Rapid Cardiology and the One Stop Cardiology Services at

Rapid Cardiologyand the One Stop Cardiology Services at

Charing Cross Hospital

Susan ConnollyConsultant Cardiologist, Imperial College

Healthcare NHS Trust31st January 2008

Dept of Cardiology, Charing Cross Hospital Imperial College, London

Patient Journey Before…..

Patient attends OPDWaits 1 hour for

15 - 30 mins with Consultant (or not)

Consultant appraises letterRoutine OPD 4-6/12

Urgent OPD 2/12

Primary care physician wants help with a patientWrites to local secondary care centre (2/52)


Starts treatmentTotal time13 months

After 2/52 Sees GPNew prescription receivedGoes to pharmacy 1/52

Second OPDDiagnosis made

Treatment recommended

Tests requested To be done over 1 -3 months

OPD to review in 6/12


A Rapid Access Clinic Model

GP wants help with a patientRefers to RAC

Patient seen same / next working day (no appointment needed)

Patient is assessed Hx, EX, ECG+/- Holter / Echo / ETT

Diagnosis establishedTreatment commencedOr patient is reassured

Total time 48 hrs!


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


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


Are We Clinically EffectiveAre We Clinically Effective

~ 24% diagnosed with likely/definite cardiac pain

““RACPC diagnosis of nonRACPC diagnosis of non--cardiac cardiac disease had a 98% negative predictive disease had a 98% negative predictive value for the development of a value for the development of a cardiac diagnosis at 1 yearcardiac diagnosis at 1 year””

Tenkorang JN, Fox KF et al. Heart 2006;92:10841090


Why Stop ThereWhy Stop There……..


RATIONALERATIONALE

Rapid Access Heart Failure Clinic

1/3 of patients with HF present to GPDx difficult w/o invxHigh risk patients (CHD+)Evidence-based Txavailable

Rapid Access Arrhythmia Clinic

Palpitations common symptomMostly benign but use up “valuable” clinic slotDx difficult w/o invx


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


Referral to EP Doc or back to GP


The Rapid Access Arrhythmia: CXH

Approx 40 patients/month


Clinical assessment, ECG, Holter/Event Recorder, ECHO if e.g. a fib


Triaged appropriately i.e. Referral to EP Doc or back to GP


Source of referrals to a RAACSource of referrals to a RAAC

referral source

other

GP

A&E

referral source

124 10.1983 80.4116 9.5

1223 100.0

A&EGPotherTotal

Frequency Percent


Diagnosis of Patients Seen in the Diagnosis of Patients Seen in the RAACRAAC

A Fib26%

Conduction disease

5%

Ventricular3%

Anxiety22%

Extrasystoles44%

Rx rate with Warfarin74%


The Rapid Access Heart failure Clinic: CXH

3-5 patients per week


Clinical assessment, ECG, CXR, labs including BNP +/- ECHO


Referral to HF nurse/HF Clinic


Prompt Initiation of Effective TherapiesPrompt Initiation of Effective Therapies

KF Fox, MR Cowie, DA Wood, AJS Coats, PA Poole-Wilson, GC SuttonEur J of Heart Failure 2000;2:423-9

ACE I not initiated

23%

ON ACE I11%

ACE I initiated55%

ACE CI10%

ACE not initated

1%


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


Patient Satisfaction QuestionnairePatient Satisfaction Questionnaire

Patient experience of CX RA Cardiac clinics

87%

2%8% 3%

positiveexperience (%)negative exp (%)

Neutral exp (+and -) (%)Indeterminate (%)


Rapid Cardiology as a Model for Rapid Cardiology as a Model for Epidemiological ResearchEpidemiological Research

Historical precedent

The epidemiology of common cardiac diseases in the populationAngina, 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?


Resources Resources -- is it feasible?is it feasible?Population 200 000

Total 5-6/ weekday (but v. variable)

Provisional staffing levelsClinicianNurse 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)


Rapid Assessment : Pros and ConsRapid Assessment : Pros and ConsInitial investment in manpower and resourcesRCT data on efficacy required

Highly effective diagnostic strategyEarly diagnosis and risk stratification allows early and appropriate therapySpecialist assessment for all presenting with cardiac disease in the communitySwift reassurance of those without pathologyGood indirect evidence of effectiveness Very popular with patients / GPs


Further OneFurther One--Stop ServicesStop Services-- The encapsulated problemThe encapsulated problem

Direct performance of the relevant test with report to GPe.g. Mon pm SpR ECHO clinicClassic - The murmur at insurance medicalSpecialist directed, rather than open access, investigation


Recurrent disease and other problemsRecurrent disease may be

serious

Rapid access clinic style evaluation not appropriate

BUT can still use a one stop assessmentMake the single visit effectiveCo-ordinated tests + consultationAssess all the problems


For all with any manifestation of CHDFor all with any manifestation of CHDCardiac Prevention and Rehabilitation Programme

Specialist nurses trained in assessing patients and supporting their recoveryCo-ordinate physical and mental rehabilitation and use of preventive medicationAll patients reviewed at a weekly ‘ward round’ to monitor progress

What does 10mins with an SHO add?

(n=262)

Nos. (%) Non-smokers 234 (92%)

Nos. (%) meeting Physicalactivity target 194 (90%)

Nos. (%) <140/85 mmHg(<130/80 if diabetic) 190 (76%)

Nos. (%) Total Cholesterol<5 mmol/l 192 (87%)

Nos. (%) Anti-plateletTherapy 221 (95%)

Nos. (%) Lipid LoweringTherapy 212 (96%)


‘‘Annual follow upAnnual follow up’’

Chronic disease is effectively managed in primary careif appropriately supported

Empower the patientannual exercise assessmentthe ‘birthday test’

If an annual echo (or other test) is neededOK - repeat each year

no change >>>> repeatif changed >>>> review


Tuesday afternoons at Charing Cross 1999 - 2007

WAS: 34 patients seen between 2pm and 6.30pmNOW: 12 patients seen between 2pm and 5pm - N:Fup >> 1

1999 2003 2007


A success story for the Rapid Access Chest Pain Clinic on the Dept of Health website


At CXH Dept of CardiologyIndividuals …..

Are Crucial Do today’s work todayAre flexibleHave busy days and less busy daysTrust each other

But this needs time, effort and constant But this needs time, effort and constant reinforcementreinforcement


So what should I think about…

Changing people

StakeholdersIndividuals matterLeadershipBeliefFeedbackTrustIncentives

Changing systems

BIG BANG v sub-radarTimingEarly gainsDemand management


SummarySummary

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

Documents

Rapid Cardiology and the One Stop Cardiology Services at