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Listen to your heart: results of the NiP/Omron UK CVD survey

Cardiovascular disease (CVD) is the most common cause of death in the UK. But many conditions associated with CVD are preventable and nurses can play a major role in their management. The Nursing in Practice/Omron UK survey looked at your experience of CVD

Elaine Linnane
Editor-in-Chief
Nursing in Practice

Cardiovascular disease is an ongoing and ever-increasing burden on the modern health service. Heart and circulatory diseases are the UK's biggest killer. In 2004, cardiovascular disease (CVD) caused 37% of deaths in the UK, and killed just over 216,000 people.(1) And every day in the UK there are 350 preventable strokes or heart attacks due to high blood pressure.
And then there are the associated conditions, such as diabetes and obesity, rarely out of the health media headlines.
It makes sense that cardiovascular disease features prominently in the day-to-day graft of the primary care nurse. But just how much knowledge and experience is there among primary care and community nurses? The latest Nursing in Practice online survey, sponsored by Omron UK, aimed to gauge the current level of knowledge of cardiovascular disease. And here are the results.

Training and education
Almost 86% of respondents had undertaken some type of basic training in cardiovascular disease, the most popular being inhouse training, with PCT training and reading/web learning not far behind. "I think it is really positive that so many nurses have done some form of training - even if it is fairly basic," commented Linda Goldie, Clinical Director at the Primary Care Training Centre.
However, worryingly, this left 14% of respondents who said they had never undertaken any type of basic training in cardiovascular disease. Marilyn Eveleigh, consultant editor of Nursing in Practice, believes that this figure is pretty poor. "With an average practice caseload having about 10% of registered patients with heart disease, this is sad," she commented. "It should be a core competency of nursing practice and certainly one to include in an induction training programme."
In terms of accredited training, 31% of respondents had completed an accredited course. The type of course included:

  • A diploma in primary care coronary heart disease prevention.
  • A diploma in secondary prevention of coronary heart disease.
  • As part of the BSc nurse practitioner course.
  • Part of advanced clinical skills training -  Masters level module.
  • Heartsave course (now Education for Health).

As a follow-up to this respondents were asked whether they felt comfortable working with patients with cardiovascular disease. A resounding 72% answered yes - "Having attended numerous study days over the past four years, along with reading journals and inhouse training, I have the confidence to work with patients with cardiovascular conditions," explained a practice nurse from London.
However, 28% answered no to this question. "I need more information so that I can offer the correct advice to the patients in my care," replied a community matron from Huddersfield. "The changing roles of the community nurse have come along too fast and many people are now responsible for cardiovascular reviews who are not adequately qualified, but are under pressure to still complete reviews with limited knowledge. I believe this is potentially harmful to the patients in our care."
Marilyn Eveleigh believes that this is a dilemma for many practitioners in a variety of situations: "The NMC code requires all nurses to work within their competency, and each registrant is accountable for their actions." Linda Goldie agrees: "The community matron's comment is so true. They work as autonomous practitioners, generally with prescribing rights and they really should be doing much more formal training which assesses knowledge and skills."
A total of 87% of respondents kept their knowledge up-to-date by reading professional journals and 45% by using the Internet (see Table 1). In comparison just 36% kept CV knowledge up-to-date by attending training courses.

[[nip43_table1_18]]

Of our respondents, 21% were independent prescribers, and 20% said that they regularly prescribed medication for cardiovascular disease, including ACE inhibitors, aspirin, ß-blockers and statins. Prescribing was very much based on local guidelines, which in turn were in line with NICE and SIGN guidelines.
With cardiovascular disease so prevalent it is important to identify those at risk as early as possible. Figure 1 lists the different ways that our respondents used to identify those at risk.

