CORONARY HEART DISEASE (CHD) MANAGED CLINICAL NETWORK (MCN) PROJECT BOARD Minutes of meeting held at 5.30pm on Thursday 28 May 2009 in Meeting Room 2, Summerfield House Present: In attendance: Videolink request (but failed): Dr Robert Liddell, Chairman, Lead Clinician CHD MCN Ms Brenda Anderson, Cardiac Rehabilitation, NHSG Ms Irene Anderson, Asst.Services Manager, Cardiac Unit, ARI, NHSG Ms Alison Davie, Lead Pharmacist, Aberdeen City CHP, NHSG Ms Roberta Eunson, Service Manager, Aberdeen City CHP, NHSG Ms Linda Juroszek obo Professor George Downie Ms Brenda Lurie, Clinical Effectiveness Facilitator, NHSG Ms Fiona MacDonald, NoS Regional Cardiac Service Improvement Manager Dr Malcolm Metcalfe, North of Scotland Lead Clinician, CHD Ms Manju Patel, Service Planning Lead, Acute Sector, NHSG Mr Robert Paton, Member of the Public Representative Ms Linda Sime, Clinical Governance, NHSG Ms Clare Smith, Unit Operational Manager, Cardiac Dept, NHSG Dr John Stout, Lead GP, CHD MCN Mr Matthew Toms, Unit, Operational Manager, Cardiac Dept., NHSG Dr Stephen Walton, Head of Service, Cardiac Dept, NHSG Mrs Christine Gray, Secretary Mr Tony Collins, Patient Representative Dr Deepak Garg, Consultant, Dr Gray s Hospital Item 1. Welcome and Apologies Actions Welcome: Alison Davie, Brenda Lurie, Fiona MacDonald and Matthew Toms Apologies: Christina Cameron, Mike Crilly, George Downie, Hussein El-Shafei, Dr Andrew Fowlie, Joy Groundwater, David Sullivan 2. Minutes of CHD Project Board MCN on 4 December 2008 Agreed Matters Arising (a) (b) (c) Roddie Wood Prior to the commencement of the meeting, members gave one minute s silence in respect of Roddie Wood who passed away last month. Roddie had been a member of the Project Board since it s commencement and had been Chairman of the CHD Public Involvement Sub Group. Gratitude was expressed for Roddie s hard work and input into the CHD MCN. Holters Clark had delayed purchase until the start of the new financial year. Heart Failure (Athena) Software Roberta stated that the Athena system was a British Heart Foundation database system and investigations were still being made as to whether to go down this route.
Item 3. Presentation Actions Audit of Cardiovascular Unit Discharge Recommendations by Alison Davie and Brenda Lurie An Audit Summary Report had previously been emailed out. (attached for information). A discussion followed to try and identify how recommendations of the audit could be taken forward. Some points noted were: Important to reinforce to clinicians the importance of detailed discharge information To note GPs did not routinely send out an appointment to any patients recently discharged from hospital the onus was currently on the patient to make their GP appointment and see that their drugs were up-titrated if necessary To note that issues with the current discharge information done by flimsy letters and followed on with a paper discharge letter would be eradicated once there was an effective electronic system in place (discussed again at another point in the meeting) It was suggested that discharge information could be emailed to the administrator email addresses at the GP surgeries. Action: Clare suggested as there was a potential patient safety issue re. correct patient medication, there was an NHSG patient safety group in operation and this audit should be placed on their agenda. Following the meeting Alison would make further contact with Clare in order to take matters forward to other group meetings as appropriate. AD/CS General Discharge letters to note that the Project Board have discussed flimsy discharge letters and the issues of illegibility etc. practically at every meeting for some considerable time and all members agreed that the matter was totally frustrating. Malcolm spoke at length about an IT solution to the problem. However, all agreed that it was not for the Cardiac Department or the MCN to make a decision on this matter it was for NHSG at the most senior level to solve this issue. It was agreed that if every hospital department set up their own IT system it would be a recipe for disaster. All agreed that whilst the problem could not immediately be solved, the MCN were to keep the pressure on to try and progress this matter so that there was an effective electronic patient discharge system in place. All Up-titration of medication this matter was discussed and suggestions made so that patients did not miss out on their up-titration. It was suggested discharge information should have a target dose stated. Also patients and their carers needed a clear explanation was to why it was important to have their drugs uptitrated. Community nursing staff doing their home visit could check this out with the patient. 4. CHD Strategy Bob had emailed notes from the CHD MCN Strategy Day which was held on 26 th March. (attached) There was discussion around: Arial Fibrillation to possibly develop an AF Clinic which could be an extended role for the GP with Special Interest in Cardiology (GPwSI) or nurse. 2
