Joint runner up in our Awards, the team from an LHCC in Lanarkshire describe how they have helped develop a seamless journey for patients post-MI
Coronary heart disease (CHD) is a leading cause of death in Scotland, causing 11 914 deaths in 2001.1 In the UK, the West of Scotland has the highest incidence of CHD, and the incidence in Lanarkshire is higher still.
Wishaw/Shotts/Newmains/Harthill Local Health Care Cooperative (LHCC) in Lanarkshire has a population of 55 000. The LHCC’s all cause standardised mortality ratio (SMR) is 109, and the SMR for CHD is 107. It also has a higher average number of years of life lost before age 75 years than the Lanarkshire average (21 compared with 16 per 1000 population).2
The management of CHD is seen as a priority in Lanarkshire Primary Care NHS Trust and the local health improvement plan. A review of Lanarkshire’s community cardiac rehabilitation service in 1998 revealed geographical variation in standards of provision, a lack of standard protocols and variation in the expertise of staff delivering the service. Communication between primary and acute care was poor, discharge documentation was inadequate and there was a lack of clarity in nursing roles and responsibilities.
The findings reflected those of an earlier study which looked at provision in the north-east of Scotland.3
The ASPIRE investigators identified the importance of appropriate secondary prevention of ischaemic heart disease in patients who have suffered a myocardial infarction.4 SIGN 41 recognises that a substantial proportion of patients at high risk of CHD go unidentified, while those who do receive treatment may receive suboptimal care.5
All patients following a myocardial infarction are at high risk, and it is important to identify those patients who may benefit from particular treatment or investigations because such a strategy will improve outcomes.5
CHD-trained nurses can significantly improve patient care by promoting a healthy lifestyle and supporting changes in behaviour.There is strong evidence for the efficacy of maintaining CHD disease registers, and recording and monitoring risk factors during follow up in general practice.6
How we improved the cardiac rehabilitation service
Our priority was to create an equitable, evidence-based service, which would provide a seamless journey for patients following MI. A collaborative group involving members of the primary care and acute trust healthcare teams was established by the clinical co-ordinator at the acute hospital. The aim was to provide a forum for communication and sharing of best practice.
The LHCC appointed a CHD lead nurse for the area. A local CHD training needs assessment was carried out, which identified a need for Heart Manual facilitator training and an education programme to ensure an appropriate level of knowledge and skills. Each primary healthcare team identified a nurse with an interest in CHD, to fulfil the role of facilitator.7
The patient pathway
The collaborative group involved patients and colleagues from a range of disciplines in designing a patient pathway (Figure 1, below).The pathway takes the patient through cardiac rehabilitation phases 2 and 3 – the early post-discharge period and a structured programme of exercise with educational and psychological support and advice on risk factors – to a secondary prevention clinic.
|Figure 1: Pathway for patients following myocardial infarction|
A review of post-MI management was conducted within the LHCC to enable us to evaluate progress in the management of lifestyle changes and in recording risk factors and clinical monitoring of patients following myocardial infarction. Data were collected on patients’ smoking, blood pressure, cholesterol, exercise, and use of statins, beta blockers, aspirin and ACE inhibitors.6, 8-15
The review reflected the findings of the initial Lanarkshire-wide audit of services, that the quality of cardiac rehabilitation provision varied across the LHCC.
All the LHCC’s practices now have a practice-based Heart Manual trained facilitator whose core responsibility is to implement the pathway. However, the pathway is negotiable and patient-led – the patient may opt in or out at any stage. The focus of the pathway is holistic and includes assessment of anxiety and depression and social circumstances.
We set up accurate CHD registers, a vital step in planning effective management of post-MI patients.16 We now have a structured and regularly updated computer register using Read codes, which will enable us to set up an efficient recall system to avoid patients being lost to follow up.
However, more work must be done to ensure that data are entered in a standardised way to be retrieved easily for audit and clinical governance.
The success of the project
Between January and February 2003, after implementing the patient pathway, we carried out a further review of data. This related to 57 patients (34 men and 22 women; mean age 64 years) identified by the cardiac rehabilitation service at Wishaw General Hospital, all of whom were discharged with a diagnosis of MI between April and October 2002 (Table 1, below).
