Rapid Cardiology and the One Stop Cardiology Services at ...

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Rapid Cardiology and the One Stop Cardiology Services at ...

  1. 1. Rapid Cardiology and the One Stop Cardiology Services at Charing Cross Hospital Susan Connolly Consultant Cardiologist, Imperial College Healthcare NHS Trust 31st January 2008
  2. 2. Patient Journey Before….. Primary care physician wants help with a patient Writes to local secondary care centre (2/52) Consultant appraises letter Routine OPD 4-6/12 Urgent OPD 2/12 Patient attends OPD Waits 1 hour for 15 - 30 mins with Consultant (or not) Dept of Cardiology, Charing Cross Hospital Imperial College, London
  3. 3. Tests requested To be done over 1 -3 months OPD to review in 6/12 Second OPD Diagnosis made Treatment recommended After 2/52 Sees GP New prescription received Goes to pharmacy 1/52 Starts treatment Total time 13 months Dept of Cardiology, Charing Cross Hospital Imperial College, London
  4. 4. 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! Dept of Cardiology, Charing Cross Hospital Imperial College, London
  5. 5. 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
  6. 6. 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
  7. 7. Are We Clinically Effective ~ 24% diagnosed with likely/definite cardiac pain “RACPC diagnosis of non-cardiac disease had a 98% negative predictive value for the development of a cardiac diagnosis at 1 year” Tenkorang JN, Fox KF et al. Heart 2006;92:10841090 Dept of Cardiology, Charing Cross Hospital Imperial College, London
  8. 8. Why Stop There…. Dept of Cardiology, Charing Cross Hospital Imperial College, London
  9. 9. RATIONALE Rapid Access Heart Rapid Access Arrhythmia Failure Clinic Clinic 1/3 of patients with HF Palpitations common present to GP symptom Dx difficult w/o invx Mostly benign but use High risk patients up “valuable” clinic slot (CHD+) Dx difficult w/o invx Evidence-based Tx available Dept of Cardiology, Charing Cross Hospital Imperial College, London
  10. 10. 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
  11. 11. 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
  12. 12. Source of referrals to a RAAC referral source other A&E referral source Frequency Percent A&E 124 10.1 GP 983 80.4 other 116 9.5 Total 1223 100.0 GP Dept of Cardiology, Charing Cross Hospital Imperial College, London
  13. 13. Diagnosis of Patients Seen in the RAAC Anxiety 22% Extrasystoles 44% Ventricular 3% Conduction disease Rx rate with 5% Warfarin A Fib 74% 26% Dept of Cardiology, Charing Cross Hospital Imperial College, London
  14. 14. 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
  15. 15. Prompt Initiation of Effective Therapies ACE not initated ACE I not 1% initiated 23% ON ACE I ACE I initiated 11% 55% ACE CI 10% KF Fox, MR Cowie, DA Wood, AJS Coats, PA Poole-Wilson, GC Sutton Eur J of Heart Failure 2000;2:423-9 Dept of Cardiology, Charing Cross Hospital Imperial College, London
  16. 16. 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
  17. 17. Patient Satisfaction Questionnaire Patient experience of CX RA Cardiac clinics 3% 8% 2% positive experience (%) negative exp (%) Neutral exp (+ and -) (%) Indeterminate (%) 87% Dept of Cardiology, Charing Cross Hospital Imperial College, London
  18. 18. Rapid Cardiology as a Model for Epidemiological Research Historical precedent The epidemiology of common cardiac diseases in the population Angina, 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
  19. 19. Resources - is it feasible? Population 200 000 Total 5-6/ weekday (but v. variable) Provisional staffing levels Clinician Nurse 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
  20. 20. Rapid Assessment : Pros and Cons Highly effective diagnostic Initial investment in strategy manpower and resources Early diagnosis and risk RCT data on efficacy stratification allows early required and appropriate therapy Specialist assessment for all presenting with cardiac disease in the community Swift reassurance of those without pathology Good indirect evidence of effectiveness Very popular with patients / GPs Dept of Cardiology, Charing Cross Hospital Imperial College, London
  21. 21. Further One-Stop Services - The encapsulated problem Direct performance of the relevant test with report to GP e.g. Mon pm SpR ECHO clinic Classic - The murmur at insurance medical Specialist directed, rather than open access, investigation Dept of Cardiology, Charing Cross Hospital Imperial College, London
  22. 22. Recurrent disease and other problems Recurrent disease may be serious Rapid access clinic style evaluation not appropriate BUT can still use a one stop assessment Make the single visit effective Co-ordinated tests + consultation Assess all the problems Dept of Cardiology, Charing Cross Hospital Imperial College, London
  23. 23. For all with any manifestation of CHD Cardiac Prevention and Rehabilitation Programme (n=262) Specialist nurses trained in assessing patients and Nos. (%) Non-smokers 234 (92%) supporting their recovery Nos. (%) meeting Physical 194 (90%) Co-ordinate physical and activity target mental rehabilitation and Nos. (%) <140/85 mmHg 190 (76%) use of preventive (<130/80 if diabetic) medication Nos. (%) Total Cholesterol 192 (87%) <5 mmol/l All patients reviewed at a Nos. (%) Anti-platelet weekly ‘ward round’ to Therapy 221 (95%) monitor progress Nos. (%) Lipid Lowering 212 (96%) Therapy What does 10mins with an SHO add? Dept of Cardiology, Charing Cross Hospital Imperial College, London
  24. 24. ‘Annual follow up’ Chronic disease is effectively managed in primary care if appropriately supported Empower the patient annual exercise assessment the ‘birthday test’ If an annual echo (or other test) is needed OK - repeat each year no change >>>> repeat if changed >>>> review Dept of Cardiology, Charing Cross Hospital Imperial College, London
  25. 25. Tuesday afternoons at Charing Cross 1999 - 2007 WAS: 34 patients seen between 2pm and 6.30pm NOW: 12 patients seen between 2pm and 5pm - N:Fup >> 1 1999 2003 2007 Dept of Cardiology, Charing Cross Hospital Imperial College, London
  26. 26. 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
  27. 27. At CXH Dept of Cardiology Individuals ….. Are Crucial Do today’s work today Are flexible Have busy days and less busy days Trust each other But this needs time, effort and constant reinforcement Dept of Cardiology, Charing Cross Hospital Imperial College, London
  28. 28. So what should I think about… Changing systems Changing people BIG BANG v sub-radar Stakeholders Timing Individuals matter Early gains Leadership Demand management Belief Feedback Trust Incentives Dept of Cardiology, Charing Cross Hospital Imperial College, London
  29. 29. Summary 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 Dept of Cardiology, Charing Cross Hospital Imperial College, London

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