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Speeding up cardiac care

Creating a rapid access chest pain clinic in Newham, East London
Why was the initiative launched?
What was done?
Rapid access Chest Pain Clinic - referral criteria
Is it working?
Tips for success
For more information contact

Creating a rapid access chest pain clinic in Newham, East London


Why was the initiative launched?


Growing recognition that the outpatient service was unsatisfactory prompted action by the Cardiology Department at Newham Hospital. Waiting times were lengthening and putting patients at risk. These problems were strengthening local GPs' demands for open access to a range of cardiac diagnostic procedures such as ECG and exercise testing.

Local Consultants were reluctant to support the development of open access facilities that would simply report on the results of the individual test without the benefit of clinical opinion. This dilemma prompted the examination of ways to speed up the assessment and diagnosis of patients with chest pain in ways that would not unduly hamper already stretched local cardiac services.

What was done?


Discussions between representative local GPs and the Department of Cardiology agreed that the solution might be to develop a local rapid access chest pain clinic. The clinic would offer a prompt diagnostic service for a limited group of patients. Criteria to guide referral to the clinic were agreed. The new clinic would not be a substitute for the existing mechanism for emergency referrals for suspected acute myocardial infarction and unstable angina.

Rapid access Chest Pain Clinic - referral criteria


No previous history of treatment for coronary heart disease.
Recent onset of chest pain, i.e. within the last 2 to 4 weeks.
Age limits: men under 30 years and women less than 40 years would not be seen.

To accommodate the new clinic, adjustments were made to the cardiology work programme and time set aside for the clinic to operate from 12 noon until 2 pm every weekday. The clinic would be led by Dr Ranjadayalan and cardiologists would man the clinic on a rota basis. Any necessary test would be done immediately. The siting of the clinic within the hospital would enable the full range of diagnostic tests to be undertaken like ECG, exercise testing, X-ray etc. The local GP fundholding group (at the time) agreed to meet the additional costs involved.

A dedicated fax line was set aside within the Cardiology Department allowing immediate referral from primary care practices to the clinic. Patients referred by GPs in a morning would be seen at the clinic on the same day: those referred in the afternoon seen the following day. There was a guarantee that patients meeting the referral criteria would be seen within 24 hours. The fax line would be accessible only to medical staff to safeguard patient confidentiality.

A computer-based proforma was designed to guide the cardiac assessment. This included a limited range of information fields: the use of drop-down menus simplified completion. Associated software created a computer-generated report for the GP. The letter was semi-structured with details of diagnosis, cardiac history, risk factors, investigation results and recommended treatment and follow-up arrangements. The report was faxed to the GP as soon as the consultation was completed.

When hospital-based care and treatment is required patients are given appointments for the regular cardiology outpatient clinic: follow-up would not be managed within the Rapid Access Chest Pain Clinic.

Is it working?


Since the new service was launched in January 1996, about 75 patients each month are being seen at the clinic, with the number growing steadily each year (Table). The service is well regarded by local GPs and patients. The mechanism for providing prompt computer-generated reports has been well received. A recent local study, using a detailed questionnaire sent to the 120 GPs who refer to the new service, showed that over 80% of GPs preferred the new approach when compared with the traditional dictated letter.


Table: Referrals to the new clinic over three years


    Monthly range
Year Total patients Low High
1996 592 30 70
1997 734 45 81
1998 853 53 86

The diagnoses made in the first 2160 patients are shown in the Figure. Sixty-nine percent of cases had chest pain of non-cardiac origin. Most patients (75%) could be referred back to the GP after the diagnosis. Admission or additional tests like angiography were rare, but 19% of patients had a subsequent hospital clinic appointment.


Figure: Diagnoses and outcomes in about 2,160 patients referred to the new clinic


 


 


The operation of the clinic is discussed regularly with local GPs as part of the local CME programme. Experience has shown that the sessions are helpful to GPs - normally about 50 GPs attend the sessions that are organised every six months. Case studies based on recent referrals are used as to illustrate good practice and for example to stress that those patients who did not meet the criteria would not be seen. They would be offered an early appointment at the "normal" outpatient clinic.

The new service has had no noticeable impact on other local cardiac work within the hospital -- the pressure on the outpatient clinics continues. Reflecting the number of patients seen at the clinic and their more prompt assessment, it is very likely that the service has had an impact of local cardiac health. After initial funding from the local fundholding GPs, support continues through the local PCG.

Tips for success


Get the criteria for the new service right and agreed -- and stick to them.
Make the service user-friendly: keep promises to GPs and see patients, and report on them promptly
Make communications between the hospital clinic and primary care practices reliable and safe.

For more information contact


Dr Adam D Timmis
Department of Cardiology
Consultant Cardiologist
London Chest Hospital
Bonner Road
London E2 9JX

Email adam@timmis-lch.demon.co.uk
Fax 0181 983 2278

The following materials are available:

The protocol - with full criteria for access to the clinic.
The input proforma (used in the clinic).
A sample of the (report) letter/fax to the GP.

ImpAct bottom line

Make new services work and be successful, so good that ways have to be found to resolve any funding issues.

 

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