Secondary Prevention of CHD in Primary Care.

Nurse Led Clinics

by Susan Neal

Nurse Practitioner North Street Medical Care

Why Do It?

HIMP Targets around setting up CHD clinics

National Service Framework Audit revealed care gaps

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

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.

Evidence Base

HA Guidelines Aspirin Ace Inhibitors Advice Beta Blockers Cholesterol Risk Factors including Blood pressure

Evidence Base

Systematic, dedicated approach is beneficial (BMJ 1998, 316: 1434-7 Campbell et al, study of 1173 patients across 19 practices)

Systematic Approach

Aims of dedicated consultations Support to patients Identification of uncontrolled symptoms Modification of risk factors

Organisation

Dedicated nurse time Extended Model of Practice Guided by evidence based protocol Computer based call and recall Clerical support

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

Case Study 48 year old male 1990 raised

cholesterol 1992 MI 1992 2 vessel CABG Dipyridamole No surgery contact 1998 called for check

Risk factors identified Symptom deterioration No medication Cholesterol 7.5 mmols/l BP 140/100

Lessons from Experience

Key is organisation with evidence based, focused, approach.

Extended model of practice. ? Concept of dedicated “clinic” Patient response Needs resourcing