[[nip43_fig1_18]]

Blood pressure
High blood pressure affects over 16 million people in the UK, and according to the Blood Pressure Association, this includes a third who do not even know they have high blood pressure. Around half of all over-65s have high blood pressure (defined as blood pressure above 160/95 mmHg), and 125,000 people experience a stroke each year at a cost of £2.3 bn to the NHS and social services.(2)
Taking a person's blood pressure is one of the very basic skills learnt during nursing training, and not surprisingly 92% of respondents routinely take their patients' blood pressure, with just over 75% saying that this was because of QOF. Keeping a record of blood pressure features in several of the QOF indicators, not just for hypertension, but also CHD, stroke and for those aged over 45. This screening data is important in raising the profile of hypertension and in being able to plan future healthcare needs and services.
Respondents were asked what they routinely do when their patient has a low/high blood pressure reading. Figures 2 and 3 show the answers to this, but comments seem to echo the response of this practice nurse from Manchester: "If this is a first raised reading I would arrange to repeat it for a further two
readings on separate occasions. I would discuss lifestyle factors such as weight, smoking, diet and exercise. If further readings are still high I would refer to a  GP for commencement of treatment and further tests, such as ECG and bloods."

[[nip43_fig2_19]]

[[nip43_fig3_19]]

Clinical Knowledge Summaries (previous Prodigy) do not recommend the routine use of ambulatory blood pressure monitoring in primary care. However, it should be considered:

  • When the blood pressures show unusual variability.
  • When hypertension seems to be resistant to drug treatment.
  • If "white coat" hypertension is suspected.
  • If hypotensive symptoms are present in people with hypertensive clinic values.
  • To identify nocturnal hypertension.
  • To determine the efficacy of drug treatment over 24 hours.
  • Forty-two percent of respondents use ambulatory BP monitoring in their practice. In addition, 41% would recommend to patients that they hire/purchase self-monitoring BP machines and 34% lend these machines to patients.

Infection control
Infection control in the primary care setting may not attract as much attention as that in hospitals. However, the large number of patients treated, and changes in the organisation of primary care services resulting in an increase in screening procedures and minor operations, gives substantial opportunity for transmission or acquisition of infection. Nurses need to be aware of current good practice including the need for effective infection control policies and appropriate decontamination of surgical instruments.
With this in mind it was perhaps surprising to discover that almost 50% of nurses said that BP cuffs are never decontaminated in their practice. This may seem like a minimal infection risk, but a study in France recognised the potential of BP cuffs as a vector of pathogenic microorganisms among patients in a hospital, and to a smaller degree this could also apply in primary care.(3)
Of those who do regularly decontaminate their cuffs, a range of materials is used, including general purpose cleaning cloths, soapy water, detergent, antibacterial wipes, surgical spirit and disinfectant spray. The CPHVA website recommends that reusable cuffs are cleaned with warm water and detergent between patient use. If visibly soiled with blood or body fluids, reusable cuffs should be cleaned according to your practice's spillage policy. For patients with a known or suspected infection, consider using a disposable cuff. It also advises that you always follow the manufacturer's instructions and adhere to local procedures and policies.

Atherosclerosis
Arteries stiffen as a consequence of age and atherosclerosis. The two leading causes of death in the developed world, myocardial infarction and stroke, are both a direct consequence of atherosclerosis. Increased arterial stiffness is associated with an increased risk of cardiovascular events. The augmentation index is a measure of systemic arterial stiffness derived from the ascending aortic pressure waveform.
Only 5% of our respondents had heard of the augmentation index for measuring arterial stiffness, but none of them actually measured this. Similarly, only 3% of practices record their patients' central systolic blood pressure.

ECG
Seventy-three percent of respondents were trained in the correct use and application of a 12-lead ECG, but only 22% were trained in the correct interpretation of the results. Again surprisingly, 50% of respondents said their ECG leads are never changed, in contrast to 20% who said their leads are changed after every use.
If a patient has an abnormal ECG 89% of respondents would routinely refer them to their GP.

Atrial fibrillation
Atrial fibrillation is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation with consequent deterioration of atrial mechanical function. It is the most common sustained cardiac arrhythmia. In 2006/07 the QOF register for atrial fibrillation included all those who currently have a clinical diagnosis of AF, including those who have
paroxysmal (intermittent) AF.
We asked our nurses how many patients they had on their AF register - 28% had fewer than 30, 42% had between 30 and 100, 24% had between 100 and 200, and the remainder had over 300. Nearly one-third (30%) of respondents said that AF screening was carried out by the nurse, 39% said it was done by the GP, and 21% said that patients were referred to hospital for AF screening. AF patients were diagnosed by 12-lead ECG in 76% of cases.

