Black Country CHD Collaborative

1
Black Country CHD Collaborative
Programme
The Team Programme Clinical leadDr. Paul
Giles Programme DirectorMr. Phil Griffin St.
Johns Medical Centre High St Walsall Wood
Walsall, WS9 9LP Office No. 01543 362025 Fax
No. 01543 372552 Project 1 - Secondary
Prevention Clinical Lead Dr P Giles, Consultant
Cardiologist, Walsall Hospitals NHS
Trust Project Manager Office No. 01543
362025 Mobile No. Project 2 - Suspected or
Confirmed AMI Clinical Lead Dr Ian
Robertson-Steel, Medical Director,
WMAS Project Manager Mrs Kate Burley Office No.
01902 643061 Mobile No. 07775 778505
Project 3 - Angina Clinical Lead Dr Alan
Cunnington, Consultant Cardiologist, Walsall
Hospitals NHS Trust Project Manager Mrs Carol
Reilly Office No. 01543 362025 Mobile No. 070946
702540 Project 4 - Heart Failure Clinical Lead
Dr Mark Payne, Consultant Cardiologist, Walsall
Hospitals NHS Trust Project Manager Miss Joanne
Gutteridge Office No. 01922 721172 Mobile No.
07946 702536 Project 5 - Revascularisation Clinic
al Lead Dr John Pidgeon, Consultant
Cardiologist, Royal Wolverhampton Hospitals
NHS Trust Project Manager Mr Thomas
Jinks Office No. 01902 643 061 Mobile No. 07946
702544 Project 6 Rehabilitation Clinical Lead
Mr Mark Walsh, Advanced Nurse Practitioner CHD,
Walsall Hospitals NHS Trust Project Manager
Suzanne Ursell Office No. 01902 643061
2
Improvement Changes Forum established for
patients and carers enabling them to become
involved in the work of the collaborative
projects. Hand held record designed by patients
and carers to be tested across the whole care
pathway for Coronary Heart Disease. If trial
successful, we intend to roll out to all CHD
patients. Call 999 campaign, a collaborative
project involving a number of stakeholders was
delivered involving local patients and carers,
radio, press and television. The campaign has
also developed an Art into Health project around
AMI and posters and leaflets with information on
AMI circulated to many public venues including
supermarkets. The aim of the campaign has been
to educate people about the symptoms of heart
attack and the immediate action to take. We hope
that the outcome of the campaign will lead to a
reduction in the onset of pain to call for help
and therefore improve the overall pain to needle
times. Some of the collaborative projects are
linking into work locally around the development
of a whole systems electronic health record.
This will allow a health care professional
locally to view data held on different systems.
So for example, a GP could access data held on
hospital and community health data
systems. Programme continues to deliver changes
that are improvements as demonstrated by
continual movement towards targets within each of
the measures. Improvements through innovation
funding
3
Spread Black Country CHD Network Board have
agreed priorities for spread in Wolverhampton and
Dudley. Clinical Leads have been identified and
project details are being worked out. Monthly
programme of spread events has continued subject
areas covered in the quarter include
Revascularisation, Rehabilitation and AMI. These
have helped to share the work of the programme
with a wider audience. Evaluation of these
events has shown it to be a tremendous success
and of value to those who attended. Local media
campaign is being delivered to inform the local
communities on development work of the
collaborative and improvements that have been
made possible in all the change strategy areas.
Supporting the Birmingham, Solihull and Sandwell
Collaborative in its development. Networking
with Local Implementation Teams, Health Action
Zones, Primary Care Trusts and the Birmingham and
Black Country Strategic Health Authority.
Sustainability Establishing networks across the
health economy who will act as vehicles for
continuous change and improvement, ensuring that
best practice is maintained and spread as
widely as possible, so that as many patients as
possible within the network area benefit from the
Collaboratives work The collaborative has begun
to engage with PCT commissioning
processes. Inter-linking care pathways with other
disease areas. e.g. diabetes, Chronic Obstructive
Pulmonary Disease.
