Upload
simon23
View
509
Download
0
Tags:
Embed Size (px)
Citation preview
The NSF for CHD Chapter 8
- some issues and some possible solutions:
Setting up and running a (rapid access) arrhythmia clinic
Kevin Fox Department of Cardiology,
Hammersmith Hospitals NHS Trust at Charing Cross Hospital
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Key challenges in Ch 8
Effective diagnosis of arrhythmias
Effective treatment for arrhythmias (RFA, PPM,,,)
Effective diagnosis and care for patients and relatives of those with SCD
Effective support for patients, relatives and carers with arrhythmias
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
A possible solution to the first challenge..
The Charing Cross Rapid Access Arrhythmia Clinic
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
A Rapid Access Arrhythmia Clinic Model
GP wants help with a patientRefers to RAAC
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!
But does the model work?
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Initial diagnosis and diagnosis at 1 yr in a cohort of patients seen in the RAAC clinic (consenters)
Card 1 yr PossCard 1yr
Not card 1 yr
Total
Card ini 96 0 35
23
244
302
131
Poss Card ini 1 2 26
Not card ini 5 2 251
Total 102 4 408
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
1 year mortality data
Cardiac deaths Non-cardiac deaths
Total deaths
Definite arrhythmiaN = 132
1(0.07%)
3(2%)
4(3%)
Possible or not arrhythmiaN = 322
0(0%)
2(0.06%)
2(0.06%)
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Cardiac Outpatients visits in the year after RAAC visit
Not cardiac Cardiac
cardiac OP for cardiac problem
26 17.0127 83.0153 100.0
yesnoTotal
Frequency Percent
cardiac OP for cardiac problem
33 55.027 45.060 100.0
yesnoTotal
Frequency Percent
cardiac OP for cardiac problem
no
yes
cardiac OP for cardiac problem
no
yes
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Visits to GP in year following RAAC visit
Not cardiac Cardiac
Number of visits to GP for cardiac symptoms
10643210
Freq
uenc
y
140
120
100
80
60
40
20
0
Number of visits to GP for cardiac symptoms
11864320
Freq
uenc
y
50
40
30
20
10
0
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Tuesday afternoons at Charing Cross 1999 - 2003
WAS: 34 patients seen between 2pm and 6.30pm
NOW: 12 - 20 patients seen between 2pm and 5pm
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Setting up a RAAC
Primary care Anticoagulant services
Clin PhysiologyInvolve stakeholdersBut don’t be put off by them
Neurology / Cof E
Managers
Clin Chemistry etc.
Patients
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Setting up a RAAC cont.
Referral criteriaMode of referralOperational timesSpace StaffingThe patient journeyClinical assessment algorithmsManagement algorithmsData recording and communication to primary careFollow upQuality control and audit
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Having a system for common presentations
Sinus tachycardia
SVEs and VE
LBBB
WPW
New AF
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Cases seen in the CX RAAC
Number of cases seen per month
0
20
40
60
Nov Dec Jan Feb Mar AprMay Jun Jul AugSep Oct Nov Dec Jan Feb Mar AprMay Jun Jul AugSep Oct NovDec Jan Feb
1999199920002000200020002000200020002000200020002000200020012001200120012001200120012001200120012001200120022002
Freq
uenc
y
0
40
80
120
160
0 1 2 3 4 5 6 7
Number of patients seen per day
Freq
uenc
y
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Volume of referrals in a RAAC
The combined CXH Rapid Cardiology Clinics(population served 150 000 - 200 000)
Rapid Access Clinics at Charing Cross Hospital
Chest pain Heart Failure Arrhythmia
No. seen / week 20 3 15
No. seen /100,000 population/weekday
2 0.3 1.6
No significant pathology (%) 71 64 63
Significant cardiac disease % 29 36 37
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Typical experience of a RAAC
- referral source
referral source
other
GP
A&E
referral source
124 10.1983 80.4116 9.5
1223 100.0
A&EGPotherTotal
Frequency Percent
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Age of attendees at a RAACdecade age
decade age
9080706050403020
Freq
uenc
y
160
140
120
100
80
60
40
20
0
Age of attendees
decade age
decade age
908070605040302010
Freq
uenc
y
120
100
80
60
40
20
0
RACPC
decade age
decade age
9080706050403010
Freq
uenc
y
50
40
30
20
10
0
RAHFC
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Ix used in 984 patients attending the Cx RAACNumber (%)
ECG 984 (100%)Blood tests 955 (97%)Holter monitoring 912 (93%)Echocardiography 311 (32%)Chest radiography 187 (19%)Exercise stress test 119 (12%)Event recorder 52 (5%)Tilt test 16 (2%)Further management
Discharged to general practitioner 659 (67%)Followed up in conventional cardiology clinic 242 (25%)Referred to specialist arrhythmia clinic 83 (8%)Admitted to hospital 22 (2%)Referred for pacemaker 21 (2%)Referred for coronary angiography 9 (1%)
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Diagnosis of patients seen in the RAAC
AF/Flutter 93 (27%)
Junctional reentrant tachy 20
(6%)
Heart block 12 (3%)
P. atrial tachy 11 (3%)
NSVT 3 (1%)
No significant arrhythmia
detected 211 (60%)
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
We are often asked:What’s the secret of our success?
THERE IS NO SECRET!
Trust the epidemiologyToday’s work today Be flexibleSort the problem out NOW
Say THANK YOU and feedback the positivesBut actually the team see the positives very quickly
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
How do you make the change?
Start smallHave a ‘champion’
BelieveYou don’t need huge resourceDelays and waits are inefficient
Build trustGather together arrhythmia referralsRun the clinic in parallel with a standard OPDLimit range of referrals or geographical area / practices
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital
Next steps
Wide discussion of the NSF Ch8
Sharing effective models of care
Co-ordinated introduction of changeSensitive to local needsSensitive to the needs of the sectorSensitive to the challenges of introducing change
But change is achievable
Hammersmith Hospitals NHS Trust Dept of Cardiology, Charing Cross Hospital