All Wales Chest Pain ClinicAll Wales Chest Pain ClinicAll Wales Chest Pain Clinic All Wales Chest Pain Clinic AuditAudit

Lucy TrentLucy TrentLucy TrentLucy TrentIndependent Nurse Practitioner in CardiologyIndependent Nurse Practitioner in Cardiology

Betsi Cadwaladr University Health BoardBetsi Cadwaladr University Health Board

B k dB k dBackgroundBackground

•• RACPC RACPC –– ‘‘a patient pathway for the Assessment, a patient pathway for the Assessment, In estigation T eatment and A dit of the ca e of thoseIn estigation T eatment and A dit of the ca e of thoseInvestigation, Treatment and Audit of the care of those Investigation, Treatment and Audit of the care of those presenting with suspected CHD and those with stable presenting with suspected CHD and those with stable angina’angina’angina angina –– Tackling CHD in Wales: Implementing Through Evidence (2001) Tackling CHD in Wales: Implementing Through Evidence (2001)

ETT i RACPCETT i RACPCETT in RACPCETT in RACPC

•• Two rolesTwo roles–– Diagnostic (imperfect)Diagnostic (imperfect)–– Prognostic (risk stratification)Prognostic (risk stratification)g ( )g ( )

•• Little use in lowLittle use in low--risk & nonrisk & non--classical classical presentations (especially females)presentations (especially females)presentations (especially females)presentations (especially females)

•• Historically a lack of other options!Historically a lack of other options!•• Worked well in the right contextWorked well in the right context

2010201020102010•• Chest Pain of Recent Onset Chest Pain of Recent Onset –– NICE 2010NICE 2010

““D t i ECG t diD t i ECG t di–– ““Do not use exercise ECG to diagnose or Do not use exercise ECG to diagnose or exclude stable angina for people without exclude stable angina for people without k CAD”k CAD”known CAD”known CAD”

I t f h b tI t f h b tImpetus for change but …..Impetus for change but …..

•• WHSCC model (2012) predicted an annual WHSCC model (2012) predicted an annual revenue cost per year for North Wales of revenue cost per year for North Wales of .

e e ue cost pe yea o o t a es oe e ue cost pe yea o o t a es o£2,842,786 to change from the clinical £2,842,786 to change from the clinical history / treadmill testing model to thehistory / treadmill testing model to thehistory / treadmill testing model to the history / treadmill testing model to the NICE Model for investigating stable chest NICE Model for investigating stable chest

iipain per yearpain per year

Still l f ETTStill l f ETT i i ht t ti i ht t tStill place for ETT Still place for ETT –– in right contextin right context

•• Exercise testing …… is important both to provide Exercise testing …… is important both to provide objective confirmation of exercise inducedobjective confirmation of exercise inducedobjective confirmation of exercise induced objective confirmation of exercise induced ischaemia and as an independent indicator of ischaemia and as an independent indicator of prognosisprognosisprognosisprognosis

–– De Bono 1999De Bono 1999

•• “Because of its simplicity and widespread“Because of its simplicity and widespread•• Because of its simplicity and widespread Because of its simplicity and widespread availability, treadmill or bicycle exercise testing, availability, treadmill or bicycle exercise testing, using 12using 12 lead ECG monitoring remains a usefullead ECG monitoring remains a usefulusing 12using 12--lead ECG monitoring, remains a useful lead ECG monitoring, remains a useful option”option”

ESC 2013ESC 2013–– ESC 2013ESC 2013

A ditA ditAuditAudit

•• What's happening across WalesWhat's happening across Wales•• Do we follow guidelines?Do we follow guidelines?•• Forms sent to 6 trusts across Wales 8Forms sent to 6 trusts across Wales 8•• Forms sent to 6 trusts across Wales, 8 Forms sent to 6 trusts across Wales, 8

forms returnedforms returned•• Thanks toThanks to

–– Sue Yorwerth, Clinical Audit, WrexhamSue Yorwerth, Clinical Audit, Wrexham–– Audit Depts and clinicians across WalesAudit Depts and clinicians across Wales

Clinic capacityClinic capacity

•• 1 1 –– 6 clinics per week 6 clinics per week •• 3 3 –– 5 patients per clinic 5 patients per clinic

Average waiting times (days)

4

Average waiting times (days)

22.5

33.5

4

no of

00.5

11.5

2clinics

No of clinics0<7 7

to15to

22to

>28No of clinics

14 21 28

time

M ( !)M ( !)Manpower (or woman power!)Manpower (or woman power!)

