University Hospital of Wales, Acute Coronary Syndrome

(ACS)Unit.

Innovation and Research-Innovative models of care.

Victoria Williams Cardiology Nurse Practitioner Louise Birch Cardiology Nurse PractitionerMichelle Ball Cardiology Nurse Practitioner

Sarah Barnett Cardiology Nurse Practitioner

Aims of the presentation

• To outline the expanding role of the nurse practitioner within Cardiology at University Hospital of Wales (UHW)

• To Describe and illustrate the development of the role through the establishment of a nurse led Acute Coronary Syndrome (ACS) service, demonstrating innovative ways of working to improve patient care.

Learning Outcomes

• To illustrate the role of the advanced practitioner within Cardiology at UHW

• To understand how the ACS service is run and how successful outcomes have been achieved

• To consider how the role and the service will evolve and develop in the future.

Background of the NP role within Cardiology

• Established in 2010• In response to European work Time

Directive (EWTD)• To streamline the patient Journey• Improve multi-disciplinary

communication• Improve patient outcomes and

satisfaction

• Cardiology Co-ordinator established role since 2004

• Roles merged 2010

• Both practitioners undertaking MSC Advanced Practitioner Pathway

• Team has expanded to include 2 further Part-time positions

• ACS service launched in September 2010.

University Hospital of Wales

• Tertiary Cardiology centre

• Contracted to provide tertiary services to District General Hospitals within south east Wales

Aims of ACS service

• Reduce patient length of stay in both DGH & tertiary centre

• Reduce waiting times for intervention

• Meet European and NICE guidelines

• Improve patient outcomes

• Improve patient journey

Collaborative working

Cardiology Nurse PractitionersCentral point of

contact.Co-ordinating the care pathway from point of referral to discharge.

Electronic referral system

Telephone triage of ACS/Complex

transfers.Advanced Clinical Assessment Skills.

Cardiac Catheter Theatre

Allocated catheter slotsRe-organisation of consultant rota

Flexi sessions to back fill for annual leave/study leave

Cardiology Ward

Protected beds within ward areaHigh turnover of ACS patients

Increased workload and expertise.Collaborative approach between nursing

staff, NPs & MedicsNurse-led discharge protocols.

District General Hospitals

Electronic referral within strict criteriaTraining and education re: ACS protocolsPre-operative workup and investigations

Repatriation of patients awaiting follow on services

Electronic ReferralPlease complete and save with patients name as file name Wales.ACS@wales.nhs.uk

Address:Surname Ref HospForename(s) Ref ConDoB WardNHS no. Ward telHosp no. Weight Kg

ECHO

Age Creat CHFBP Heart Rate ArrestST deviation Troponin DiabetesHypertensionFamily Hist

BLOODS

HbPltWbcTrop I/T

CRPCreatinine

DATE (DD/MM/YYYY)

Free text:

©drf reeman.comFor UHW use

Date on LadderDate and time procedure performed

Accepted byDate and time tranferredWardConsultant

Clexane dose adjustment for renal function?

Smoking PreviousElevated Cholesterol

NO

300mg loading + 75mg maintenance

600mg loading + 75mg Maintenance

None given

REFERRERS DETAILS

Clopidogrel

Aspirin

Prasugrel

Other

2.65

<364

MRSA status (if known)

09/11/2011

ASSESSED AND REFERRED BY? (Full Name)

A Doctor

CONTACT DETAILS (Hosp switch and bleep)

02920 744744 (6565)

1.0 15.0

14.8260

9

Type given

unknown

NO

Risk of Death/MI (%)

In Hospital

To 6 months 4.0 23.0

Risk of Death (%)

50 to <60

Anticoagulation

No

2

Antiplatelets

I (no CHF)60 to <70

RESULTS & TREATMENT

GRACE RISK SCORE

NO

08/11/2011 10:00DD/MM/YYYY HH:MM

awaited

08/11/2011 13:0008/11/2011 13:2009/11/2011 11:00

SYMPTOM ONSET

REFERRAL TO UHW

LOCAL HOSP ARRIVAL

35 to 70

YES Elevated

A123456

PRESENTATION DETAILS

Condition for transfer NSTEACS

79Kg

2/7 hx of intermittent chest pain, initially on exertion, last episode @ rest raditing to Lt arm assoc SOB. ECG inferior TWI. PMH: Nil