|Table 1: Comparison of data on MI patients collected March 2002 and January/February 2003 from Wishaw LHCC practices|
|Patients taking aspirin||80%||87%||90%||82%|
|Patients who have had a cholesterol check||80%||71%||80%||94%|
|Patients with cholesterol <5 mmol/l||50%||40%||50%||74%|
|Patients with cholesterol 35 mmol/l on a statin||10%||11%||10%||14%|
|Patients who have had an annual blood pressure check||80%||79%||90%||100%|
|Patients whose blood pressure is <140/85 mmHg||50%||56%||60%||65%|
|Patients with BMI checked within the past year||60%||73%||80%||84%|
|Patients with smoking history recorded||70%||89%||80%||84%|
|Patients post-MI who do not smoke||50%||28%||50%||67%|
|Patients with alcohol consumption recorded||60%||61%||80%||80%|
|Patients taking a beta blocker||50%||51%||50%||53%|
|Patients who have had urea and electrolytes checked||70%||28%||90%||100%|
|Patients taking an ACE inhibitor||50%||28%||70%||73%|
|Patients taking an ACE inhibitor who have had U&Es checked||70%||21%||70%||100%|
|Patients taking a statin||50%||45%||90%||98%|
|Patients who have had LFTs||70%||32%||70%||74%|
|Patients taking a statin who have had LFTs||70%||24%||70%||69%|
|* Clinical governance targets set by Wishaw LHCC|
The information was collated from computerised and paper records. All data were retrieved confidentially and anonymised. The review was compared with the earlier review carried out before implementation of the pathway.
Comparison between the two reviews demonstrates a significant increase in the monitoring and recording of most clinical data, and lifestyle and pharmacological information.
More patients are now taking statins and ACE inhibitors, more have cholesterol levels below 5 mmol/l and more patients are having their drug dosage titrated. We have improved the provision of services to post-MI patients in line with the recommendations of SIGN 41.5
A patient satisfaction survey conducted by telephone reflected a high level of patient satisfaction.
The learning environment
Primary care and acute care staff are committed to a shared learning environment to meet the needs of all health professionals involved in delivering CHD care.
The collaborative group has provided training for staff in all disciplines with an interest in CHD. The training has included presentations from staff in a variety of disciplines as well as leisure and voluntary groups. A journal club and working lunches also help to address the training needs of all those involved in the management of CHD.
Plans for the future
The patient pathway has achieved what we intended, reflecting the evidence and improving patient care through the implementation of local and national guidelines. It addresses the deficiencies in care of post-MI patients identified by the SIGN guideline on secondary prevention of coronary heart disease.5
Following the second review, we will now re-examine the patient pathway to see how it can be improved. We will include opportunities for referrals to other agencies, for example for help in stopping smoking and dietary advice.
We have introduced cardiac rehabilitation phases 2 and 3 for patients and we are working with leisure agencies and patient groups to establish phase 4 exercise classes in the community.
We hope to extend the pathway to include patients with angina, those who have undergone coronary artery bypass graft or angioplasty, and heart failure patients.
- http://www.show.scot.nhs.uk/isd/heart_disease/heart_ htm
- Lanarkshire Health Board. Annual Report of the Director of Public Health. Lanarkshire NHS Board, 1999.
- Campbell NC,Thain J, Deans HG et al. Secondary prevention clinics for coronary heart disease: randomised trial effect on health. Br Med J 1998; 316: 1434-7.
- (4) Bowker TJ, Clayton TC, Ingham J et al. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996; 75: 334-42.
- Scottish Intercollegiate Guidelines Network. SIGN 41. Secondary Prevention of Coronary Heart Disease following Myocardial Infarction. Edinburgh: SIGN, 2000.
- Scottish Executive. Coronary Heart Disease/Stroke Strategy for Scotland. Edinburgh: Scottish Executive, 2002. http://www. show.scot.nhs. uk/sehd/mels/HDL2002_74.pdf
- Lewin B,Robertson IH,Cay EL, Irving JB,Campbell M. Effects of self help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992; 339: 1036-40.
- Hansson L, Zanchetti A, Carruthers SG et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) Randomised trial. HOT Study Group. Lancet 1998; 351: 1755-62.
- Ramsay LE,Williams B, Johnston GD et al. British Hypertension Society guidelines for hypertension management 1999: summary. Br Med J 1999; 319: 630-5.
- Knowler W C, Barrett-Connor E, Fowler S E et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin N Engl J Med 2002; 346: 393-403.
- Shaper AG, Pococh SJ,Walker M et al. Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study. J Epidemiol Community Health 1985; 39: 192-209.
- Held PH, Yusuf S. Effects of beta-blockers and calcium channel blockers in acute myocardial infarction. Eur Heart J 1993; 14(Suppl F): 18-25.
- Pfeffer MA,Braunwald E, Moye LA et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial.The SAVE Investigators. N Engl J Med 1992; 327: 669-77.
- Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 1993; 342: 821-8.
- Kober L,Torp-Pederson C, Carlsen JE et al. A clinical trial of the angiotensinconverting- enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group. N Engl J Med 1995; 333: 1670-6.
- Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study Group (4S). Lancet 1994; 344: 1383-9.
Look out for joint runner up Harrow PCT’s article in next month’s issue of Guidelines in Practice