Nurse1 NursePractitionerCardiologist +1

1

gRegCardiologist +5

1 Spec NurseNP + CardiacPh i l i t

1

Physiologist

N /Ph i l i t L d S i ( 6)N /Ph i l i t L d S i ( 6)Nurse/Physiologist Led Services (n=6)Nurse/Physiologist Led Services (n=6)

•• 4 clinics run autonomously4 clinics run autonomously•• 2 run alongside Cardiologist Clinics2 run alongside Cardiologist Clinics

•• All have a NonAll have a Non--Medical prescriberMedical prescriber

G id li iG id li iGuidelines in useGuidelines in use

NICE +Local

Local

ESCNo of clinics

NICE

0 2 4 6 8

NICE

0 2 4 6 8

A il bl t tA il bl t tAvailable testsAvailable testsSt h

CTCA

Stress echo

CTCS

CTCA

No of clinics

ETT

MPI

0 5 10

NB. 1 clinic outsources CTCS/CTCA to Bupa, only 1 clinic offers all 5 tests, 1 clinic only has access to ETT and stress echo

W iti ti f i ti tiWaiting times for investigations

3 54 <1

2.53

3.52 to 45 t 8

1.52

2.5No of clinics 5 to 8

9 to 12

00.5

19 to 12>12

0MPI ETT CTCS CTCA SE

T tTest

Discharge from clinic withDischarge from clinic withDischarge from clinic withDischarge from clinic withno further investigationsno further investigations

70

60

70

50

30

40% discharged

20

30 g

0

10

01 2 3 4 5 6 7 8 Mean – 29%

% of patients having each investigation% of patients having each investigation

SE8

CTCS876

CTCA65

MPI 43

Angio32

ETT 1

0 20 40 60 80 100

Snapshot audit 2010Snapshot audit 2010Snapshot audit 2010Snapshot audit 2010in Wrexham using PTPin Wrexham using PTP

•• CT calcium scoring/CTCA CT calcium scoring/CTCA -- 26% (16)26% (16)

•• Functional Imaging Functional Imaging -- 14% (31)14% (31)

•• Invasive Coronary angiographyInvasive Coronary angiography -- 60% (3)60% (3)•• Invasive Coronary angiography Invasive Coronary angiography -- 60% (3)60% (3)

P blP blProblems Problems

•• Variable access to testingVariable access to testingU bl t f ll NICEU bl t f ll NICE–– Unable to follow NICEUnable to follow NICE

•• Rapid Access is not Rapid anymore! Rapid Access is not Rapid anymore! –– 6 clinics report >21 day waiting time for RACPC appt6 clinics report >21 day waiting time for RACPC appt–– 1 clinic >12 weeks wait for every test apart from ETT1 clinic >12 weeks wait for every test apart from ETT

•• Challenging financial position inhibits progressChallenging financial position inhibits progress

R d tiR d tiRecommendationsRecommendations

•• Investment in CT is likely to be beneficial Investment in CT is likely to be beneficial as 2013 ESC guidance suggests useful upas 2013 ESC guidance suggests useful upas 2013 ESC guidance suggests useful up as 2013 ESC guidance suggests useful up to PTP of 50%to PTP of 50%D ’ h h b b i h h b hD ’ h h b b i h h b h•• Don’t throw the baby out with the bath Don’t throw the baby out with the bath water water –– Treadmill testing should still be used in Treadmill testing should still be used in

appropriate situations appropriate situations •• symptoms of typical anginasymptoms of typical angina•• moderate PTP (15 moderate PTP (15 –– 65%) 65%) ESC 2013ESC 2013

R d tiR d tiRecommendationsRecommendations

•• Employ more Chest Pain Nurses to Employ more Chest Pain Nurses to i li i iti li i itincrease clinic capacityincrease clinic capacity

•• Innovate to reduce referrals to RACPCInnovate to reduce referrals to RACPCo ate to educe e e a s to C Co ate to educe e e a s to C C–– Formalise triage of referralsFormalise triage of referrals

Links/education with GPsLinks/education with GPs–– Links/education with GPsLinks/education with GPs–– Community based Chest Pain Nurse Community based Chest Pain Nurse

•• see Dr Graham Thomas GPwSIsee Dr Graham Thomas GPwSI

Thank youThank youThank you Thank you Any questions? Any questions?