Telecare, cardiology

Delivering expert cardiac support in the community

Cardiac conditions such as coronary heart disease represent the single biggest burden on the NHS today, from primary through to acute care — the estimated cost in the UK is over £34 billion in treatment, provision of care and non-health costs such as loss of productivity and informal care (British Heart Foundation Statistics Database, 2006). (1)

Research findings estimate that the cost to the taxpayer of treating patients who are admitted to hospital as cardiac emergencies is around £305,000 per patient (Dr Foster Intelligence, 2006), highlighting the extent of the burden on secondary care provision in the NHS.(2)

Only 10% of the British population are free from all the major risk factors for coronary heart disease. Individuals with no obvious risk factors are still more likely to die of myocardial infarction than from any other cause (Moulton and Yates, 2006).(3)

It’s an issue which Government and Department of Health (DoH) initiatives have sought to address, by increasing public awareness of cardiac complaints, in order to detect and diagnose any problems at an earlier stage, ensuring more preventative and proactive care can be delivered in primary healthcare settings, thereby helping to free up resources in secondary care.

Cardiology in a primary care setting

The concept of diagnosing and treating cardiac problems within the primary care setting at an earlier stage is a fundamentally sound one — improving care for patients by providing more timely and preventative support, and also helping to reduce the overall burden on the NHS, by reducing the need for emergency ambulances and visits to acute trusts.

One issue that must be considered however is that cardiology is a highly specialised branch of medicine, whereas non-cardiac nurse practitioners and general practitioners, by their very nature deliver more general care over a much wider medical spectrum.

At Bridgwater Community Hospital, only an estimated 5% of patients attending the minor injury service require an ECG as part of their clinical assessment. While all senior nurses are from emergency care backgrounds, not all have been able to maintain their skills in ECG interpretation, especially the ability to detect subtle but important ECG changes.

Chest pain is a worrying symptom for both patient and nurse practitioner. The patient knows that chest pain occurs in a heart attack and the nurse practitioner is aware that the symptoms of myocardial infarction can be very different from the classical descriptions in the textbooks.

Deciding the best approach for ECG analysis

Previously, all patients with chest pain or known cardiac conditions were referred automatically to the neighbouring acute NHS trusts for assessment, diagnosis and management. Such an approach was time-consuming, often stressful for the patient and placed a significant workload on secondary care provision as well as on the ambulance service.

A number of alternative services were considered, including remote ECG monitoring and interpretation carried out with the help of secondary care providers within the NHS community — an approach which involved 12-lead ECGs being faxed for the attention of the emergency medicine or cardiology services. However, not only did this represent a drain on acute resources, there was also the drawback that there was no guarantee of a rapid response, as clinicians are not desk based, and are not always readily available to give an immediate analysis.

A study by Grimshaw et al (2005) found that NHS ECG telemetry practice in the UK was far from standardised, and was considered haphazard, variable and poorly supported by adequate protocols.(4)

The approach favoured at Bridgwater Community Hospital was a cardiac telemedicine service. A six-week pilot of the service was trialled and used for all patients requiring an ECG as part of their clinical assessment. The pilot with Broomwell Healthwatch proved successful, and was duly rolled out on a permanent basis. As opposed to the telemetry services described by Grimshaw, Broomwell is an NHS-accredited dedicated national cardiology reporting service with clear operational guidelines and defined responsibilities supporting best practice.

The service is now an integral part of an overarching healthcare initiative to deliver enhanced diagnostic support at a primary care level. Bridgwater Hospital now has a minor injury service, managed by advanced emergency nurse practitioners supported by senior nurses and staff nurses between 7am and 11pm seven days a week. It provides urgent unscheduled care for around 20,000 patients a year with a greater scope to treat a wider range of medical complaints than many similar services, reducing the pressures on neighbouring acute trusts.

A key element of this new approach was the assessment and diagnosis and where possible treatment of non-cardiac chest pain in the community. The ECG analysis service has been used for over 600 patients at Bridgwater to date. It has proven to be a vital diagnostic aid for nurse practitioners both in making informed clinical decisions and improving outcomes. Importantly the service has also helped provide robust clinical risk management.

The obviously ill patients are relatively easy to manage; these patients receive prompt intervention, stabilisation and rapid referral to the appropriate facility — either the emergency department or coronary care unit at the Acute Trust. All nurse practitioners are certified by the Resuscitation Council as advanced life support providers. Those patients with subtle signs and symptoms are more challenging to manage, however, and this is where Broomwell’s expert service is of most benefit.

The ultimate clinical responsibility rests with the nurse practitioner managing the patient. All staff are acutely aware that a normal ECG does not exclude a developing myocardial event, and as such all chest pains and collapses are treated cautiously. However, the telemedicine service has proven to be an invaluable clinical aid.

The service also ties in well with the DoH’s ‘chest pain awareness campaign’. The early identification of cardiac risk factors coupled with prompt and expert cardiology advice on 12-lead ECGs provides a safe and effective service to our local population.

Telemedicine ECG – how it works

A major advantage of the telemedicine ECG service is its ease of use — readings can be carried out by all grades of staff before being sent off for analysis. When the ECG is complete, it is transmitted as a sound signal by landline telephone or by fax in just 45 seconds to Broomwell’s monitoring centre, where it is displayed on screen for interpretation by cardiologists.

Based on the high quality ECG trace, Broomwell staff give an immediate verbal interpretation by phone so that action can be taken quickly, if needed. A full written ECG report is returned to the minor injury service by fax for inclusion in the patient’s clinical notes, usually within eight minutes.

