Rapid Cardiology


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Rapid Cardiology

  1. 1. Rapid Cardiology and the one stop cardiology services at Charing Cross Hospital Kevin Fox Hammersmith Hospitals NHS Trust and Imperial College, London
  2. 2. A Rapid Access Clinic Model GP wants help with a patient Refers to RAC 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!
  3. 3. The Charing Cross Hospital Rapid Cardiology Service <ul><li>Rapid Access Chest Pain Clinic </li></ul><ul><li>Rapid Access Arrhythmia Clinic </li></ul><ul><li>Rapid Access Heart Failure Clinic </li></ul><ul><li>First presentations of suspected angina, tachy or bradyarrhythmia, or heart failure </li></ul><ul><li>Clinic runs each weekday morning, no appointments necessary – just a referral note from GP, A and E… </li></ul>
  4. 4. The Rapid Cardiology Service <ul><li>Approx 30-40 patients / week </li></ul><ul><li>Electronic record and computer generated letters </li></ul><ul><li>Staffing: </li></ul><ul><li>Nurse Practitioner- enhanced role particularly with RACPC patients History/physical measurements/exercise testing </li></ul><ul><li>Clinical Fellow - medical supervision of the day’s clinics with responsibility for diagnosis and management </li></ul><ul><li>Clinical measurement (and admin) support </li></ul>
  5. 5. The combined Rapid Cardiology Clinics (population served 150 000 - 200 000)
  6. 6. Source of referrals to a RAAC
  7. 7. One stop services for recurrent disease and other problems <ul><li>Recurrent disease may be serious. </li></ul><ul><li>However: </li></ul><ul><li>It’s difficult to add years e.g. post CABG angina </li></ul><ul><li>Rapid access clinic style evaluation not appropriate </li></ul><ul><li>BUT can still use a one stop assessment </li></ul><ul><li>co-ordinated tests + consultation </li></ul><ul><li>Make the single visit effective </li></ul><ul><li>Assess all the problems </li></ul><ul><ul><li>don’t leave a BP of 142 / 86 </li></ul></ul>
  8. 8. Further one-stop services - The encapsulated problem <ul><li>The murmur at insurance medical </li></ul><ul><li>Possible white coat hypertension </li></ul><ul><li>Direct performance of the relevant test with report to GP </li></ul><ul><li>e.g. Mon pm SpR echo session </li></ul><ul><li>Specialist directed, rather than open access, investigation </li></ul>
  9. 9. Tuesday afternoons at Charing Cross 1999 - 2003 <ul><li>WAS: 34 patients seen between 2pm and 6.30pm </li></ul><ul><li>NOW: 12 - 20 patients seen between 2pm and 5pm </li></ul>
  10. 10. What about outcomes?
  11. 11. Rapid Cardiology Follow up Study <ul><li>One Year follow up study </li></ul><ul><li>Hypothesis : </li></ul><ul><li>Rapid Cardiology clinics promptly diagnose and effectively manage patients with first presentation of coronary heart disease, significant arrhythmia and heart failure. </li></ul><ul><li>(And this is cost effective) </li></ul><ul><li>Study supported by the CHD Collaborative </li></ul>
  12. 12. Methods <ul><li>940 consenting patients seen between November 2002 and October 2003 </li></ul><ul><li>Follow up questionnaire study sent at 1 year </li></ul><ul><li>Further follow up of patients through hospital datasets, GP questionnaires, ONS flagging </li></ul>
  13. 13. All patients - initial versus final diagnosis
  14. 14. Rapid Access Cardiology Clinics Initial diagnosis and diagnosis at 1 yr 731 617 61 53 Not card 1 yr 940 22 187 Total 631 2 12 Not card ini 104 18 25 Poss Card ini 205 2 150 Card ini Not card 1yrTotal Poss Card 1yr Card 1 yr
  15. 15. Key Points – PPV of diagnosis <ul><li>Positive predictive value of a non cardiac diagnosis is 98% </li></ul><ul><li>Positive predictive value of a cardiac diagnosis is 76% </li></ul><ul><li>4% ‘Cross-over’ patients (i.e. those referred to the ‘wrong clinic’) </li></ul>
  16. 16. 1 year mortality data <ul><li>There were 26 (10 cardiac) deaths amongst the cohort of 940 patients </li></ul><ul><li>Initial diagnosis ‘cardiac’ </li></ul><ul><ul><li>Cardiac mortality for those diagnosed initially with cardiac disease was 7/205 (3.4%) </li></ul></ul><ul><li>Initial diagnosis ‘possible or not cardiac’ </li></ul><ul><ul><li>Cardiac mortality for those with non-cardiac/possible diagnosis 3/735 (0.4%). </li></ul></ul>
  17. 17. Cardiac Outpatients visits – ‘ Definite’ versus ‘Not cardiac ’
  18. 18. Visits to GP Definite Not cardiac
  19. 19. Patient satisfaction questionnaire
  20. 20. What’s the secret of our success? <ul><li>THERE IS NO SECRET! </li></ul><ul><li>Trust the epidemiology </li></ul><ul><li>Today’s work today </li></ul><ul><li>Be flexible </li></ul><ul><li>Say YES not NO </li></ul><ul><li>Sort the problem out NOW </li></ul><ul><li>Say THANK YOU and feedback the positives </li></ul>
  21. 21. Rapid Cardiology Questions <ul><li>Does it need a ‘doctor’? </li></ul><ul><li>Does it need to be in secondary care? </li></ul><ul><li>Is it cost effective? </li></ul><ul><li>How should the service be introduced? </li></ul>
  22. 22. Rapid assessment : pros and cons <ul><li>Highly effective diagnostic strategy </li></ul><ul><li>Facilitates prompt initiation of appropriate therapy </li></ul><ul><li>Provides a specialist assessment for all patients presenting with cardiac disease in the community </li></ul><ul><li>Swift reassurance of those without pathology </li></ul><ul><li>Expanding evidence of effectiveness </li></ul><ul><li>Very popular with patients / GPs </li></ul><ul><li>Initial investment in reengineering manpower and resources </li></ul><ul><li>RCT data on efficacy not available </li></ul>
  23. 23. Referrals following opening of the CX RAAC
  24. 24. Resources - is it feasible? <ul><li>Population 200 000 </li></ul><ul><ul><li>Total 8 / weekday (but v. variable) </li></ul></ul><ul><li>Provisional staffing levels </li></ul><ul><ul><li>Clinician </li></ul></ul><ul><ul><li>Nurse Practitioner (ETT +/- Echo) </li></ul></ul><ul><ul><li>Technician (ECG, ETT, Echo, Holter) </li></ul></ul><ul><ul><li>Administrative support </li></ul></ul><ul><li>Significant proportion of total OPD workload dealt with </li></ul><ul><ul><li>(and the great majority of new OPDs) </li></ul></ul>
  25. 25. Diagnosis of patients seen in the RAAC
  26. 26. Diagnostic pattern seen in the Bromley RAHFC (393 cases over 15 months)
  27. 27. Age distribution RAAC RACPC RAHFC
  28. 28. Outline structure of cardiology services at CXH: Population: High CAD risk Healthy Newly Symptomatic Prevalent disease Screening + Prevention services GP CCU + Secondary care in-patient services 999 / A+E Rapid assessment for chest pain / heart failure / arrhythmia / Other Specialist clinics: CAD / HF / Rhythm / Valve / ACHD Tertiary care (surgery, revascularisation, pacing, electrophysiology, transplantation) The community heart failure team 1 o PCI
  29. 29. Final Diagnosis in patients initially diagnosed 'non cardiac'
  30. 30. All responders - symptom severity