Published: 11/11/2004, Volume II4, No. 5931 Page 26 27

As cardiology pathways co-ordinator at a Middlesbrough trust, Sarah Bolton has improved care by making communication more effective and streamlining contact between patients and staff.She explains how it was done

Managing patients with acute coronary syndromes (ACS) - heart attacks, unstable angina - poses one of the biggest challenges in cardiology.

Patients require complex packages of care because of related co-morbidities.And the increase in patients referred to tertiary centres for further management of their ACS is putting pressure on waiting times for urgent procedures.

ACSs account for approximately 120,000 of UK hospital admissions a year.At the James Cook University Hospital in Middlesbrough they comprise up to 90 per cent of all urgent cardiology referrals. In April last year, the trust developed a new role - cardiology pathways coordinator - in an attempt to tackle the rise in waiting times for patients requiring further management of ACS and to improve the patient experience.

The role of the cardiology pathways co-ordinator is to optimise patient care delivery across different pathways and provide equity of access for all cardiology patients, in particular those requiring further ACS management.

At a recent coronary heart disease collaborative conference, it was flagged up as an example of good practice that should be adopted more widely.

Government policy is for people and processes to be focused on the patient journey.More specifically, the coronary heart disease national service framework highlights the need to put systems in place to ensure that patients with suspected or confirmed CHD receive timely and appropriate treatment and investigation.

The James Cook University Hospital cardiology directorate serves a population of approximately 1.5 million, with referrals from 11 secondary care hospitals in northern region. Before the appointment of the cardiology pathways co-ordinator, inter and intrahospital transfers were beset by poor communication and haphazard, unco-ordinated practices.

Feedback from patients in a revascularisation process mapping exercise confirmed the need for a more coordinated approach that reduced the number of professionals with whom patients come into contact, thereby minimising error, duplication and delay.We needed to ensure that bed and cardiac catheter laboratory capacity were used to their maximum potential and that care was delivered in a timely manner and directed to those with most to gain.

Once the co-ordinator was appointed, collaboration with key individuals across the trust and referring hospitals, together with channels of communication to medical and nursing colleagues, was crucial in developing the role and addressing expectations.Moreover, this approach speeded up service development.

Preliminary work focused on what information and communication systems were already established in the trust that could be used to support the patient journey.

Only then were additional processes developed to enhance existing systems.

Local clinical guidelines for the management of ACSs had existed within all referring hospitals for years. But there had been resistance to making them more prescriptive because we wanted to maintain a dialogue between the tertiary centre and referring hospitals and to preserve individual clinical judgement.

Establishing key roles and responsibilities around the co-ordination of the patient journey provides greater clarity for healthcare professionals and patients. But the biggest impact has been the presence of the cardiology pathways co-ordinator as a single point of contact.

Access to high-quality, accurate information can directly influence patient flow. The cardiology pathways co-ordinator met with cardiologists to determine and negotiate the basic structure of their operating list and patient case-mix. This information was qualified by previous work examining time taken by each consultant to perform specific procedures and has enabled realistic operating lists to be compiled. Uncertainty surrounding the timing of procedures has all but been eliminated and the ritualistic practice of 'routine' starving (for procedures requiring general anaesthetic) arising from such uncertainties has been removed.

To ensure that operating lists were both effective and realistic in delivering the elective and non-elective noninterventional and interventional programmes, demand and capacity needed to be calculated.Data from a number of sources, including patient case-mix and consultant timings, suggested that 14 patients requiring urgent cardiology investigation or intervention could be scheduled each week. Referral data collected from November 2002 to March 2003 suggested that the directorate received 13 referrals per week, so there appeared a congruency between capacity and demand.

But on closer inspection it was clear that the data only included referrals from secondary care hospitals and not from within the trust itself. Capacity was also underestimated as the information on consultants' elective case-mix did not include variations in clinical need.

Data collected now accurately reflects the demands of the service. Regular feedback to cardiologists on how elective waiting lists are impacting on urgent cases allows them to manage their case mix better. As a result, capacity for urgent procedures has risen from 14 to 24 per week.

Better co-ordination, changes to elective patient case-mixes, improved demand and capacity calculations and the appointment of an additional interventional cardiologist have enabled us to reduce our waiting times for urgent procedures. For example, the average wait from date of referral to date of procedure for all patients requiring angiography and/or angioplasty fell from 10 to six days from April 2003 to March 2004. In addition, the disparity between waiting times for patients referred from secondary care compared to those referred internally has dropped from eight days to one.

Within the trust itself there was a need to establish greater equity of care for patients requiring further management of their ACS. Before the appointment of the cardiology pathways co-ordinator, nurse practitioners were only available to heart patients in the cardiology unit.

The role of the nurse practitioner is to optimise patient management for those requiring cardiology intervention and/or investigation by providing clinical expertise, pre and post-operative information, health promotion and education and obtaining informed consent.

Patients on non-cardiology wards who did not receive this service often had their treatment delayed.Now all heart patients receive the service, ensuring equity of care across the trust.

The principles of this service improvement are now being extended to cardiac surgery, to ensure similar improvements in the management of care for patients awaiting urgent procedures who require complex packages of care during the pre-operative phase. Nurse practitioners will be responsible for managing the patient journey and co-ordinating care.

Support for the role of the cardiology pathways coordinator, and the principles it embodies, is growing nationally. Research suggests that the development of services that combine greater co-ordination and high levels of interaction amongst healthcare professionals will result in improved patient outcome.

Sarah Bolton is South Tees Hospital trust cardiology pathways co-ordinator.

Key points

The James Cook University Hospital appointed a cardiology pathways co-ordinator to reduce waits for those with acute coronary syndromes.

The approach, in line with the coronary heart disease national service framework, has reduced error, duplication and delay.

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