Item Strategy for GPs which patients they could be looked after within Primary Care and which patients to refer to secondary care. GPwSI could offer advice to straightforward patients. Cardiomyopathy/valve clinics progress was being made to set up these clinics with no extra resource implications Cardiac Rehabilitation the question was raised as to how the MCN saw Phase 4 cardiac rehabilitation and what support could the MCN give to Grampian Cardiac Rehabilitation Association (GCRA) (Not necessarily financial) but help and guidance as to where Phase 4 should be going in order to try and incorporate the new CHD QIS Standards. Malcolm suggested that GCRA possibly align with other charities e.g. British Heart Foundation to explore a funding stream. To note GCRA wished to appoint a Manager and this would cost approximately 40,000 per year. It was suggested that GCRA could write a business case to a charity and see what develops. Bob stated that the MCN fully supported cardiac rehabilitation and the works they were doing and would welcome hearing more from GCRA as to what they wished to accomplish and would try and support CR in whatever way they could. Cardiac rehabilitation would be included in the CHD strategy document. Manju stated that it was important not to lose anything that was captured in the strategy day and suggested an action plan of care groups to see the strategy moving forward. Bob assured Manju that this would be the case. Actions 5. QIS Draft Clinical Standards on Prevention and Treatment of CHD Bob had attended an NHS Quality Improvement Scotland (QIS) consultation event on 16 th April and made some notes on the day that he had forwarded to members. (attached). It was noted that members received extremely short notice for invitation to this Consultation Day apparently QIS had sent the notice out via the wrong channels. After some discussion and comments made by members, it was agreed that Bob would submit a co-ordinated response on behalf of the MCN to Quality Improvement Scotland. RL 6. Cardiology Fellowship 2009/10 Proposed dates and an invitation flyer were emailed out for information. It was noted that Island Boards were keen to be involved e.g. Orkney GPs. Fiona would circulate notice around Island Boards. To note, however, dates set were provisional at this stage and needed to be confirmed with Dr Hannah. FM 7. NHSG Local Delivery Plan Clare gave an update There was an Acute Sector Planning Day held on 22 May. Discussed: Access Targets, Staffing European working time and the day touched on MCNs as well. There was commitment to deliver cardiology within the Community. There was a need for an equitable ECHO service. Brenda had given a talk on cardiac rehabilitation and Phase 4 was mentioned. Thrombolysis in the community, paramedic support discussion to note once technology was sorted the service could be commenced. Audit primary PCI service also. 3
Item 8. North of Scotland Regional Delivery Plan Actions To note Fiona MacDonald Service Recruitment Manager was now in post. Discussed: Optimal Reperfusion Therapy (ORT): Grampian are behind Highland and Tayside. Highland has introduced a "decision support" mechanism for front-line staff attending patients with potential STEMI. The ECG can be electronically transmitted to the CCU and assistance re thrombolysis etc made. The uptake was slow initially but now seems to be running well. Highland hope later in the year to commence day-time PPCI which will be coordinated by this system too. Tayside are planning to introduce PPCI shortly too. Electro physicist: A new start to commence in post on 14th July which would be half funded by NoS and half by the Consortium. EP Service: This is likely to be the biggest growth area for cardiology in the short to medium term. Radiofrequency ablation (RFA) is becoming an increasing option not only for paroxysmal but sustained AF. CRT devices for heart failure are likely to be implanted in patients with lesser degrees of failure at least doubling current numbers. Implantable defibrillators (ICDs) have been devolved to other Boards but Grampian