CALL FOR HELP

GynaAnne

21 River St, Cardiff, CF123AB

564509/12/1958123456789

Llandough HospitalDr C Pain

CCU

Email with patient name in SUBJECT headingPLEASE NOTE: You are sending confidential patient information, this form should ONLY be sent from an NHS email address

110 to <120

Previous interventions

RISK

Major complications

History/Co-m orbidities

PATIENT DETAILS

University Hospital of Wales

Acute Coronary Syndrome Inpatient Referral form

Please complete and save with patients name as file name Wales.ACS@wales.nhs.uk

Address:Surname Ref HospForename(s) Ref ConDoB WardNHS no. Ward telHosp no. Weight Kg

ECHO

Age Creat CHFBP Heart Rate ArrestST deviation Troponin DiabetesHypertensionFamily Hist

BLOODS

HbPltWbcTrop I/T

CRPCreatinine

DATE (DD/MM/YYYY)

Free text:

Email with patient name in SUBJECT headingPLEASE NOTE: You are sending confidential patient information, this form should ONLY be sent from an NHS email address

130 to <140

Previous interventions CABG (Please include graft details)

RISK

Major complications Tachyarrythmia (not AF) (echo mandatory)

History/Co-m orbidities

PATIENT DETAILS

PainMike

32 craze Rd. Cardiff, CF321ba

564509/12/1978123456789

Llandough HospitalDr C Pain

CCU

141 to 176

YES Elevated

A123456

PRESENTATION DETAILS

Condition for transfer NSTEACS

79Kg

Chest pain.

CALL FOR HELP

08/11/2011 10:00DD/MM/YYYY HH:MM

awaited

08/11/2011 13:0008/11/2011 13:2009/11/2011 11:00

SYMPTOM ONSET

REFERRAL TO UHW

LOCAL HOSP ARRIVAL

70 to <80

Anticoagulation

No

2

Antiplatelets

III (Pulmonary oedema)90 to <100

RESULTS & TREATMENT

GRACE RISK SCORE

YES

9

Type given

unknown

YES

Risk of Death/MI (%)

In Hospital

To 6 months 76.0 86.0

Risk of Death (%)

49.0 62.0

10260

09/11/2011

ASSESSED AND REFERRED BY? (Full Name)

A Doctor

CONTACT DETAILS (Hosp switch and bleep)

02920 744744 (6565)

REFERRERS DETAILS

Clopidogrel

Aspirin

Prasugrel

Other

2.65

45155

MRSA status (if known)

Clexane dose adjustment for renal function?

Smoking PreviousElevated Cholesterol

YES

300mg loading + 75mg maintenance

300mg loading + 75mg Maintenance

None given

For UHW use

Date on LadderDate and time procedure performed

Accepted byDate and time tranferredWardConsultant

©drf reeman.com

University Hospital of Wales

Acute Coronary Syndrome Inpatient Referral form

Advanced clinical skills • All members of the team are at

different stages of their Msc pathway

• We all utilise advanced clinical skills as part of the role to enhance the service.

• Undertaking regular competency based training and assessment

Wider components of the NP role within cardiology

• Co-ordination and organisation of complex patients

• Organisation of in-patient and outpatient pacing calendar

• Reviewing A&E admissions with the Cardiology SPR.

• Assist the junior medical team and nursing staff with ward duties as necessary.

Successful outcomes

• Reduced bed days in DGH and tertiary centre

• Reduced waiting times for intervention• A more streamlined service for patients• Improved communication between all

members of the team• Improved patient satisfaction and less

complaints

Comparative information for ACS patients referred to UHW from DGHs Within the South East Cardiac Network. (Aug 2010/June

2011)

0

2

4

6

8

10

12

14

16

18

20

Average total prereferral days

Averagetotalreferral to transfer

days

Average totalUHW bed days

Average total beddays

no

of

Days

Aug-2010

Jun-2011

The future of the ACS service

• Plans to develop a cardiology assessment ward utilising 19 beds within the directorate

• accommodating all cardiology admissions and transfers

• Development of an assessment tool and pathway to be utilised in A&E by both NPs and SPR

• To streamline in house service

Future of the NP role

• Independent prescribing

• Post intervention clinics

• Ultimately all Msc trained

• first point of contact for the assessment acute and sick patients

• Incorporated into the junior doctor rota.