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