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On the move with cardiac assessment

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A Lincolnshire hospital’s mission to meet targets for coronary heart disease has led to the setting up of an award-winning mobile team of cardiac assessment nurses.

A ZERO success rate in meeting a national target tends to concentrate the mind. Then achieving 100 per cent success almost overnight, thanks to a new nurse-led system, means immense job satisfaction for the staff.

The first, woeful statistic - for administering thrombolytic therapy to patients with potential myocardial infarction (MI) within 30 minutes of them coming through the hospital door - was certainly not unique to Pilgrim Hospital in Boston, Lincolnshire. The target - enshrined in The National Service Framework for Coronary Heart Disease - has proved to be a wake-up call for trusts across the country.

The Pilgrim’s solution is a mobile team of cardiac assessment nurses who can be called by bleep to see any patient admitted anywhere in the hospital with chest pain. But the service goes a lot further. The nurses also provide vital training and support for other frontline professionals, including night staff, A&E nurses and doctors, paramedics in the local ambulance trust and staff from an outlying hospital.

As a result of these efforts the team’s bleep can now be handed over to specially trained cardiac nurses out of hours, ambulance crews are helping to optimise delivery of thrombolysis, and the outlying unit no longer has to send its suspected MI patients on a 30-minute journey to the Pilgrim.

The strength of this joined-up approach was recognised in January 2005 with the Best Practice in Integrated Cardiac Care award from Shire Health, sponsored by Roche Products.

Four cardiac assessment nurses - three full-time and one part-time - cover the hospital from 7.30am to 8.00pm, seven days a week, with occasional nights when the rota allows.

When called out, they perform a detailed assessment including ECG and blood tests, arrive at a diagnosis and deliver treatments ranging from pain relief to thrombolysis according to a series of patient group directives. They stay with patients until they are stabilised and follow them up after their admission to the coronary care unit.

Their impact is evident from the hospital’s audit data. Daytime compliance with the 30-minute target went from 0 to 100 per cent almost as soon as the team was up and running. And a study of cardiac arrests among admissions before and after the scheme has shown a sustained reduction of 50 per cent.

There is usually just one cardiac assessment nurse on duty. And as emergency patients can be delivered to either A&E or the medical admissions unit (MAU) - sometimes even to both at the same time - the bleep-holder has to be fleet of foot. ‘People joke that we must cover many miles - and we do,’ explains cardiac assessment nurse Maria Willoughby.

‘We are on duty for our whole shift - there is no protected time for meals or breaks. So if you are in the canteen having your lunch when the bleep goes you end up bringing your meal with you. Other times you might be in the middle of training a paramedic or another nurse - and they just have to get to the emergency with us. Our days are completely unpredictable - something I really enjoy.’

Ms Willoughby, whose background is in coronary care and A&E, had long harboured an ambition to ‘get out there’ and tackle thrombolysis. She joined the team when it was first set up in August 2001, and her experience with a recent patient sums up why she has stayed.

‘A young man came in with chest pain and suspected MI. I had just started to examine him when he had a cardiac arrest.’ she explains. ‘I immediately used the defibrillator - and got him back with one shot. Then I assessed him using our usual criteria, and delivered thrombolysis.

‘That all happened within 20 minutes. Then just an hour later I saw him sitting up having a cup of tea - and his ECG was totally different. It is incredibly exciting to treat these patients, to see the difference it makes, and to know you have done it all yourself, without a doctor making the decisions and telling you what to do.’

Cardiac assessment nurse Janine Rennie-Lovley had her work cut out on one shift, with six patients in A&E, two of whom were being thrombolysed at the same time. ‘I just made sure they were positioned as close together as possible,’ she recalls.

On busy days, an A&E nurse may perform the ECG and bring it to the cardiac assessment nurse for reading. ‘Then you have to judge whether you can leave the patient you are with to move on to the next one,’ she explains.

Doctors are only called in if it is impossible to manage all the cases. ‘We have to make sure the doctor realises we have a serious situation on our hands and that they need to drop what they are doing,’ she says.

Sometimes the doctor - often a junior in A&E - may not agree with an assessment. ‘In those situations we have to be the patient’s advocate. We know what they need - and we know that a lot of the doctors haven’t had our years of experience. Fortunately they do respect our knowledge and our decisions.’

Two of the original team have taken their skills on to other roles. Donna Procter is now a heart failure nurse in the trust. And Jason Williams transferred to the ambulance trust to train paramedics in pre-hospital thrombolysis.

Mr Williams played a key role in founding the team. As ward manager of the MAU when it became clear the hospital had to tackle its thrombolysis targets, his challenge was to persuade the trust to adopt the mobile option.

He is just as enthusiastic about his move into the wider team. ‘We were making a big difference in the hospital. But it was clear we needed to look not just at door-to-needle times, but at call-to-needle times, so patients would get the treatment they needed at the earliest possible time. And, of course, it was this sort of cross-party working that won us the award.’

How to Integrate Cardiac Care

 Map patients’ journeys from call-out to care to see where the delays occur.

 If possible, develop a service for all patients admitted with chest pain, not just for those needing thrombolysis.

 Recruit designated cardiac assessment nurses, rather than giving the role to staff with ward responsibilities, and make sure the recruits have appropriate qualifications and experience.

 Design a mobile system so that staff travel to patients, not the other way round.

 Make sure everyone involved works to agreed protocols and criteria.

 Establish patient group directives allowing nurses to prescribe, as this cuts out unnecessary delays.

 Produce a portable case file of previous cardiac patients so the assessment team can have immediate access to patients’ notes where necessary.

 Organise teaching sessions for all other staff in the broader team.

 Extend the assessment service to cover night-time by transferring the bleep to cardiac nurses who have been trained to deliver thrombolysis.