is likely to see a progressive increase in implantation rates for primary reasons as the region is currently behind the UK as a whole. CS expressed a concern that the increased numbers were not funded but MM pointed out that this was in the EP business case approved by the Chief Executives for each Board. SW also pointed out the clinical difficulty in restricting potentially life-saving treatment. Angioplasty: Highland are hopeful of starting a service of 200 cases per annum in the near future subject to BCIS approval. Whilst revenue funding has been approved capital to develop a new cardiac cath lab has not as yet. They will therefore start their service in a modular facility. TAVI (trans-arterial valve implantation): Has been funded to a limited extent for the patients in Grampian. Scotland-wide discussion is ongoing about establishing a Scottish centre. Device closures: Service not provided yet to look into this. Telehealth: It was agreed that this was useful for follow up patients, however, seeing new patients via this method was more difficult but all agreed to strive to use more telehealth services locally. To note Stroke/Neuro were building in a telehealth service at ARI. Cardiology would look into this also. 9. Community Cardiology Clinics Inverurie Treadmill needed replacing as problems could be incurred if it broke down. Clare stated that the clinic would need to submit an application to JMEC as soon as possible. Chest Pain Clinics waiting list ok. Open Access ECHOs waiting list was long. Trying to produce referral guidelines. BNP it was suggested to talk to Dr Andrew Hannah regarding what stage he was at in considering BNP development. Peterhead Funding to note the Harbour Board had donated funding for Peterhead Clinic to buy equipment. 4
Item Actions Over 40s Screening it did not look likely that this screening could be considered due to funding implications. AstraZeneca were keen to be involved in primary screening and were willing to support nurses at GP Practices to do this. 10. One Day Workshop in Improvement Methodologies for the NHS Scotland CHD Community 26 February 2009 Quality Improvement Scotland Irene attended this event and reported back to the group. To note Clare Smith and Dr John Stout also attended the event. It was a good day well motivated speakers. The key message was to commence collecting useful data rather than perfect data to just make a start on this. Safety and quality were high on the agenda. There were innovative ideas regarding improvement/audit plus patient safety. Discussions followed regarding struggling with IT systems and getting no where and the problems with illegible discharge information etc. Action: To invite Stuart Scott and Managerial IT group to come along to the next CHD MCN meeting to explore how IT issues could be taken forward. Christine would contact Stuart Scott and Irene would see if a SCI representative could attend. CG/IA 11. (a) AOCB Unit Operational Manager, Cardiac Dept, ARI Matthew Toms was welcomed to the meeting. He would be taking over from Clare who was moving to the Surgical Unit. Thanks were expressed to Clare for all her hard work during her time in the Cardiac Unit. 12. Dates of Future Meetings 24 September 09 at 5.30pm Summerfield House 26 Nov 09 at 5.30pm Summerfield House 5
Audit of Cardiovascular Unit Discharge Recommendations Date Published Summary Report AUTHOR(S) Dr M Elfellah (1), Alison Davie (2), Brenda Lurie (3) (1) Specialist Pharmacist, Aberdeen Royal Infirmary, (2) Lead Pharmacist, Aberdeen City CHP, (3) Team Leader/Clinical Effectiveness Facilitator, Clinical Governance & Risk Management Unit INTRODUCTION Good communication between primary and secondary care is very important in order to ensure seamless care for patients when leaving hospital. 1,2 In the UK, a hand-written discharge summary (flimsy) letter is given to the patient. The summary contains information about the admission, including, diagnosis at discharge from hospital, co-morbidities and a list of currently prescribed medicines. The summary is given to the patient at discharge and a copy either posted, or as in Grampian given to the patient to hand in to their general practitioner. The hand-written discharge summary is usually written by a junior doctor and is followed by a detailed typed letter written by a more senior doctor. The aim of this project was to audit any discrepancies between the hand-written and typed discharge letters and to determine whether the recommendations in the discharge letters had been acted on in general practice