Project team:

1
South Coast Coronary Heart Disease
Collaborative(formerly known as Southampton
Winchester)

• Project team
• Ian Simpson- clinical lead, Lisa Sheron, Ken
  Kelly, Anita Smith, Dr Powell- Jackson, Alison
  Scott, Jane Hayward, Adrian Duncome, Karen
  Elkins, Neil Robinson, Marion Slevin, Caroline
  Taylor.
• Network
• South Coast Coronary Heart Disease Collaborative
• Project
• Acute Myocardial Infarction
• Slice
• Southampton East, Central Southampton and Mid
  Hants PCG/Ts
• Name of Project Manager Jane Druce/Sharon
  Osterfield
• Contact No (023) 8072
  5585/5502
• Email project manager
• jane.druce_at_sswh-ha.swest.nhs.uk
• sharon.osterfield_at_sswh-ha.swest.nhs.uk
•  
•  

2
ACUTE MYOCARDIAL INFARCTION PROJECT 

• Aim Statement To improve the speed and quality
  of treatment for patients admitted to Southampton
  General Hospital and Royal Hampshire County
  Hospital with suspected or confirmed myocardial
  infarction.
•  
• This will be achieved by
•  
• 1.  Reducing the time from onset of pain to the
  delivery of appropriate treatment
•  
• 2.  Ensuring seamless consistent care throughout
  the patients journey - from call for help to
  discharge
•  
• 3.  Transition to rehabilitation and primary care
•  

3
Mr Bloggs has an Acute Myocardial Infarction 

• This is his journey
•  
• Mr Bloggs is experiencing chest pain.
•  
• He presents to the AE department at Southampton
  University Hospital via ambulance. Both the AE
  and EMAU departments are aware of his arrival
  because the ambulance crew have phoned ahead to
  warn the departments that they have a patient
  with chest pain.
•  
• During his journey to hospital Mr Bloggs is
  attached to a monitor/external defibrillator
  (Lifepak 12). This makes his handover to the AE
  staff more efficient as the electrodes used are
  compatible with the ECG machines/monitors used in
  AE/EMAU/CCU (WEHT).
•  

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5
AE Department/EMAU

• The diagnosis of AMI is confirmed and Mr Bloggs
  is seen by the Thrombolysis Nurses.
•  
• Mr Bloggs data is placed onto the MINAP database
  (Datacam in WEHT) that is in turn used to give
  feedback to different professional groups for
  assessment of specific progress and issues for
  patient care.
•  
•        Evidence based risk stratification
  pathway developed and printed, for use in AE for
  chest pain assessment
•        Agreed to increase flexibility for
  admissions via A/E to prevent backlogs building
•        GP admissions direct to CCU if EMAU and
  A/E full
•        Thrombolysis Nurses at SUHT now in post
•        Thrombolysis Nurses to be able to use
  space in A/E bay 10 to maintain flexibility in
  care
•        New clocks ordered for A/E to ensure
  accurate timekeeping
•        Thrombolysis Nurses now advise on ECGs in
  AE when required
•        Information placed on MINAP (SUHT) and
  Datacam (WEHT) is regularly used for audit
  purposes
•  
•  
•  

6
Inpatient

•  
• Mr Bloggs is transferred to CCU where he is
•        Placed on an Integrated Care Pathway
•        All barn-door AMIs now have pre-discharge
  ETT and echo as per ICP (WEHT 3 sessions per
  week)
•        Reviewed by the Consultant for the
  Hospital at Home Service
•        Liaison Nurse offering choice and booking
  primary care appointment for follow up pre
  discharge of patients from CCU
•        WEHT Rehab Nurse now all booking patients
  follow up for joint AMI rehab clinic whilst on
  Clark ward
•  

7
Discharge

• Mr Bloggs is ready to go home
•        The discharge information is faxed to the
  GP surgery to allow for primary care follow-up
  the aim is to do within 24 hrs of discharge
•         
•  
•        Patients are now booked for a joint AMI
  Rehab clinic by the Rehab Nurse (WEHT)
•        Rehab Nurse to audit discharge patients
  to see if they were contacted by a health
  professional within 4 days of discharge (WEHT)

8
Future Issues/Changes

•        AE and CCU (SUHT) are to have receiving
  telemetry units installed thereby enabling
  Ambulance crews to transmit ECGs of patients with
  suspected AMI the aim is to improve
  door-to-needle times
•        A telephone algorithm adapted from NHS
  Direct for use be GP reception staff has been
  recently presented for spread
•        The WEHT AMI/Unstable Angina ICP is
  currently out for discussion
•        Possible purchase of a Troponin machine
  for ward D2E (EMAU) _at_ SUHT, to reduce bed
  occupancy times
•  

9
Heart Attack Awareness Leaflets

• Aim To reduce Pain-to-Call Time
•  
• This leaflet has been produced in consultation
  with various stakeholders. The leaflet has been
  distributed in both primary and secondary care
  and uptake is currently being monitored.
•  

10
AMI CHANGES

• june- ?? practice nurses have post MI information
  booklet for patients, on file, previously only
  available in secondary care, allows reinforcement
  in primary care
• May- C4-
• CCU ward pharmacist writing up discharge drugs at
  SUHT to facilitate patient discharge.
•  
• April- B2- standardisation of ECG monitor tabs in
  AE/ CCU at Winchester, less time wasted changing
  equipment on transfer.
•  
• June- D2-
• Practice nurses have post MI information booklet
  for patients, on file, previously only available
  in secondary care, allows reinforcement in
  primary care.
•  
• August- E2-
• Barn door MIs have pre-discharge ETT and echo as
  per ICP to reduce post discharge appointments,
  and more timely risk assessment.
•  
•  

