Post on 22-Nov-2014
description
Rapid Cardiologyand the One Stop Cardiology Services at
Charing Cross Hospital
Susan ConnollyConsultant Cardiologist, Imperial College
Healthcare NHS Trust31st January 2008
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Patient Journey Before…..
Patient attends OPDWaits 1 hour for
15 - 30 mins with Consultant (or not)
Consultant appraises letterRoutine OPD 4-6/12
Urgent OPD 2/12
Primary care physician wants help with a patientWrites to local secondary care centre (2/52)
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Starts treatmentTotal time13 months
After 2/52 Sees GPNew prescription receivedGoes to pharmacy 1/52
Second OPDDiagnosis made
Treatment recommended
Tests requested To be done over 1 -3 months
OPD to review in 6/12
Dept of Cardiology, Charing Cross Hospital Imperial College, London
A Rapid Access Clinic Model
GP wants help with a patientRefers to RAC
Patient seen same / next working day (no appointment needed)
Patient is assessed Hx, EX, ECG+/- Holter / Echo / ETT
Diagnosis establishedTreatment commencedOr patient is reassured
Total time 48 hrs!
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid Access Chest Pain Clinics
NSF- Standard eight: People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events
NSF states that a RACPC is an “appropriate method”for delivering systematic care
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The Rapid Cardiology Service: CXH
Approx 50 patients/month
Led by Nurse Practitioner- enhanced role
Clinical assessment including ECG, labs +/- ETT +/- myoview etc
Booked for angio (if indicated) and referred to CPRP that day
NB Electronic DB and computer generated letters that day
Liaises with Clinical Fellow
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Are We Clinically EffectiveAre We Clinically Effective
~ 24% diagnosed with likely/definite cardiac pain
““RACPC diagnosis of nonRACPC diagnosis of non--cardiac cardiac disease had a 98% negative predictive disease had a 98% negative predictive value for the development of a value for the development of a cardiac diagnosis at 1 yearcardiac diagnosis at 1 year””
Tenkorang JN, Fox KF et al. Heart 2006;92:10841090
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Why Stop ThereWhy Stop There……..
Dept of Cardiology, Charing Cross Hospital Imperial College, London
RATIONALERATIONALE
Rapid Access Heart Failure Clinic
1/3 of patients with HF present to GPDx difficult w/o invxHigh risk patients (CHD+)Evidence-based Txavailable
Rapid Access Arrhythmia Clinic
Palpitations common symptomMostly benign but use up “valuable” clinic slotDx difficult w/o invx
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The RAAC and RAHFC: CXH
Led by Clinical Fellow
If RAHFC – clinical assessment, ECG, CXR, BNP +/- ECHO
If RAAC – clinical assessment, ECG, Holter/Event Recorder, ECHO if abnormal exam/ECG
NB Electronic DB and computer generated letters that day
Referral to EP Doc or back to GP
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The Rapid Access Arrhythmia: CXH
Approx 40 patients/month
Led by Clinical Fellow
Clinical assessment, ECG, Holter/Event Recorder, ECHO if e.g. a fib
NB Electronic DB and computer generated letters that day
Triaged appropriately i.e. Referral to EP Doc or back to GP
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Source of referrals to a RAACSource of referrals to a RAAC
referral source
other
GP
A&E
referral source
124 10.1983 80.4116 9.5
1223 100.0
A&EGPotherTotal
Frequency Percent
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Diagnosis of Patients Seen in the Diagnosis of Patients Seen in the RAACRAAC
A Fib26%
Conduction disease
5%
Ventricular3%
Anxiety22%
Extrasystoles44%
Rx rate with Warfarin74%
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The Rapid Access Heart failure Clinic: CXH
3-5 patients per week
Led by Clinical Fellow
Clinical assessment, ECG, CXR, labs including BNP +/- ECHO
NB Electronic DB and computer generated letters that day
Referral to HF nurse/HF Clinic
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Prompt Initiation of Effective TherapiesPrompt Initiation of Effective Therapies
KF Fox, MR Cowie, DA Wood, AJS Coats, PA Poole-Wilson, GC SuttonEur J of Heart Failure 2000;2:423-9
ACE I not initiated
23%
ON ACE I11%
ACE I initiated55%
ACE CI10%
ACE not initated
1%
Dept of Cardiology, Charing Cross Hospital Imperial College, London
The Combined Rapid Cardiology Clinics(population served 150 000 - 200 000)
Rapid Access Clinics at Charing Cross Hospital
Chest pain Heart Failure Arrhythmia
No. seen / week 12 3 10
No significant pathology (%) 80 64 63
Significant cardiac disease % 20 36 37
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Patient Satisfaction QuestionnairePatient Satisfaction Questionnaire
Patient experience of CX RA Cardiac clinics
87%
2%8% 3%
positiveexperience (%)negative exp (%)
Neutral exp (+and -) (%)Indeterminate (%)
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid Cardiology as a Model for Rapid Cardiology as a Model for Epidemiological ResearchEpidemiological Research
Historical precedent
The epidemiology of common cardiac diseases in the populationAngina, Heart Failure, AF
The clinical course of incident cardiac disease
Models of care for patients presenting with suspected cardiac disease
Is rapid access best?What happens to rapid cardiology patients?
