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Ischaemic heart disease surveillance clinics

Elaine Fullard
MBE RGN RHV
Director
National Primary Care Facilitation Programme
Oxford Centre for Innovation, Oxford

Lilian Vincent
Bsc(Hons) NP(Dipl) SRN
Nurse Practitioner North Solihull Primary Care Trust
Solihull
West Midlands

Evidence that the contribution of nurses can have significant impact on the improvement of care (for example, smoking cessation,(1) hypertension,(2) secondary prevention of heart disease,(3) and heart failure(4)) strengthens the case for nurse involvement in the primary, secondary and tertiary care of heart disease. There is, however, a gap between the current evidence of the scope for health gain in heart disease and its implementation. Establishing a structured approach is one way of improving performance, and an initial baseline audit/review of the clinical notes can inform areas of success and identify room for improvement.

Establishing structured care within a nurse-led clinic
Protected time, space and team support are prerequisites. Timesaving opportunities need to be addressed: could phlebotomy be carried out by someone else? what non-nursing duties could be relinquished? what non-evidence-based clinical work could cease? A system that ensures patients have the required blood tests before their annual review will make time spent on consultation more efficient. An agreed protocol that includes target group detail, aims of care and the specific organisational, clinical and audit plans would also save time.
Advice on non-pharmacological management, patient education and sources of patient information need to be included, as well as targets for treatment, referral guidelines and training opportunities for the nurse starting the clinic. An example of such a protocol can be found in Appendix A, page 23, of the National Service Framework on Coronary Heart Disease (CHD). British Heart Foundation (BHF) Heartsave Courses are available nationally for nurse training.

Creation and maintenance of a disease register
Inclusion on a register greatly increases the likelihood of patients being adequately assessed and optimally treated.(5) A total of 70% of eligible patients can be identified by first identifying patients already given specific Read codes relating to CHD, then cross-referencing them with a drug search for patients prescribed nitrates. By adding aspirin to the search, 96% of eligible patients can be identified. Other methods of identifying patients include: when diagnosed with the GP; capturing information from discharge letters; tagging repeat prescriptions; publicising clinics by posters in the surgery or the practice newsletter; and referring all new CHD patients to the clinic.

Organisation of care
Calculate the number of hours needed to offer annual review with sufficient time for more frequent follow-up for some patients. A practice of 10,000 patients will have between 300 and 500 patients with established CHD (incidence rates of 3-5%). By allowing a 20-minute initial consultation and a 10-minute review for those requiring follow-up, five hours of nursing time was estimated to be sufficient to see every patient at least once a year.(6) However, should the treatment of heart failure be included in these reviews, the consultation time may need to be lengthened.
It is worth considering others who could assist - for example, the cardiac rehabilitation team or the BHF liaison nurse - as they may organise home visiting following discharge after myocardial infarction. Consider too the methods that are in place for the fast transfer of information from the hospital. It may be worthwhile appointing a "named" nurse within the practice to receive and act on information on patients being discharged home.

Record-keeping and ongoing audit
Computer templates for management and review are available on all general practice software systems, although
many of them need to be modified to be in line with current guidelines. Some patient-held records have been developed, although there is currently no evidence that these improve care.
A programme of continuous audit is needed for team motivation, to fulfil requirements for the clinical governance
teams and to review any outstanding gaps in performance.

References

  1. Yudkin PL, Jones L, Lancaster T, Fowler GH. Which smokers are helped to give up smoking using transdermal nicotine patches? Results from a randomized, double blind, placebo controlled trial. Br J Gen Pract 1996;40:145-8.
  2. Robson J, Boomla K, Fitzpatrick S, et al. Using nurses for preventive activities with computer assisted follow up: a randomised controlled trial. BMJ 1989;298:433-6.
  3. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998;316:1434-7.
  4. Stewart S, Morley JE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999;354:1077-83.
  5. Moher M, Yudkin P, Turner R, et al. An assessment of morbidity registers for coronary heart disease in primary care. Br J Gen Pract 2000;50:706-9.
  6. Fullard EM. Organization of secondary prevention of coronary heart disease in primary care: the nurse's perspective. Coronary Health Care 1998;2:193-201.

Resources
British Society for Heart Failure
Encourages nurse membership
T:01235 537780
F:01235 537782
E:bsh@cbcoxf.com
W:www.cbcoxf.com