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Secondary Prevention of CHD in Primary Care.
Nurse Led Clinics
by Susan Neal
Nurse Practitioner North Street Medical Care
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Why Do It?
HIMP Targets around setting up CHD clinics
National Service Framework Audit revealed care gaps
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North Street Medical Care
12,500 patients Six partners. Three practice nurses One nurse practitioner Paperless, fully computerised Computer held CHD register of 418. Opportunistic approach
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Results
Performance in risk factor modification variable
Recording of advice given poor (except smoking)
Half on medication they should be Cholesterol management fair, lipid
prescribing low.
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Evidence Base
HA Guidelines Aspirin Ace Inhibitors Advice Beta Blockers Cholesterol Risk Factors including Blood pressure
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Evidence Base
Systematic, dedicated approach is beneficial (BMJ 1998, 316: 1434-7 Campbell et al, study of 1173 patients across 19 practices)
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Systematic Approach
Aims of dedicated consultations Support to patients Identification of uncontrolled symptoms Modification of risk factors
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Organisation
Dedicated nurse time Extended Model of Practice Guided by evidence based protocol Computer based call and recall Clerical support
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Outcomes
82 consultations, 50% uptake 10 patients prescribed/advised aspirin 1 commenced beta blockers 20 patients required cholesterol check 9 subsequently required action 24 required BP check 14 subsequently required action
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Case Study 48 year old male 1990 raised
cholesterol 1992 MI 1992 2 vessel CABG Dipyridamole No surgery contact 1998 called for check
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Risk factors identified Symptom deterioration No medication Cholesterol 7.5 mmols/l BP 140/100
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Lessons from Experience
Key is organisation with evidence based, focused, approach.
Extended model of practice. ? Concept of dedicated “clinic” Patient response Needs resourcing