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Resources Resources -- is it feasible?is it feasible?Population 200 000
Total 5-6/ weekday (but v. variable)
Provisional staffing levelsClinicianNurse Practitioner (ETT +/- Echo)Cardiac Physiologist (ECG, ETT, Echo, Holter)
Administrative support
Significant proportion of total OPD workload dealt with (and the great majority of new OPDs)
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Rapid Assessment : Pros and ConsRapid Assessment : Pros and ConsInitial investment in manpower and resourcesRCT data on efficacy required
Highly effective diagnostic strategyEarly diagnosis and risk stratification allows early and appropriate therapySpecialist assessment for all presenting with cardiac disease in the communitySwift reassurance of those without pathologyGood indirect evidence of effectiveness Very popular with patients / GPs
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Further OneFurther One--Stop ServicesStop Services-- The encapsulated problemThe encapsulated problem
Direct performance of the relevant test with report to GPe.g. Mon pm SpR ECHO clinicClassic - The murmur at insurance medicalSpecialist directed, rather than open access, investigation
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Recurrent disease and other problemsRecurrent disease may be
serious
Rapid access clinic style evaluation not appropriate
BUT can still use a one stop assessmentMake the single visit effectiveCo-ordinated tests + consultationAssess all the problems
Dept of Cardiology, Charing Cross Hospital Imperial College, London
For all with any manifestation of CHDFor all with any manifestation of CHDCardiac Prevention and Rehabilitation Programme
Specialist nurses trained in assessing patients and supporting their recoveryCo-ordinate physical and mental rehabilitation and use of preventive medicationAll patients reviewed at a weekly ‘ward round’ to monitor progress
What does 10mins with an SHO add?
(n=262)
Nos. (%) Non-smokers 234 (92%)
Nos. (%) meeting Physicalactivity target 194 (90%)
Nos. (%) <140/85 mmHg(<130/80 if diabetic) 190 (76%)
Nos. (%) Total Cholesterol<5 mmol/l 192 (87%)
Nos. (%) Anti-plateletTherapy 221 (95%)
Nos. (%) Lipid LoweringTherapy 212 (96%)
Dept of Cardiology, Charing Cross Hospital Imperial College, London
‘‘Annual follow upAnnual follow up’’
Chronic disease is effectively managed in primary careif appropriately supported
Empower the patientannual exercise assessmentthe ‘birthday test’
If an annual echo (or other test) is neededOK - repeat each year
no change >>>> repeatif changed >>>> review
Dept of Cardiology, Charing Cross Hospital Imperial College, London
Tuesday afternoons at Charing Cross 1999 - 2007
WAS: 34 patients seen between 2pm and 6.30pmNOW: 12 patients seen between 2pm and 5pm - N:Fup >> 1
1999 2003 2007
Dept of Cardiology, Charing Cross Hospital Imperial College, London
A success story for the Rapid Access Chest Pain Clinic on the Dept of Health website
Dept of Cardiology, Charing Cross Hospital Imperial College, London
At CXH Dept of CardiologyIndividuals …..
Are Crucial Do today’s work todayAre flexibleHave busy days and less busy daysTrust each other
But this needs time, effort and constant But this needs time, effort and constant reinforcementreinforcement
Dept of Cardiology, Charing Cross Hospital Imperial College, London
So what should I think about…
Changing people
StakeholdersIndividuals matterLeadershipBeliefFeedbackTrustIncentives
Changing systems
BIG BANG v sub-radarTimingEarly gainsDemand management
Dept of Cardiology, Charing Cross Hospital Imperial College, London
SummarySummary
Rapid Cardiology services are efficient, effective and popular
It is feasible in a modest sized department
The one stop approach optimises patient journeys
And does not overload departments
The introduction of these services does not require magic
But it does need leadership, planning, demand management, goodwill and ongoing resolve