Support
Appropriate ongoing treatment can only take place with the right support network in place. It was therefore heartening to find that 57% of respondents had a GP lead for cardiovascular disease in their practice and 62% had access to a specialist cardiovascular nurse. "Great news that over half of respondents have access to a specialist CV nurse," commented Linda Goldie. "Could it be that the others just don't know that the nurse is there - most areas do have specialist CV nurses."
Seventy percent of practices also had nurse-led clinics available to patients with or at risk of cardiovascular disease. Examples of these included:

  • A cardiac rehab clinic, and rapid access chest pain clinic run by a community heart failure specialist nurse.
  • A cardiac nurse-led rapid access chest pain clinic available at the local hospital.
  • A hypertension clinic run by a practice nurse.
  • Healthy heart clinics run by the health board, PCT nurses and doctors.
  • A CHD clinic run by a practice nurse with appropriate training.
  • An ischaemic heart disease clinic in practice run by nurses.
  • A heart failure clinic provided by the PCT with community facilities run by heart failure-trained nurses.

In addition, 91% of respondents had a nurse/HCA-led smoking cessation group available in their practice/PCT (there are now QOF points available for those patients with CHD, stroke or TIA and hypertension, who smoke and have been offered smoking cessation advice or have been referred to a specialist service in the last 15 months); 59% had exercise groups available; and 73% had a weight management group. Linda Goldie believes that the availability of resources for primary care nurses to help patients make lifestyle changes to improve their health is great. "The role of the healthcare assistant is invaluable here - as long as they too have had adequate training," she added.
Primary care and community nurses are in an excellent position to offer lifestyle/dietary advice to their patients, both opportunistically and in dedicated clinics. Not surprisingly, 94% of our respondents said that they do routinely offer patients advice, on exercise, reducing salt intake, eating five portions of fruit and vegetables a day, smoking cessation and so on. Seventeen percent also routinely recommend alternative or complementary therapies, the main examples being relaxation techniques, aromatherapy, acupuncture, hypnosis, yoga, reflexology and massage. "I believe that alternative therapies have a part to play in the management of cardiovascular disease," said Linda Goldie. "Patients with a long-term condition are more prone to depression. Nurses need to be alerted to this and consider the effect that stress and depression has on their overall ability to manage their condition. Alternative and complementary therapies may benefit some patients leading them to be able to self-manage more effectively, improving both quality and quantity of life."
Other sources of support information recommended to patients included:

  • The British Heart Foundation (leaflets and information on website).
  • The Patient UK website.
  • Diabetes UK.
  • The British Hypertension Society.

Conclusion
Considering the breadth of knowledge primary and community nurses need to meet the planned and opportunistic needs of patients, this survey is very positive. There are some elements that need to be built upon - training in care underpinning knowledge being one. Clarity and consistence need to be made around ambulatory blood pressure machines and infection control and equipment. Nursing in Practice will bring some of these answers in future editions.

This cardiovascular disease online survey took place from 12 May to 3 June 2008. A total of 845 primary care nurses completed the survey - 77% practice nurses, 15% nurse practitioners, 5% district nurses, 3% health visitors. In terms of geographical spread, 78.5% came from England, 14% came from Scotland, 3% from Wales, 2% from Northern Ireland and 2.5% from overseas. The survey was sponsored by Omron UK.

References

  1. Joint British Societies' (JBS 2) guidelines on the prevention of cardiovascular disease in clinical practice were prepared by the British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society and The Stroke Association.
  2. Rothwell PM. The high cost of not funding stroke research: a comparison with heart disease and cancer. Lancet 2001;357:1612-16.
  3. De Gialluly C, Morange V, De Gialluly E, Loulergue J, van der Mee N, Quentin R. Blood pressure cuff as a potential vector of pathogenic micro-organisms: a prospective study in a teaching hospital. Infect Control Hosp Epidemiol 2006;29:940-3.