Jane Stubbs, BSc (Hons), RN.
Project Manager at West Midlands South CHD Collaborative
CORONARY HEART DISEASE
CORONARY HEART DISEASE
The treatment of patients with coronary heart disease (CHD) has altered significantly over the past decade, driven by technological advances and political initiatives.
In particular, the role of percutaneous coronary intervention (PCI) in the treatment of patients with stable or unstable CHD has developed rapidly. PCI offers symptomatic relief to patients with CHD by increasing blood flow through narrowed or blocked coronary arteries (DH, 2000).
The most commonly used method is percutaneous transluminal coronary angioplasty (PTCA), in which a balloon-tipped catheter is passed into the narrowed coronary artery, and the balloon inflated to dilate the artery (Reynolds et al, 2001). An adjunct to this procedure is the insertion of a coronary artery stent, a wire mesh that supports the treated area of the coronary artery and lowers the incidence of acute or chronic reocclusion (Lindsay and Pinnow, 2000). The decision to proceed to PCI is usually made immediately after a diagnostic coronary angiogram.
The fact that PCI provides greater symptomatic relief than medical treatment (Lindsay and Pinnow, 2000), while being less traumatic and more affordable than coronary artery bypass graft (CABG) surgery (Jones and Goode, 2003), has underpinned the increase in the number of procedures. Within the UK, the provision of PCI has increased from 174 procedures per million population in 1991 to 590 procedures per million population in 2000 (British Cardiac Society and Royal College of Physicians of London, 2002).
This increase in the provision of PCI was given new impetus by the publication of the National Service Framework for Coronary Heart Disease in 2000 (DH, 2000). One of the priorities of the NSF for CHD was an increase in the provision of PCI for patients. Specifically, a target was set that the number of PCIs should be increased from a rate of some 550 per million population to 750 per million population (DH, 2000).
Following the publication of the NSF in 2000, a programme of capital investment was announced to increase PCI capacity in the NHS over the next decade (DH, 2003). This programme has seen the provision of ‘600 million to build new cardiac centres or to expand existing ones, coupled with a significant increase in the specialist cardiac workforce (DH, 2004).
Despite this expansion in facilities, those NHS trusts currently delivering PCI services have seen additional demands placed on them because of the targets set out in the NSF.
This article will examine one area of that additional demand - the transfer of patients from district general hospitals (DGHs) to a tertiary NHS trust for PCI - and how changes in practice can streamline the patient journey.
CONTEXT OF CHANGE
The changes in practice were implemented in a large, acute NHS trust (referred to as the tertiary centre). The cardiac centre within the trust offers a range of diagnostic and therapeutic cardiac services, including PCI.
The trust carries out about 1000 PCI procedures annually of which approximately 50% are elective cases, with the remainder being urgent or emergency cases. A significant number of the urgent cases are patients transferred from surrounding DGHs, which do not currently possess facilities for performing PCI. In 2002, 352 patients were transferred to the tertiary centre for urgent investigation with or without PCI.
Traditionally, patients in the DGHs with unstable cardiac conditions would be identified by their cardiologist as being in need of investigation and possible intervention through coronary angiogram with or without PCI, thereby requiring transfer to the tertiary centre. Referral would be made to a member of the on-call cardiology team at the tertiary centre who would write the patient’s name on a transfer list located in the coronary care unit (CCU). Patients’ names would be added to the bottom of the list, unless the patient required emergency PCI, in which case immediate transfer would usually be arranged.
Once a bed became available within CCU, the patient from the top of the list was selected for transfer, and sent by ambulance from the DGH. The patient would then wait for their procedure at the tertiary centre, and be discharged home once medically fit following PCI.
Transfer waiting times were continuously audited by the tertiary centre to allow for close monitoring of standards. A locally agreed standard between the cardiologists stated that patients should wait no longer than three days between referral to the tertiary centre and transfer. Although the mean waiting time in a period before the change was introduced was just under three days (Figure 1), nearly one in three patients waited for longer than the target time (Figure 2), with some patients waiting up to 10 days.
An analysis was carried out to discover the reasons for these delays in transfer. This analysis identified two key delaying factors:
- Limited availability of in-patient beds in the tertiary centre
- Poor prioritisation of waiting patients due to a lack of relevant information.
PROCESS OF CHANGE
Following agreement that change needed to be made, members of the multidisciplinary teams at the tertiary centre and local DGHs developed a standardised referral form to provide consistency of information from the DGHs. The aim was to ensure that, for every patient referred to the tertiary centre, the information required to prioritise the patient for transfer is available. This referral pro forma was made available electronically via the intranet of the tertiary centre and also through an email circulation to key stakeholders.
In addition to the standardisation of patient information, changes were made to the referral process. Before implementation of change, a doctor-to-doctor referral would simply be made over the telephone.
In the re-engineered process, the referring doctor enters details of patients requiring transfer onto the standard pro forma, along with the name of the doctor at the tertiary centre who has accepted the patient. The completed form is then faxed to the CCU at the tertiary centre where they are viewed by the cardiology registrar on call. This provides a central point for patient referrals and constitutes a valuable audit tool, while also allowing for informed prioritisation of waiting patients.
The new pro forma and referral process improved communication between the DGH and tertiary centre, and facilitated prioriti- sation of waiting patients. However, availability of in-patient beds remained a restraining influence.
To increase capacity for in-patient transfers, it was decided to use an existing resource within the tertiary centre - the day-case cardiology unit. The unit is a key part of the cardiology service, providing capacity for elective day-case cardiac procedures (such as coronary angiography and cardioversion). Patients are admitted in the morning, nursed on trolleys rather than beds, and are discharged by the evening of the same day. Any patients requiring an overnight stay are transferred to the adjacent cardiology ward or CCU.