following patient discharge from Aberdeen Royal Infirmary. METHOD A pilot project took place in Aberdeen City Community Health Partnership (Aberdeen City CHP) to identify any discrepancies between the flimsy discharge letter and the typed consultant s letter for patients discharged from the Cardiovascular Unit at Aberdeen Royal Infirmary. It was agreed with the Aberdeen City CHP Lead Pharmacists that practice pharmacists would undertake the data collection. The pilot was completed in May 2006 and identified a number of issues about the quality of discharge information and whether discharge recommendations from ARI were being acted on in general practice. A number of changes were made following the pilot. A larger study began in early 2007. 68 patients from participating practices in Aberdeen City CHP were identified for inclusion in the audit whilst receiving inpatient treatment at the Cardiovascular Unit, ARI. 64 data collection forms were returned to the Clinical Effectiveness Team for analysis. 22 patients were excluded from the audit during data collection and so the results of the audit are based on the analysis of 42 data collection forms. RESULTS (n=42) 29 (69%) flimsy discharge sheets were received at general practices within seven days of being signed and dated at ARI. 30 (72%) were easy to read however 10 (24%) were difficult to read and 1 (2%) was very difficult to read. For 18 flimsys (43%) the pharmacists indicated that they would not be able to easily contact the prescriber from the information provided on the flimsy discharge sheet. 20 (48%) formal discharge letters were received in the practices within two weeks of dictation and 33 (79%) within four weeks of dictation. There were a number of discrepancies between the information contained in the discharge flimsy and the discharge letter. Most were not deemed to have been significant but some could have affected patient care. Of the 33 recommendations from ARI regarding continuing treatment in general practice with a drug started while the patient was in ARI five had not been actioned although there was a valid reason for not doing so in four patients. 12 discharge flimsys contained recommendations for dose titration. Six patients did not have their dose titrated although there were valid reasons for not doing so in two patients. GPs had changed the drug regimens of 14 (33%) patients after discharge and there were appropriate reasons for doing this for 13 (93%) of these patients. 6
CONCLUSION Interventions to improve communication should be made at various points in the admission discharge cycle. Hospital clinicians should be made aware of the importance of completing the discharge flimsy as comprehensively as possible, given the time taken for full discharge recommendations to arrive in primary care. Primary care clinicians should ensure that robust systems are in place both for dealing with the immediate recommendations of discharge communications and the subsequent requirement for ensuring patients medical records are updated. This in turn will help to ensure accurate information is available to hospital clinicians, should a patient be re-admitted or referred for a specialist consultation. ACTION PLAN Dissemination of results December 2008. Remind medical staff that the reasons for starting and stopping medicines should be written on the flimsy to avoid inherent omissions Remind medical staff and independent/supplementary prescribers to write their contact details legibly and ensure that all copies in the flimsy are legible Remind clinicians that the discharge flimsy letter should be filed in the patient record in order that it is available when the discharge letter is dictated Remind GPs to act on recommendations in the flimsy and typed discharge letters 7
Notes from CHD MCN Strategy Day March 2009 Prevention - We will have a prevention strategy. We will be better at identifying and managing risk factors. Ideally, we will be offering systematic screening for risk factors from age 40. CHD Stable CHD - Almost all patients with stable CHD will be managed in general practice all will be offered an appropriate level of rehabilitation. Acute Coronary Syndrome All heart attack patients will be delivered to a heart attack centre without delay. - ST segment elevation myocardial infarction people within 60 minutes travel time will have PCI 24/7. The rest will receive thrombolysis and rescue PCI if necessary. - Non STEMIS and unstable angina we will reduce the length of stay in hospital by reducing the waiting time for pre discharge