4
Black Country CHD Collaborative
Angina
Contact Details Clinical Lead Dr. Alan
Cunnington Walsall Hospitals NHS Trust 01922
721172 Project Manager Mrs Carol Reilly C/o St
Johns Medical Centre High Street Walsall
Wood WS9 9LP Office 01543 362025 Fax 01543
372552 Mobile [phone] E-mail
reillyc_at_gp.walsall-ha.wmids.nhs.uk
Aim statement Optimise appropriateness of
referrals to RAAC and to meet NSF targets to be
seen within two weeks of referral. To implement
treatment plan and monitor compliance with the
aim of improving outcomes in terms of symptom
relief and patient experience for patients
presenting at the South/East PCG in Walsall.
Spreading across North/West PCG into
Wolverhampton and Dudley.
5
Improvement Changes Rapid Assessment Angina
Clinic (RAAC), consultant led, one stop, four
clinics a week established to meet the 14 day NSF
target. Faesability to meet fluctuating demand.
Referral criteria refined to improve referral
process and ensure appropriateness of referrals.
Systems put in place to enable information to be
sent to GPs and patients within five days.
Patient and Carer information updated and
disseminated from the clinic. Information prior
to consultation includes map of department with
an overview of the visit to the clinic and after
the consultation on life style, angiography
procedure, rehabilitation. National database for
Rapid Assessment Angina Clinic commenced to
enable management plans to be e-mailed to
GPs. Paper system established for partial booking
patients into general cardiology clinic. A
database system to be tested. In-patient
pre-assessment and rehabilitation referral
refined for day case angiography
patients. Results from the questionnaires and
discovery interviews have enabled the project to
give more information and support to patients and
carers from secondary and primary care. A patient
and carer forum has been established for the
Black Country Cardiac Care Collaborative. A
patient and carer have joined the Angina Core
group since attending the forum, to enable their
continued involvement in the work. Patients and
carers are supported in the community by staff
undertaking the training for the Angina Plan.
6
Spread Involving patients and carers from
across the borough in the ongoing work of the
project, enabling them to see themselves as part
of the same system, e.g. hand held record,
contact list for patients and carers. Establishing
links with other projects across the whole of
the patient pathway. Networking with new
Collaboratives and clinicians from Wolverhampton
and Dudley in the spread area, involving them in
the project meetings, to enable spread of the
methodology and setting up of clinics, e.g. Rapid
Assessment Angina Clinic. Networking with
stakeholders in GP practices, Trusts, Primary
Care Groups/Trusts, Health Authorities and the
voluntary and Private Sector in Walsall,
Sustainability Funding established to maintain 14
day National Service Framework target. Funding
secured for a static catheter lab on the Manor
Hospital site, to enable the target to be met for
angiography waiting times. Electronic system for
general cardiology clinics, to enable all
patients to partially book their outpatients
appointment. Electronic storage of ECGs in Manor
Hospital, Walsall from AE, RAAC, MAU and
CCU. National database for RAAC to enable
information to be e mailed to GP the same day as
patient has attended the clinic and copied to
patients and carers.
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Black Country CHD Collaborative
(A)MI
Contact Details Clinical Lead Dr. Iain
Robertson-Steel Medical Director West Midlands
Ambulance Service NHS Trust 01384 215555 Project
Manager Kate Burley C/o St Johns Medical
Centre High Street Walsall Wood WS9 9LP Office
01543 362025 Fax [phone] Mobile
07775778505 E-mail Burleyk_at_gp.walsall-ha.wmids.nh
s.uk
Aim statement Our aim is to reduce the time
from the onset of chest pain to when the patient
calls for professional help, thereby reducing
overall pain to treatment times. Within this we
aim to shorten pain to call times, reconfigure
the administration of thrombolysis as necessary,
to deliver pain relief (opiates) in the minimum
appropriate time, to ensure a defibrillator and
trained person arrive with the patient as soon as
possible.
8

• Improvement Changes
• Successful launch of the developed comprehensive
  Pain to Call campaign to increase the publics
  awareness of the importance of calling for help
  early when experiencing chest pain/discomfort .
  Four initiatives have been introduced which are
  
• Local television coverage and programme,
• Drama group enactment being rolled out to public
  areas such as pubs, clubs etc. telling the
  story of a heart attack victim.
