A countywide angioplasty service is speeding up recovery times through multi-trust cooperation, reports Alison Moore
Primary angioplasty is the gold standard treatment for many heart attack patients, offering a better chance of survival, quicker recovery and improved quality of life afterwards.
The dynamics of working across multiple PCTs, multiple trusts and multiple staff groups have been for us the main achievement
But introducing it in a health economy can be a difficult and lengthy project as it is unlikely to be offered at all hospitals.
In Kent and Medway, all suitable heart attack patients are now being taken to the William Harvey Hospital in Ashford, just off the M20 motorway. This can mean patients travelling 40-50 miles and bypassing other hospitals with accident and emergency departments. Although the new system has only been live since April, the results are encouraging, with patients discharged rapidly.
But setting up the new care pathway took two years and close working with primary care trusts, other trusts, GPs and the ambulance service.
Cardiac/respiratory services manager Gary Lupton says: “It’s preparation, preparation, preparation which has contributed to its success.
“The dynamics of working across multiple PCTs, multiple trusts and multiple staff groups have been for us the main achievement.”
The new £2.5m a year service would have financial implications for NHS organisations throughout the county. Other trusts would lose income as they would no longer treat emergency patients or offer them immediate aftercare. East Kent Hospitals University Foundation Trust would double the number of procedures it did (some procedures are done electively) and would need to run a 24/7 rota involving interventionist cardiologists and specialist nurses.
PCTs would include some additional costs initially - the stents, which are inserted to improve blood flow in arteries, cost up to £450 and several may be needed for some patients. However, they would benefit from shorter lengths of stay and less care needed in the future: angioplasty patients are often “cured” while many patients who are thrombolysed go on to require surgery.
The ambulance service would need to invest in equipment to take ECGs and transmit them to Ashford; crucial to ensuring only appropriate patients were taken to the William Harvey.
A business case for the new service showed that at the estimated 500 patients a year, the national tariff for the work would not cover costs so, with the support of the Kent cardiovascular network, a premium of over 10 per cent above tariff was agreed with PCTs. Longer term the service should be roughly cost neutral for PCTs as the patients require less care during the rest of their lives. Length of stay has also dropped to three and a half days, compared with six and a half for older treatments.
Cooperation from other trusts would be needed to staff a 24/7 service at the William Harvey and meet a 150 minute “call to balloon” time for patients.
Clinical sign-up from the county’s cardiologists was boosted by the strong evidence that patients would benefit. Ten cardiologists - drawn from the four trusts in the county - now provide the on-call rota, staying at the hospital if necessary, while East Kent Hospitals University Foundation Trust provides the in hours service using its own cardiologists.
Although other trusts are not performing the immediate work, patients are likely to be referred back to them for longer term rehabilitation.
Nurses on the cardiac unit also agreed to new ways of working, including longer days. Staff now cope with much sicker patients on a regular basis and feel confident and competent in dealing with them.
Any concerns of staff have been largely allayed by the buzz they get from seeing patients recover, says Mr Lupton.
In the early days of the service, daily briefings were held to discuss any immediate problems. Monthly clinical governance meetings look at difficult cases.
The new service also requires ambulance staff to act differently: they no longer deliver a patient to the nearest A&E. Instead, protocols have been drawn up with South East Coast Ambulance Service Trust under which ambulance staff take an ECG from patients with chest pains. This is electronically transmitted to the cardiac catheter unit at the William Harvey (and can be sent on to a consultant by smartphone) and the ambulance staff will be advised whether or not to bring the patient in. The patient then bypasses A&E, is brought straight into the unit and can be in theatre within minutes.
And the benefits for patients? Ambulance staff have been able to stay to see people’s pain almost disappear as the stent is inserted via an incision on their wrist.
Longer journey but swifter recovery
Persuading the public that an extra 30 minutes or longer in an ambulance is actually better for the patient is also challenging. “There is no doubt that it is beneficial to go to a specialist centre - the delay in getting there is well worth it,” says cardiologist Intisar Mirza.
Advertising on local radio and articles in local papers have also highlighted the benefits of the new service. And the recovering patients are often the service’s best advert; one man was back home three and a half days after a heart attack and digging his garden on day six.
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