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Auditing a nurse-led lipid clinic

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The lipid clinic at Guy's and St Thomas' NHS Foundation Trust was set up for patients who are diagnosed as having dyslipidaemia and are referred to see the specialist lipid nurse.

The lipid clinic at Guy's and St Thomas' NHS Foundation Trust was set up for patients who are diagnosed as having dyslipidaemia and are referred to see the specialist lipid nurse.

Doctors will have seen all patients previously and the request to be seen in the nurse-led follow-up clinic will be written in the patient's notes and on the letter to the GP.

An audit of the lip unit was conducted in line with the clinical guidance group requirement in order to have the lipid nurse-led clinic guidance updated and resubmitted.

The aims of the audit were to:
- Assess the number of patients seen by the nurse
- Assess what type of medical problems patients had
- Assess the number of patients who were non-compliant
- Record the nurse's decision/action relating to patients' treatment
- Record the type of referrals
- Record the number of discharges.

The audit was carried out by specialist lipid nurse Zofia McMahon, senior lecturer/honorary consultant Anthony Wierzbicki and the Diabeta 3 system administrator undertook the procedure. Copies of all the patients' letters, which the nurse sent to patients' GPs, were analysed, and data was collected from the patient management system database for the lipid clinic, the Diabeta 3 (Lipida) database.

The database records all patients' visits, cardiovascular risk factors, family history, laboratory results, medication, past medical history including past surgical procedures and patients' lifestyle education. It provided data on all patients' visits from 1 January 2006 to 31 December 2006 inclusive.

The database search criteria recorded in line with procedural requirements and manual analyses conducted were:
- Number of patients seen by the nurse
- Type of medical problems patients had
- Non-compliant patients
- Range of criteria requiring treatment
- Indication for referrals
- Number of discharges.

Results
Total number of patients reviewed: 210 (100%)
Number of patients whose lifestyle was discussed during visit: 210 (100%)
Number of patients with familial hypercholesterolaemia: 38 (18%)
Number of patients with hyperlipidaemia and hypertension: 63 (30%)
Number of patients with hyperlipidaemia and type 2 diabetes or insulin resistance syndrome: 20 (9.5%)
Number of patients with hyperlipidaemia, type 2 diabetes or insulin resistant syndrome and hypertension: 21 (10%)
Number of patients with morbid obesity: 23 (10%)
Number of patients with hyperlipidaemia or hypercholesterolaemia (polygenic or secondary): 35 (18%)
Number of non-compliant patients: 21 (10%)
Number of patients requiring change of medication: 9 (4%)
Number of patients requiring additional medication: 15 (7%)
Number of patients requiring a reduced dose of statin: 5 (2%)
Number of patients requiring an increased dose of statin: 1 (0.5%)

Referrals
Bone unit: 1
Diabetic nurse specialist: 1
Weight Watchers: 3
Renal unit: 2
Erectile dysfunction: 1
Discharged: 9

This report indicates that the Diabeta 3 (Lipids) database was not able to provide us with all the necessary information. Therefore it was necessary to do a manual analysis of copies of each patient's GP letter.

The results show the data obtained during the period from 1 January 2006 until 31 December 2006. The total number of follow-up patients seen by the nurse during that time in the clinic was 210.

All of the patients seen had the opportunity to discuss their lifestyle with the nurse. Relevant leaflets were also given, to cover lifestyle issues discussed, including information on cholesterol, exercise, how to lose weight, depression and anxiety.

Most patients with diabetes are managed in the diabetes unit. Many of those patients are also managed in the lipid unit. Similarly, cases of severe hypertension were mostly managed within the hypertension unit but many of those patients were also managed in the lipid unit.

The nurse identified 21(10%) of patients who were non-compliant with their treatment. The identified reason for non-compliance among these patients was either a lack of clarity as to what medication they should be taking as a result of difference between primary and secondary care perceptions of medications prescribed, or patients' intolerance to the drug. Only one patient was identified as having stopped taking medication for reasons unknown.

All patients seen were follow-up patients and they were either on medical treatment for their already established condition(s) or they were given some advice about their lifestyle at their previous visits to the lipid clinic.

Within the time period the nurse made nine referrals to other healthcare specialists. Lipid patients are discharged back to the GP once they had reached the set target for total cholesterol levels.

Conclusion
Useful baseline parameters have been obtained from the database. The lipid nurse's skills are used appropriately in the clinic and satisfactory outcomes are being achieved.

No changes to current practice are required. However, the selective targeting of patients with severely abnormal results suitable for more frequent assessment will be considered.

The additional resources that have been required to undertake this audit have not significantly disrupted the efforts required to undertake a full range of clinical practice.

The exercise will provide a stimulus for future improvements in practice.

The recommendations arising from this audit are:
- Selective targeting of patients with severely abnormal results suitable for more frequent assessment will be considered
- Repeat the audit annually
- Develop a discharge protocol based on target achieved.

Zofia McMahon
zofia.mcmahon@gstt.nhs.uk

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