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Description and Development of a Nurse-Led Cardiac Assessment Team

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Description and Development of a Nurse-Led Cardiac Assessment Team ORIGINAL RESEARCH Future Healthcare Journal 2020 Vol 7, No 1: 78–83 WORKFORCE Description and development of a nurse-led cardiac assessment team Authors: C h u n S h i n g K w o k , A T a m a r a N a n e i s h v i l i , B S o n i a C u r r y , C C h a r l o t t e A s t o n , D M i c h e l l e B e e s t o n , C S a r a h C h e l l , C J a m e s C r i p p s , C B o b G u n t e r , C D e b b i e J a c k s o n , C D i a n e T h o m a s ,C A n g e l a J o n e s , C H e l e n B e t h e l l , C K u l l y S a n d h u , E D o t M o r g a n - S m i t h F a n d R h y s B e y n o nG A problem was identified where patient care was affected hospitals, accounting for 10% of all inpatient episodes among 2 because of delays in receiving specialist cardiology input. This men and 6.2% among women. Pressures on hospital resources report describes the experience of developing a specialist has led to a need for early specialist review so as to improve the cardiac assessment where senior cardiac nurses were trained to patient journey and reduce unnecessary admissions. provide a 24-hour presence in the emergency department (ED). Timely specialist input is critical in some cardiology conditions, ABSTRACT We describe the service and our evaluation of the service. These such as acute myocardial infarction, acute heart failure and dedicated specialised nurses can optimise patient management ventricular arrhythmias, and cardiology departments struggle to including admission or safely discharge patients with relevant provide immediate specialist review due to lack of trained staff. follow-up when necessary. The team also runs three clinics per Most district general hospitals (DGHs) do not have a dedicated week with consultant support. The team of 10 nurses provides cardiology registrar on call out of hours and in tertiary centres a cardiology opinion to approximately 400 patients a month the on-call cardiology registrar may be busy in the catheter lab or in the ED and 100 patients a month in the acute medical unit managing acute emergencies. Therefore, there is great interest in (AMU). Eighty-seven per cent of patients are seen in the ED developing innovative ways, such as a nurse-led service, to improve within 30 minutes of referral. Approximately 40% of patients and provide more rapid cardiology specialist input. reviewed are accepted directly into cardiology beds thus A few previous studies have evaluated the role of nurses in avoiding admission to the AMU. It has been estimated that 6 early triage of patients. One study compared the management bed-days are saved each day, which translated to an estimated of non-ST elevation myocardial infarction patient prior and post £400,000 each year. The team also provides outpatient rapid development of a nurse-led early triage and found significant access services which generates £121,792 income for the increases in electrocardiography performed within 10 minutes of directorate. We demonstrate that a cardiac nurse assessment admission, higher rate of prescription of clopidogrel and greater 3 team can provide a cost-effective 24-hour presence in the ED. number of patients being managed in coronary care unit. T h e r e has also been an audit describing use of fast-track troponin KEYWORDS: Nursing , cardiac assessment team , cardiology measurements and specialist chest pain nurses which reduced time from chest pain onset to troponin blood test, reduced admissions to Introduction the hospital wards from the acute medical receiving unit, reduced 4 Cardiovascular disease is a major problem in the UK, associated admission time and reduced length of stay. This combination of fast-track measurements and specialist nurses saved approximately with significant morbidity and mortality which is a huge burden 4 to healthcare services. 1 Cardiology conditions account for a 2,000 bed-days per annum and released 5–6 acute beds per day. significant percentage of patients attending the emergency Specialist nurses have also been evaluated in triaging patients with syncope and have been found to have low predictive accuracy in department (ED) and any medical take. In the UK, there were more 5 than 1.6 million episodes related to cardiovascular disease in NHS identifying high-risk individuals. There has also been a qualitative study of nurses’ cardiac triage decisions and they found that the nurse’s ultimate goal is to have the patient receive prompt electrocardiography and prompt medical evaluation and to Authors: A cardiology registrar, Royal Stoke University Hospital, advocate for the patient. 6 While nurses are aware of age and sex Stoke-on-Trent, UK ; B core medical trainee, Royal Stoke University differences in myocardial infarction presentation, some nurses still Hospital, Stoke-on-Trent, UK ; C cardiac specialist nurse, Royal Stoke hold cultural biases and stereotypes that may interfere with timely University Hospital, Stoke-on-Trent, UK ; D directorate manager, Royal delivery of emergency cardiac healthcare. 6 Stoke University Hospital, Stoke-on-Trent, UK ; E cardiology registrar, We describe our cardiology services before and after the Royal Stoke University Hospital, Stoke-on-Trent, UK ; F advanced nurse development of the cardiac assessment nurse team. This practitioner, Royal Stoke University Hospital, Stoke-on-Trent, UK ; description includes the specifics of the selection and training of G consultant cardiologist, Royal Stoke University Hospital, Stoke-on- the nurses and the services they provide. In addition, we describe Trent, UK our evaluation of the cardiac assessment nurse team service. 78 © Royal College of Physicians 2020. All rights reserved. FFHJv7n1-Shing-Kwok.inddHJv7n1-Shing-Kwok.indd 7788 22/13/20/13/20 33:51:51 PPMM Nurse-led cardiac assessment team Cardiology services at our centre definitive assessment or investigation being arranged. Some patients were unnecessarily admitted with conditions that In addition to a coronary care unit and two cardiology wards, our could be managed at home with the help of rapid access clinics. cardiology service has four catheter labs (including a dedicated Significant patient dissatisfaction was noted with these delays and electrophysiology lab) and one minor procedure room for nurse-led the local health economy perceived the pathway negatively due to loop recorder implants / direct current cardioversion. We also have the cost burden of additional outpatient appointments following a primary percutaneous coronary intervention (PCI) service and ED presentation. Discussions with consultants from the ED and we are the largest pacing/device centre in UK and in the top six AMU revealed frustration with the level of cardiology input into PCI (by volume) centres. We have a large structural heart disease the emergency portals. Like most hospitals in the UK, the Royal programme in the catheter lab with transcatheter aortic valve Stoke had significant bed pressures and outpatient appointment implantation, Mitraclip, atrial septal defect closure and left atrial waits, and this traditional model did little to help reduce the length appendage occlusion procedures. Furthermore, we undertake a full of stay and clinic backlogs. An example of patient flow prior to spectrum of electrophysiology work and we have cardiothoracic development of the cardiac specialist nurse team is shown for a surgery on site. patient presenting with chest pain (Fig. 1 ). Area for improvement in cardiology care Proposed solution to improve care: cardiac In the UK, patients presenting to ambulance crews or EDs with assessment nurse team service acute ST elevation myocardial infarctions, complete heart block or A working group of consultants, senior nurses and managers ventricular tachycardia are usually directly referred to tertiary cardiac concluded that what was needed was a 24 hours a day senior units or managed by DGH consultant cardiologists on call from cardiology presence in the ED. Ideally this would be provided by a home. These cases form a small portion of the patients presenting stable workforce who would divert patients directly from the ED with potential cardiac conditions. The majority of patients are seen to the cardiology ward if appropriate, would assess and arrange in the ED by ED doctors with three possible outcomes. appropriate outpatients investigation and follow-ups for patients > Discharge from the ED without follow-up. who could be managed at home, and would reassure those patients > Discharge from hospital and referred to cardiology outpatient who were not thought to have a significant cardiology condition. services. It was clear to the department that the consultant body would > Transfer to acute medical receiving units where patients are not be able to provide this role, the on-call registrar was already too assessed on the post-take ward rounds. These patients are busy and we were unlikely to be able to attract enough registrars to then often referred to cardiology units to be seen on the next provide a second cardiology on-call team. A potential solution was to cardiology ward round. intensively train a dedicated team of specialised senior cardiac nurses to be supported by the on-call registrar and consultants. A team of six A group of cardiology consultants, senior nurses and managers would be required to provide a 24-hour presence in the ED. concluded that this traditional model could be improved with the delivery of more timely care for patients at our tertiary centre.
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