Reaping the benefits

There has been overwhelming support for the service among clinicians. Having access to fast expert advice on sometimes complex cardiac issues is an invaluable aid, assisting in the delivery of optimal patient care.

A number of GPs within the area have contacted the minor injury service and expressed an interest in joining the service — they see it as an integral part of modern healthcare provision and want it for their own surgeries.

The ECG reporting service has also delivered clear cost benefits on a wider cross-trust scale. It has reduced the number of patient referrals to the local acute hospitals, freeing up beds and reducing some of the pressures on the ambulance service and local emergency departments.

Another area where it has brought real and tangible benefits is that of staff development, refreshing skills potentially lost when senior nurse practitioners transferred from emergency medicine in the acute sector to primary care. For junior staff it’s a fantastic learning opportunity, giving them a greater understanding of cardiac monitoring and how to interpret results.

Patient-focused care

The benefits of using telemedicine to bring essential health services closer to patients have been warmly embraced not only by nurse practitioners and other clinical staff, but also by patients — the response from patients has been overwhelmingly positive, and the benefits to patients speak for themselves.

Coupled with detailed history taking, physical examination and cardiac telemedicine, fast and accurate diagnosis can be made, and the majority of patients are discharged from the minor injury service, reassured that they are not suffering from any immediately threatening condition.

Those that are in immediate danger are stabilised and transferred to definitive care — the interpretation service brings emergency department diagnostic standards into the community.

It’s also more convenient for patients to attend their local and trusted community hospital than travel some considerable distance for non-emergency care; patients, especially the elderly, are often much less stressed and anxious.

A case in point

The service has already proven effective in saving lives. Recently, a patient attended having fallen and sustained a fractured distal radius and ulna. A staff nurse identified a slow heart rate and performed a 12-lead ECG, revealing a profound bradycardia with heart block — probably the cause of the fall.

Broomwell confirmed the ECG as a complete heart block and the patient was transferred directly to the coronary care unit for immediate pacing, the fractured wrist finally getting manipulated two days later! Without the astute observation of the staff nurse and Broomwell’s reporting service the heart block could have been overlooked with potentially devastating outcomes.

Proven benefits — UK pilot provides further proof

Bridgwater Community Hospital has not been alone in its approach of using cardiac telemedicine to improve patient care and help alleviate some of the burden on NHS resources.

A number of pilots across the UK have highlighted the benefits of a telemedicine ECG service, and how it has been successfully harnessed to reduce avoidable hospital admission and save millions in NHS costs.

A six-month pilot of cardiac telemedicine services, which involved 15 GP practices and two NHS walk in centres in Cumbria and Lancashire (all using Broomwell Healthwatch’s reporting service) has demonstrated the potential to save 90,000 A&E visits, 45,000 hospital admissions and hundreds of lives each year in England (NHS North West 2006).(5)

The pilot results also estimated the minimum savings to the NHS from the use of telemedical ECG tests at £46 million per year, simply by cutting unnecessary hospital admissions and emergency department visits for symptoms of chest pain.

Data from the pilot showed that 82% of patients receiving ECGs did not need to go to hospital (neither emergency department nor outpatients) following the test — giving rapid reassurance and reducing stress and anxiety.

The results of the pilot showed that access to ECG tests through this technology can save hundreds of lives each year by early detection of heart problems. Such early detection is proven in helping to avoid irreversible heart damage. A further benefit is that patients can be accurately diagnosed within local healthcare settings, instead of having to travel to hospital for testing.

This pilot has helped to demonstrate not only the benefits to patients — accessing care in the local community and preventing unnecessary trips to hospital — but also the potential financial benefits to the NHS. Cardiac telemedicine is an excellent way to ensure that expert advice is available in a matter of minutes, not only to the patient but also to the healthcare professionals involved with the care.

A win-win situation

I am of the strong belief that cardiac telemedicine services such as this should be deployed more widely within the primary care environment — for Bridgwater Hospital it has been like bringing some of the diagnostic standards of an emergency department to a small but busy community hospital.

Both the North West pilot and the work done in Somerset over the past 18 months all point to the overriding benefits, both to patients with cardiac conditions and to those tasked with treating them.

Cardiac telemedicine for Bridgwater has brought the expertise of leading cardiologists right into the immediacy and convenience of the primary care setting, meaning that patients receive early, preventative care in their local environment.

The approach Bridgwater has taken has not only reduced avoidable admissions into emergency departments, it has reduced the number of 999 calls relating to cardiac problems, as many of these can be managed by nurse practitioners at the hospital or by GPs in their surgeries.

It is precisely this sort of proactive, preventative approach which will not only help to provide more timely care for those that need it, but will also help ensure NHS resources are optimised and used as effectively as possible.

Mike Paynter is Nurse Practitioner in Emergency Care at Bridgwater Community Hospital in Somerset.

References

1. British Heart Foundation Statistics Database, 2006.

2. Dr Foster Intelligence, 2006.

3. Moulton C, Yates D. Emergency Medicine.  Blackwell Publishing, Oxford, 2006.

4. Grimshaw A, Stefano E D, Saltissi S. Current ECG telemetry practice in the UK: a national audit.  British Journal of Cardiology, 2005; 12:142-144.

5. Cardiac Telemedicine in Primary Care: Delivering Benefits for Patients and the NHS in Lancashire and Cumbria. NHS North West, 2006.