A study by Blackman et al (2002) suggested that day-case transfers from DGHs to tertiary centres for coronary angiography with or without PCI was both safe and practical. It was therefore agreed to pilot such a scheme, utilising the day-case cardiology unit to provide the required capacity.
Comprehensive discussions were held with key stakeholders, including nursing and medical staff from local DGHs and the tertiary centre and local ambulance trust representatives.
These discussions resulted in the introduction of the re-engineered transfer process. Following referral using the standard pro forma, patients are prioritised, and a date for their procedure timetabled. To ensure patient safety and a smooth passage of care, a checklist is used by nurses to screen patients for their suitability to be cared for in the day-case cardiology unit as day cases (see above, right).
One restricting factor in the introduction of the change was the availability of nurse escorts to accompany patients on their journey from the DGH to the tertiary centre. Previously, a nurse escort had been required for most transfers, and this was putting significant pressure on the nursing teams in the DGHs. Following discussion with the ambulance service, it was recognised that paramedic crews have the ability to manage any deterioration in patients en route, and that a nurse escort would not routinely be required. This change in policy reduced the workload of DGH staff, while acknowledging the skills possessed by modern paramedic crews.
On the morning of their planned procedure patients are transferred from the DGH to the day-case cardiology unit at the tertiary centre. Nursing staff at the DGH have responsibility for preparation of the patient, including ensuring that he or she has been kept nil by mouth for an appropriate period, and that an intravenous cannula is in situ. Following transfer, the bed at the DGH is then reserved for that patient’s return.
If clinically stable, patients are then transferred back to the referring DGH on the evening following angiography with or without PCI. Any patients who are not deemed stable enough to return to the DGH are nursed in the cardiology ward or the CCU.
EVALUATION OF THE CHANGE
The introduction of the standardised referral pathway, coupled with the use of the day-case cardiology unit for in-patient transfers, was in place by August 2003. Any changes in performance were monitored through the ongoing audit process.
In a like-for-like period before and after the changes were introduced, mean waiting times fell from 2.96 to 2.58 days (Figure 1). There was also a fall in the number of patients waiting longer than three days for transfer, from nearly one in three to just over one in four (Figure 2).
In addition to the demonstrable improvement in transfer times, more qualitative benefits have become apparent.
Communication between key stakeholders in the DGHs, tertiary centre and the ambulance service has been enhanced. This improved communication has resulted from the streamlining of the referral and transfer system, but also through the discussions and co-operation that underpinned the change process.
The enhanced prioritisation of patients has been another positive outcome of the change process. By highlighting those patients whose needs are most urgent, resources can be targeted appropriately and effective treatment delivered promptly.
The change process that has been implemented has demonstrated how multidisciplinary co-operation can result in effective streamlining of the patient pathway.
Changes in referral procedures, coupled with the innovative use of resources and improvements in clinical practice, can have wide-reaching effects on the patient journey. The impact of these changes can be effectively monitored through an ongoing and robust audit strategy within the cardiology unit.
The described changes in practice have brought about improvements in key areas of health-care delivery - clinical effectiveness, utilisation of resources, and interdisciplinary communication. By doing so, they provide an example of good practice that may provide a template for improvements within the wider NHS.
- There is increasing demand for cardiac services in the NHS
- Waiting times for patients requiring transfer to specialist cardiac centres can be longer than clinically desirable
- Delays in patient transfers occur due to limited bed availability and a lack of relevant information
- Reorganising the referral processes and better use of resources can improve the patient pathway.
- Co-operation between all stakeholders is fundamental to the change process. Latest policy
Policies relating to percutaneous coronary intervention
National service framework for coronary heart disease
In 2000, the National Service Framework for Coronary Heart Disease set targets for increased provision of percutaneous coronary intervention (PCI) in the NHS. It specified that the number of PCIs should be increased from a rate of some 550 per million population to 750 per million population (DH, 2000).
Delivering better heart services
In 2003, a programme of capital investment was announced to increase PCI capacity within the NHS over the next decade (DH, 2003). This programme has seen the provision of ‘600 million to build new cardiac centres or to expand existing ones, coupled with a significant increase in the specialist cardiac workforce (DH, 2004).
Authors contact details
David Barrett, Lecturer in Clinical Nursing, Faculty of Health and Social Care, University of Hull, Cottingham Road, Hull. Email: email@example.com
Blackman, D.J., Clarke, N.R., Orr, W.P. et al. (2002)Day-case transfer for percutaneous coronary intervention with adjunctive abciximab in acute coronary syndromes. Heart 87: 375-376.
British Cardiac Society and Royal College of Physicians of London. (2002)Fifth report on the provision of services for patients with heart disease. Heart 88: (suppl III), iii1-iii59.
Department of Health. (2000)National Service Framework for Coronary Heart Disease. London: DH.
Department of Health. (2003)Delivering Better Heart Services: Progress Report 2003. London: DH.
Department of Health. (2004)Winning the War on Heart Disease. Progress Report 2004. London: DH.
Jones, I., Goode, I. (2003)Percutaneous coronary intervention. Nursing Times 99: 27, 46-47.
Lindsay, J., Pinnow, E. (2000)Outcomes of percutaneous transluminal coronary revascularization. In: Apple, S., Lindsay, J. (eds). (2000)Principles and Practice of Interventional Cardiology. Baltimore, Md: Lippincott.
Reynolds, S., Waterhouse, K., Miller, K.H. (2001).Patient care after percutaneous transluminal coronary angioplasty. Nursing Management 32: 9 (Critical Care edition), 51-56.