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  • 1. The NSF for CHD Chapter 8 - some issues and some possible solutions: Setting up and running a (rapid access) arrhythmia clinic Kevin Fox Department of Cardiology, Hammersmith Hospitals NHS Trust at Charing Cross Hospital
  • 2. Key challenges in Ch 8 Effective diagnosis of arrhythmias Effective treatment for arrhythmias (RFA, PPM,,,) Effective diagnosis and care for patients and relatives of those with SCD Effective support for patients, relatives and carers with arrhythmias Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 3. A possible solution to the first challenge.. The Charing Cross Rapid Access Arrhythmia Clinic Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 4. A Rapid Access Arrhythmia Clinic Model GP wants help with a patient Refers to RAAC Patient seen same / next working day (no appointment needed) Patient is assessed Hx, EX, ECG +/- Holter / Echo / ETT Diagnosis established Treatment commenced Or patient is reassured Total time 48 hrs! Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 5. But does the model work?
  • 6. Initial diagnosis and diagnosis at 1 yr in a cohort of patients seen in the RAAC clinic (consenters) Card 1 yr Poss Not card Total Card 1yr 1 yr Card ini 96 0 35 131 Poss Card ini 1 2 23 26 Not card ini 5 2 244 251 Total 102 4 302 408 Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 7. 1 year mortality data Cardiac deaths Non-cardiac Total deaths deaths Definite 1 3 4 arrhythmia (0.07%) (2%) (3%) N = 132 Possible or not 0 2 2 arrhythmia (0%) (0.06%) (0.06%) N = 322 Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 8. Cardiac Outpatients visits in the year after RAAC visit Not cardiac Cardiac cardiac OP for cardiac problem cardiac OP for cardiac problem Frequency Percent Frequency Percent yes 26 17.0 yes 33 55.0 no 127 83.0 no 27 45.0 Total 153 100.0 Total 60 100.0 cardiac OP for cardiac problem cardiac OP for cardiac problem no yes yes no Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 9. Visits to GP in year following RAAC visit Not cardiac Cardiac 140 50 120 40 100 80 30 60 20 40 Frequency Frequency 10 20 0 0 0 1 2 3 4 6 10 0 2 3 4 6 8 11 Number of visits to GP for cardiac symptoms Number of visits to GP for cardiac symptoms Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 10. Tuesday afternoons at Charing Cross 1999 - 2003 WAS: 34 patients seen between 2pm and 6.30pm NOW: 12 - 20 patients seen between 2pm and 5pm Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 11. Setting up a RAAC Primary care Anticoagulant services Clin Physiology Neurology / Cof E Involve stakeholders But don’t be put off by them Patients Managers Clin Chemistry etc. Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 12. Setting up a RAAC cont. Referral criteria Mode of referral Operational times Space Staffing The patient journey Clinical assessment algorithms Management algorithms Data recording and communication to primary care Follow up Quality control and audit Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 13. Having a system for common presentations Sinus tachycardia SVEs and VE LBBB WPW New AF Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 14. Cases seen in the CX RAAC 160 120 Number of cases seen per month Frequency 80 60 40 0 40 0 1 2 3 4 5 6 7 Frequency Number of patients seen per day 20 0 Nov Dec Jan Feb Mar Apr May Jun Jul AugSep Oct Nov Dec Jan Feb Mar Apr May Jun Jul AugSep Oct Nov Dec Jan Feb 1999 1999 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2001 2000 2001 2001 2001 2001 2001 2001 2001 2001 2001 2001 2001 2002 2002 Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 15. Volume of referrals in a RAAC The combined CXH Rapid Cardiology Clinics (population served 150 000 - 200 000) Rapid Access Clinics at Charing Cross Hospital Chest pain Heart Failure Arrhythmia No. seen / week 20 3 15 No. seen /100,000 2 0.3 1.6 population/weekday No significant pathology (%) 71 64 63 Significant cardiac disease % 29 36 37 Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 16. Typical experience of a RAAC - referral source referral source referral source other A&E Frequency Percent A&E 124 10.1 GP 983 80.4 other 116 9.5 Total 1223 100.0 GP Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 17. Age of attendees at a RAAC decade age Age of attendees 160 140 120 100 decade age 80 RACPC 60 120 40 F requenc y 20 100 0 20 30 40 50 60 70 80 90 decade age 80 60 decade age 50 40 Frequency 40 20 30 0 20 RAHFC 10 20 30 40 50 60 70 80 90 F requ enc y 10 decade age 0 10 30 40 50 60 70 80 90 decade age Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 18. Ix used in 984 patients attending the Cx RAAC Number (%) ECG 984 (100%) Blood tests 955 (97%) Holter monitoring 912 (93%) Echocardiography 311 (32%) Chest radiography 187 (19%) Exercise stress test 119 (12%) Event recorder 52 (5%) Tilt test 16 (2%) Further management Discharged to general practitioner 659 (67%) Followed up in conventional cardiology clinic 242 (25%) Referred to specialist arrhythmia clinic 83 (8%) Admitted to hospital 22 (2%) Referred for pacemaker 21 (2%) Referred for coronary angiography 9 (1%) Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 19. Diagnosis of patients seen in the RAAC Heart block P. atrial tachy 12 (3%) 11 (3%) NSVT 3 (1%) Junctional reentrant tachy 20 (6%) No significant AF/Flutter 93 arrhythmia (27%) detected 211 (60%) Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 20. We are often asked: What’s the secret of our success? THERE IS NO SECRET! Trust the epidemiology Today’s work today Be flexible Sort the problem out NOW Say THANK YOU and feedback the positives But actually the team see the positives very quickly Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 21. How do you make the change? Start small Have a ‘champion’ Believe You don’t need huge resource Delays and waits are inefficient Build trust Gather together arrhythmia referrals Run the clinic in parallel with a standard OPD Limit range of referrals or geographical area / practices Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 22. Next steps Wide discussion of the NSF Ch8 Sharing effective models of care Co-ordinated introduction of change Sensitive to local needs Sensitive to the needs of the sector Sensitive to the challenges of introducing change But change is achievable Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
  • 23. Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital