Cardiac care

Harrow Primary Care Trust takes cardiac care into the community

Problem

Harrow Primary Care Trust (PCT) serves a population of nearly 250,000 in a busy commuter-belt suburban area of North-West London. More than 100 GPs dispense a wide range of clinical services from 37 GP practices with the support of specialist nurses and other healthcare professionals.

In 2005, an audit of cardiology outpatients at the nearby Northwick Park Hospital revealed an average waiting time for a cardiology appointment of more than 17 weeks, giving rise to considerable distress to anxious patients.

Furthermore, restricted capacity for specialist tests, such as electrocardiograms (ECG), blood pressure (BP) and cardiac event monitoring, were leading to additional delays — often in excess of 12 weeks — before an appropriate care plan could be implemented. Meanwhile, consultation appointments with a cardiologist were being wasted because patients were either inadequately investigated or referred inappropriately.

There appeared to be ample evidence that these investigations could be carried out more effectively and much quicker in primary care, and in many cases eliminating the need for referral to secondary care altogether.

It was clear that the local service to patients could be improved, providing rapid and timely access to specialist cardiac care by developing a highly-trained mobile cardiac task force based in the community, involving GPs, specialist nurses and healthcare assistants (HCAs) — all supported by hospital-based heart disease specialists.

Solution

It was decided to establish an electronic, paper-free, primary care-based diagnostic and clinical assessment service — one that could be accessed on-line by all 37 practices within the PCT.

This community-based cardiac diagnostics system has been made possible by using Welch Allyn’s CardioPerfect PC-based resting electrocardiogram (ECG). This 12-lead ECG device connects to CardioPerfect Workstation software, installed in all 37 general practices within the PCT.

It is designed to store and retrieve thousands of ECGs, and can compare different ECGs on the same patient. It enables the healthcare professional to record ECGs at the bedside or while visiting a patient at home. Hard copy printouts can be produced directly on any MS Windows-compatible printer.

This is a portable ECG system, suitable for both hospital and GP surgery use, automatically storing and analysing recorded ECG data using existing computer hardware. There are networking facilities and integrated transmission features for telemedicine applications. The system is electronic medical record (EMR)-ready, with the capacity to integrate with other patient information systems.

It offers the flexibility for PCTs to manage all of their cardiopulmonary test data within one software package without disrupting the routine work of GP practices. It can operate on both stand-alone and networked PCs, and facilitates quick and easy retrieval and analysis of data, allowing staff to interact more efficiently with patients.

It saves time and eliminates the need for repeat ECGs — by reviewing a complete 12-lead report on-screen prior to printing. Using the onscreen ECG report editor function enables GPs to change or add a diagnosis, as well as carrying out a comparison of previous ECGs to highlight changes.

The service was established early in 2006, offering a wide range of cardiac investigations, previously only available via secondary care referral. We have invested in state-of-the art equipment for ECG and BP recording, and will expand this to include 24-hour ECG and cardiac event monitoring (see panel 1).

HCAs are employed to maintain and run the service, supported by two GPwSIs (GPs with a special interest) and two specialist cardiology nurses who carry out most of the investigations, and who underwent diploma courses in cardiology to ensure there were those with sufficient skills to provide correct interpretation of ECG data. Consultant cardiologists from St Mary’s Hospital and Northwick Park Hospital provide support to allow the service to run within the community.

Every general practice is now connected via PCs to a central email server, allowing ECG and BP data to be requested by individual GPs and the results returned to them electronically. Alternatively, GPs can undertake their own ECG and BP tests and have them analysed by the assessment and diagnostic service.

Either way, the time from the GP requesting an ECG (or interpretation of an ECG) to the patient receiving a clear idea of what his or her cardiac management should be has been slashed from weeks or months to hours or days.

Of course, there is a fast-track to secondary care when abnormal ECGs dictate that referral to a cardiologist is warranted — but the vast majority of patients are seen and discharged with a clinical management plan that can be supervised in the community by their own GP and the community cardiology team. A cardiology patient pathway makes it clear which patients are suitable for ongoing primary care management and those who are not.

Implementation

Leveraging existing IT infrastructure

The Welch Allyn CardioPerfect workstation software, was installed onto existing machines in the surgeries, the only additional requirement was two portable computers for use by the nurse specialists. Each surgery has their own SQL database which stores all their patient records. Results are be transmitted to other surgeries for a second opinion using the inbuilt telemedicine system, which utilises a central e-mail server. Patient confidentiality is assured by encrypting these communications.

Delivering fast-track diagnostic services in the community

From being totally dependent upon hospital-based diagnostic services, Harrow PCT is aiming to become diagnostically less reliant on secondary care resources.

The assessment service has now been up-and-running for nearly two years, and is now taking on a significant diagnostic workload. Between April and June 2007, for example, Harrow PCT carried out 123 24-hour ECGs, 76 24-hour BPs, 138 resting ECGs and dealt with 14 cardiac events. Secondary referrals to outpatient clinics have been reduced by 30-40%.

All patients attending the community cardiology service get a self-assessment satisfaction questionnaire, the returns from which indicate a 95% satisfaction rate. This reflects that most patients are seen within 2-3 weeks and do not have to travel to Northwick Park Hospital or even further for their diagnostic investigation.

The current service is just the first step towards having a comprehensive community-based cardiology service in Harrow. It is hoped to add exercise ECG and 24-hour Holter facilities, connecting to the existing software. The ability to carry out community-based ECGs 24 hours a day 7 days a week especially for patients with suspected arrhythmias — will herald a significant advance. At the moment, all this paper data is transported to and from Northwick Park Hospital by hand, and the diagnosis can take up to two weeks.

HCAs have been trained to take the ECGs — including preparing the patients, placing the ECG leads and recording the results — and all ECGs are validated by a specialist within the PCT.

In 90% of cases, the GPwSI or PwSI is able to make a diagnosis and institute a management plan (eg a recommendation the GP to initiate warfarin and heart rate controlling medication for a patient who’s ECG suggests a trial fibrillation or a referral to the CAS so that patients can be investigated more thoroughly).

It means that not every practice has to have its own ECG equipment — each of which would require a significant financial investment. For the smaller practices in Harrow PCT, such equipment would be redundant for much of the time. Instead, they send their patients to one of the PCT’s cardiac diagnostic specialists, who carry out the ECG before emailing the analysis back to the GP.

GPs and nurses who want to learn the practical side of cardiac diagnostics will receive all necessary support to enhance their diagnostic skills. However, in most cases, it is considered that ECG recordings are best undertaken by trained HCAs, allowing the PCT-based specialists to interpret the data and advise individual GPs accordingly. Expertise in this field, as in many other diagnostic areas, is established by doing hundreds of ECGs over time.

It is a completely paper-free system. This avoids the need to fax or post paper copies, thus minimising the risk of lost receipts or having to interpret recordings and copies of poor quality.

Another important feature of this service is that the equipment being used is highly mobile, enabling HCPs to take ECG readings in the homes of housebound patients, bringing the data back for interpretation and analysis. In effect, the CAS can be accessed from any site.

Community-based diagnostics — is it justified and who benefits?

The main aim of this initiative has been to support direct access to diagnostic ECGs and ambulatory blood pressure for local GPs in order to improve patient outcomes. This is the first such project upon which Welch Allyn has embarked within the NHS. It is now involved in setting up a similar initiative in South Manchester.

Until this service was established, the PCT was committing considerable sums of money to send patients to hospital for their ECGs or manage patients with raised blood pressure, so it made sense to invest that money in primary care — paying extra to train GPs and nurses and to buy the equipment, but in return, delivering an efficient diagnostic service closer to where the patients live.

And of course, it is the patients who benefit. Only for the more complex cardiac investigations do patients now have to wait more than a couple of weeks for confirmation of a problem or re-assurance that there is nothing to worry about.

This is a valued-added service, saving time and improving patient care and experience within the NHS. Every visit to the hospital is stressful — even the car-parking! The potential to reduce the time patients have to wait for endless follow-up appointments, referrals and re-referrals is enormous, and any savings can be re-invested into patient care.

This is a highly-sophisticated diagnostic initiative, and patients’ lives depend on the PCT to deliver a competent service. It simply could not have afforded to embark on this enterprise without the necessary support and training back-up, all of which is provided by Welch Allyn in addition to the essential hardware and software upon which the service depends.

Benefits

A cost-effective investment in telecardiology — the latest heart disease monitoring equipment, allied to an IT network linking 37 general practices to a central email server — has enabled Harrow PCT to ensure there is equity of access for all patients to a high-quality cardiac diagnostic service.

Importantly, this service is delivered in community-based settings: in GP surgeries, in community healthcare centres and in patients’ homes. In most cases, it means that patients will not have to be referred unnecessarily to hospital.

It is unacceptable and inappropriate for patients to have waited many weeks and sometimes months for what are relatively simple cardiac investigations. This was a service that was crying out for change and the PCT believes it has gone some way to effecting much-needed improvements to locally-based cardiac care, with a dramatic impact on successful patient outcomes.

Dee Hannah, Cardiac Nurse Consultant, based in Harrow PCT.
Jonathan Pope, Medical Systems Engineer, Welch Allyn.

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