11
ANGINA PROJECT 

• Aim statement To improve the access, speed of
  diagnosis, treatment and experience for patients
  with suspected or diagnosed angina in the whole
  patient slice. 
• This will be achieved by
•  1.  Using a booked appointment system for
  patients referred from primary care to general
  cardiology clinics for both Southampton and
  Winchester hospitals, or through a partial
  booking system if waiting more than 13 weeks for
  their appointment. 
• 2.  By managing the time from initial
  presentation to GP to result of angiogram at
  Southampton being available to the requesting
  physician for 95 of patients within 366 days
  and for 95 of patients and their GP to have a
  final management plan following attendance at
  Rapid Access Chest Pain Clinic available within 5
  days.
•  
• By working towards 90 of patients being able to
  rate their pain at level 3 or above, and for them
  to be able to rate levels of information and
  support provided at 8 or more according to the
  national questionnaire scores

12
Mr Bloggs has Chest Pain

• Mr Bloggs lives in Southampton and has developed
  chest pain. There are 4 possible routes that can
  be taken which will result in his treatment
•   
• 1.             GP Route
• Mr Bloggs presents to his GP. His GP may refer
  him direct to
•        AE
•        CCU (Cardiac Care Unit)
•        RACPC (Rapid Access Chest Pain Clinic)
•        OPD (Out-Patients Department)
•  
• 2.             AE Department
• Mr Bloggs presents direct to AE via ambulance or
  walk in
•  
• 3.             Regional Units
• Mr Bloggs is transferred from the Regional Unit
  to Southampton University Hospital via ambulance
  to undergo investigations such as coronary
  angiogram 
•  

13
Mr Bloggs has Chest Pain

• 1.             RACPC
• The GP refers Mr Bloggs to the RACPC via
  telephone, fax or referral letter. During the
  clinic Mr Bloggs
•        Sees a Doctor for history and physical
  examination
•        Undertakes a resting ECG
•        Undertakes an Exercise Tolerance Test
  (ETT) (if required)
•        Undertakes further investigations if
  required (e.g. 24 Hr Holter recording,
  Echocardiogram)
•        The Doctor decides on the diagnosis and
  relevant treatment and informs Mr Bloggs
•  
• Mr Bloggs is then given information about the
  RACPC and risk factor information as appropriate.
  His results are faxed to his GP on the same day
  that he attends the RACPC, in addition
  information is sent to CHD Lead Practice Nurse to
  ensure that Mr Bloggs is placed on the CHD
  register and followed up.
•  
• The RACPC results are printed on pale yellow
  paper, this indicates that Mr Bloggs requires an
  angiogram. His results are then sent to the
  relevant secretary and his medical notes are made
  up by the Cardiothoracic library. He is placed
  on the waiting list.
•  

14
Rapid Access Chest Pain ClinicSouthampton
University Hospital Trust

•       Established in November 1994 as a pilot
  to assess demand for service
•  
•       May 1996 Merged with the medical led
  Chest Pain Clinic (similar clinics, on different
  sites)
•  
•       July 2000 in line with CHD NSF guidelines
  and changes to RSH, all Chest Pain Clinics are
  now held at SUHT
•  
•       Presently 8 sessions per week Mix of
  Cardiology Registrars and Clinical Assistants
•  
•       Plans to expand the service by a further 2
  sessions per week and possibly introduce
  out-of-hours/weekend service
•  
•       Pale yellow paper is used for those
  patients seen in RACPC who require angiogram
  this allows for more effective tracing of the
  patient route to the cardiac cath lab
•  
•  

15
Rapid Access Chest Pain ClinicRoyal Hampshire
County Hospital Trust(Winchester Eastleigh
HealthCare

•       Chest Pain Clinic has recently relocated
  to Cardiac Measurement as a one stop clinic thus
  reducing the distance for patients seeing their
  Doctor and having ETTs
•  
•       New guidelines for chest pain assessment
  referral have been developed by a Consultant
•  
•       The guidelines have been circulated to the
  local GPs
•  
•       A new Consultant Cardiologist has been
  appointed and is due to start in April 2002
•  
•       The start date for the new Rapid Access
  Chest Pain Clinic is set to coincide with the
  arrival of the new Consultant
•  

16
Day Case Cardiac Angiography

• The results of Mr Bloggs RACPC referral indicate
  that he requires a further investigation by way
  of a Cardiac Angiogram.
•  
• Mr Bloggs has been deemed suitable for Day Case
  Angiography because he fits the following
  criteria
•  

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18
Cardiac AngiographySouthampton University
Hospital Trust

•        A common waiting list has been devised
  for all angiograms
•  
•        A dedicated escort nurse for the cathlab
  has been identified
•  
• Day Case Angiography
•        There is a regular session per week for
  day cases
•  
•        SUHT angiogram access data has shown that
  there is a definite advantage for patients seen
  in the RACPC in accessing the angiogram service
•  
•        Nurse Practitioners preclerk patients in
  Winchester as part of the regular clinic
•  
•        Winchester patients are given extra
  notice of the clinic appointments thereby
  reducing the DNAs
•  
•        Day case lists are audited by the cathlab
  for reasons for delay, improvements have been
  made since the introduction of pre-clerking
•  
•