cath lab was 286,147. The cath lab procedural needs of this population could be accommodated in 12 weekly cath lab sessions of four hours each. Hence, a second cardiac catheterisation laboratory at UHW was not justified on this basis.

I made the following recommendations. The range of planned cath lab work that UHW currently undertakes for its catchment population should continue. The cath lab service at UHW should be funded and staffed to provide 12 sessions of planned cath lab activity weekly. A contingency for radiological equipment failure during a procedure, such as a portable fluoroscopy unit with an image intensifier, should be established if it is not in place already. The cardiology services in the south-south west hospital group, and especially the teams at UHW and Cork University Hospital, CUH, should agree a strategy that makes best use of their combined excellent skills, cath lab facilities and teams in order to optimise clinical outcomes for all of the patients across the hospital group.

Regarding the 4% of patients who undergo emergency procedures, I concluded that the limited-hours, daytime primary PCI service at UHW does not meet the British Cardiovascular Intervention Society, BCIS, minimum standard of 100 cases per year. BCIS has since updated its guidance and the absolute minimum standard is now 150 cases per year unless there is extreme geographical isolation. The updated BCIS guidance has been made available to the committee.

It was, and remains, my opinion that expanding the service to provide 24-7 cover is not a sustainable solution. Of the options available to resolve this situation, I concluded that UHW should cease the provision of primary PCI and that the interventional management of patients with ST elevation myocardial infarction, STEMI, from this region should be consolidated in CUH and St. James's Hospital, Dublin.

I made the following recommendations. The current limited-hours provision of primary PCI at UHW should cease so as to allow the centre to focus on the much larger volume of planned cath lab work. Patients arriving to the emergency department at UHW should be considered as within a 90-minute drive time of CUH and should be transferred there for primary PCI without delay, irrespective of the time of day or night. The interventional cardiologists at UHW should continue to make their primary PCI skills accessible for the benefit of patients by taking part in the 24-7 primary PCI rota centred in CUH. A group of local clinical stakeholders, including representatives of the ambulance service, should review the current operation of the optimal reperfusion protocol for patients with STEMI in the south east who are more than a 90-minute drive from a 24-7 primary PCI centre. The group should design the best future reperfusion protocol for these patients and should be led by the ACS programme of the HSE.