A Lincolnshire hospital’s mission to meet targets for coronary heart disease has led to the setting up of an award-winning mobile team of cardiac assessment nurses.

A ZERO success rate in meeting a national target tends to concentrate the mind. Then achieving 100 per cent success almost overnight, thanks to a new nurse-led system, means immense job satisfaction for the staff.

The first, woeful statistic - for administering thrombolytic therapy to patients with potential myocardial infarction (MI) within 30 minutes of them coming through the hospital door - was certainly not unique to Pilgrim Hospital in Boston, Lincolnshire. The target - enshrined in The National Service Framework for Coronary Heart Disease - has proved to be a wake-up call for trusts across the country.

The Pilgrim’s solution is a mobile team of cardiac assessment nurses who can be called by bleep to see any patient admitted anywhere in the hospital with chest pain. But the service goes a lot further. The nurses also provide vital training and support for other frontline professionals, including night staff, A&E nurses and doctors, paramedics in the local ambulance trust and staff from an outlying hospital.

As a result of these efforts the team’s bleep can now be handed over to specially trained cardiac nurses out of hours, ambulance crews are helping to optimise delivery of thrombolysis, and the outlying unit no longer has to send its suspected MI patients on a 30-minute journey to the Pilgrim.

The strength of this joined-up approach was recognised in January 2005 with the Best Practice in Integrated Cardiac Care award from Shire Health, sponsored by Roche Products.

Four cardiac assessment nurses - three full-time and one part-time - cover the hospital from 7.30am to 8.00pm, seven days a week, with occasional nights when the rota allows.

When called out, they perform a detailed assessment including ECG and blood tests, arrive at a diagnosis and deliver treatments ranging from pain relief to thrombolysis according to a series of patient group directives. They stay with patients until they are stabilised and follow them up after their admission to the coronary care unit.

Their impact is evident from the hospital’s audit data. Daytime compliance with the 30-minute target went from 0 to 100 per cent almost as soon as the team was up and running. And a study of cardiac arrests among admissions before and after the scheme has shown a sustained reduction of 50 per cent.

There is usually just one cardiac assessment nurse on duty. And as emergency patients can be delivered to either A&E or the medical admissions unit (MAU) - sometimes even to both at the same time - the bleep-holder has to be fleet of foot. ‘People joke that we must cover many miles - and we do,’ explains cardiac assessment nurse Maria Willoughby.

‘We are on duty for our whole shift - there is no protected time for meals or breaks. So if you are in the canteen having your lunch when the bleep goes you end up bringing your meal with you. Other times you might be in the middle of training a paramedic or another nurse - and they just have to get to the emergency with us. Our days are completely unpredictable - something I really enjoy.’

Ms Willoughby, whose background is in coronary care and A&E, had long harboured an ambition to ‘get out there’ and tackle thrombolysis. She joined the team when it was first set up in August 2001, and her experience with a recent patient sums up why she has stayed.

‘A young man came in with chest pain and suspected MI. I had just started to examine him when he had a cardiac arrest.’ she explains. ‘I immediately used the defibrillator - and got him back with one shot. Then I assessed him using our usual criteria, and delivered thrombolysis.

‘That all happened within 20 minutes. Then just an hour later I saw him sitting up having a cup of tea - and his ECG was totally different. It is incredibly exciting to treat these patients, to see the difference it makes, and to know you have done it all yourself, without a doctor making the decisions and telling you what to do.’

Cardiac assessment nurse Janine Rennie-Lovley had her work cut out on one shift, with six patients in A&E, two of whom were being thrombolysed at the same time. ‘I just made sure they were positioned as close together as possible,’ she recalls.

On busy days, an A&E nurse may perform the ECG and bring it to the cardiac assessment nurse for reading. ‘Then you have to judge whether you can leave the patient you are with to move on to the next one,’ she explains.

Doctors are only called in if it is impossible to manage all the cases. ‘We have to make sure the doctor realises we have a serious situation on our hands and that they need to drop what they are doing,’ she says.

Sometimes the doctor - often a junior in A&E - may not agree with an assessment. ‘In those situations we have to be the patient’s advocate. We know what they need - and we know that a lot of the doctors haven’t had our years of experience. Fortunately they do respect our knowledge and our decisions.’

Two of the original team have taken their skills on to other roles. Donna Procter is now a heart failure nurse in the trust. And Jason Williams transferred to the ambulance trust to train paramedics in pre-hospital thrombolysis.

Mr Williams played a key role in founding the team. As ward manager of the MAU when it became clear the hospital had to tackle its thrombolysis targets, his challenge was to persuade the trust to adopt the mobile option.

He is just as enthusiastic about his move into the wider team. ‘We were making a big difference in the hospital. But it was clear we needed to look not just at door-to-needle times, but at call-to-needle times, so patients would get the treatment they needed at the earliest possible time. And, of course, it was this sort of cross-party working that won us the award.’

How to Integrate Cardiac Care

 Map patients’ journeys from call-out to care to see where the delays occur.

 If possible, develop a service for all patients admitted with chest pain, not just for those needing thrombolysis.

 Recruit designated cardiac assessment nurses, rather than giving the role to staff with ward responsibilities, and make sure the recruits have appropriate qualifications and experience.

 Design a mobile system so that staff travel to patients, not the other way round.

 Make sure everyone involved works to agreed protocols and criteria.

 Establish patient group directives allowing nurses to prescribe, as this cuts out unnecessary delays.

 Produce a portable case file of previous cardiac patients so the assessment team can have immediate access to patients’ notes where necessary.

 Organise teaching sessions for all other staff in the broader team.

 Extend the assessment service to cover night-time by transferring the bleep to cardiac nurses who have been trained to deliver thrombolysis.

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