angioplasty (by extending opening hours of cath labs) Heart Failure - We will concentrate the efforts of the heart failure specialist nurses on the patients most at risk ie. those in the first 3/12 following hospital discharge, where there is the best evidence for reduction in mobility when HF nurses are deployed. - We will have clarified the best diagnostic algorithm for HF (ie. BNP/echo). Atrial Fibrillation (AF) - The vast majority of patients will be managed in general practice. - There will be clarification of the role of the specialist (ie. cardioversion and electrophysiology). - GPSIs will take on AF as part of their role. Valvular Heart Disease We will have streamlined arrangements for follow up of valve patients (probably a technician led service). - We will have started to perform percutaneous aortic valve replacement. Adult Congenital Heart Disease (ACHD) - We will have improved arrangements for the 200 patients with ACHD. Cardiomyopathy - We will have a specialist clinic for cardiomyopathy. 8
Arrhythmias, electrophysiology and devices More patients will be fitted with implantable defibrillators. More patients will be offered radiofrequency ablation (RFA) for paroxysmal atrial fibrillation (PAF). More patients with heart failure will be treated with cardiac resynchronisation devices (CRT). More closure devices will be used for example, for patients with patient foramen orale who have had strokes, and for patients with atrial fibrillation who cannot be antioagulated and can be offered atrial appendage closure in order to prevent stroke. In view of this, increased cath lab time will be needed, and in time probably a third cath lab. (Note: CRT devices approx 5,000 ICD approx 12,000-13,000 CRT/ICD combined approx 17,000-18,000) Education We will have a clear education programme for patients, nurses and GPs. 9
Dear Colleagues Re: Draft Clinical Standards On Prevention and Treatment of CHD I recently attended a consultation event on these standards. We have a chance to feedback both individually and as an MCN. I would like to take any feedback to the MCN board and submit it thereafter. (Christine ask QIS if we can submit at end of May) I attach the standards (Christine please attach to e-mail) for information. I made some notes on the day that you may find useful. P11 Standard 2.5 printed immediate discharge letter. P12 3.1 & 3.2 need CHD action plan for training and education and a designated lead. P13 Standard 4 a lot of resource implication as goes well beyond QOF in terms of primary prevention. 4.2 & 4.3 may be impossible to identify these individuals. P14 5.4 refers to rapid access chest pain service and patients who need such a service. Change in language desirable P16 Information will be extracted from SAS on our behalf. P20 10.1 significant resource issue for cardiac rehab. P22 11.5 do we really want patients with well controlled SVT to be referred to electrophysiologists? P23 Standard 12 extraction tools being written for practice systems and we will be given results. Note goes beyond what practices currently offer patients with AF, and certainly beyond what is coded. P24 13.5 big resource implication if ICD is to be extended to this group of patients.. P26 Standard 14.6 why refer patients with HF and preserved LV function to cardiology? Massive numbers of patients. Certainly not evidence based. P30 17.1 refers to patients who are persistently in NYHA III IV. Please e-mail comments to Christine and we can include them in our discussions at the next project board. Yours sincerely, DR ROBERT W LIDDELL CLINICAL LEAD ABERDEENSHIRE CHP
Reply to QIS Feedback from Grampian Cardiac MCN on Draft Clinical Standards on Prevention and Treatment of CHP Thank you for receiving our comments after the official deadline. We considered the standards at our MCN meeting on 28 th May. Standard 4 = Substantial resource implication as goes well beyond QOF in terms of primary prevention. 4.2 & 4.3 it may be impossible to identify these individuals in any systematic fashion. Standard 5.4 = This should be stated to refer to a rapid access chest pain service. Standard 11.5 = The MCN does not accept that it should be standard practice to refer all patients with SUT. Standard 12 = Much of the information is not coded in GP notes and will not be extracted. A manual audit will be time consuming and not acceptable to practices. Standard 14.6 = The MCN does not accept that patients with diastolic heart failure should be referred almost all are and will continue to be managed perfectly well within primary care. 11