• Public awareness posters.
• Leaflets which are issued by General
  Practitioners to at risk patients.
• Many ambulance service improvements which enhance
  the patients journey from Call to Door these
  are
• The introduction of 12 lead ECG capability into
  Walsall based ambulances, this practice produces
  a more comprehensive and thorough reading of the
  electrical conductivity of the heart, thereby,
  increasing the identity of more AMI patients,
  which the crews are using to alert the receiving
  hospital.
• Chest pain score criteria developed for the
  determination of alerting the receiving AE unit
  or for direct access into CCU.
• Official Door time agreed as the at hospital
  time recorded by the ambulance services Patient
  Report Forms (PRFS) and Automatic Vehicle
  Location system (AVL)
• Introduction this spring of opiate pain relief
  (Morphine Sulphate)
• Lead thrombolysis nurse appointed in AE unit at
  Walsall Manor Hospital.
• Consistent time being recorded due to the
  purchase of atomic clocks in both the AE and CCU
  departments at Walsall Manor Hospital.
• Results from the questionnaires have enabled all
  6 projects to give and gain more information and
  support to and from patients and carers,
  especially through the patient and carers
• forum that has been established for the Black
  Country Cardiac Care Collaborative.

9
Spread Involving patients and carers from
across the borough in the ongoing work of the
project, enabling them to see themselves as part
of the same system. Dispersal of good practices
and sharing of ideas which are working well in
Walsall as a result of the PDSAs which have
prove successful and gone through the process of
improvement. Establishing links with other
projects across the whole of the patient pathway.
Networking with new Collaboratives, both
locally and nationally and with clinicians and
contacts from Wolverhampton and Dudley in the
spread area, involving them in the project
meetings, to enable spread of the methodology
e.g. Pain to Call initiative. Networking with
stakeholders in GP practices, Trusts, Primary
Care Groups/Trusts, Health Authorities and the
voluntary and Private Sector in Walsall.
Sustainability Funding to maintain the supply of
Pain to Call posters and leaflets to sustain
and reinforce the message that is already
beginning to have an impact on influencing the
publics awareness of the importance of calling
for help early when experiencing chest
pain/discomfort. Identify local General
Practitioners who would take on a proactive
programme of Pre-hospital thrombolysis in the
borders of the Walsall community. Role out of 12
lead telemetry systems on West Midland Ambulances
to be provided by Mobimed Introduction of JRCALC
recommendations to the ambulance service for the
delivery of Pre-hospital thrombolysis by
paramedics. Continuation of Direct Access for
MI/?MI into CCU at Royal Wolverhampton Hospital,
and role out into the Dudley hospitals.
10
Black Country CHD Collaborative
Cardiac Rehabilitation
Contact Details Clinical Lead Mr Mark
Walsh Walsall Hospitals NHS Trust 01922
721172 Project Manager Mrs Suzanne Ursell C/o
Walsall Cardiac Rehabilitation Trust Heart
Care 30 Hollyhedge Lane Walsall WS2 8PT Office
01922 725050 Fax [phone] Mobile 07946
702541 E-mail ursells_at_gp.walsall-ha.wmids.nhs.uk
Aim statement Our aim is to provide a complete
cardiac rehabilitation service that is widely
accessed, and that is tailored to meet the
individual CHD patients assessed social,
psychological and physical needs. Within this we
aim to improve support to patients
pre-revascularisation , suffering from stable
angina and heart failure.
11
Improvement Changes Phase 1 Direct booking of
patients for initial cardiac rehab appt. Single
record card for all appointments Give
pre-discharge 12 lead ECG and information
sheet All post MI patients referred to Community
Cardiac Nursing Team for contact within 4 working
days of discharge Phase 2 High use of hand held
record card Continual development of Support
Group Referral pathways established for heart
failure patients, angina patients, revasc
patients, fit for surgery patients, educational
only patients and patients who DNA Structured
rolling educational programme Phase
3 Satisfaction questionnaire Agreed referral
pathway for patients to Psychology
Service Reducing defaults to Post MI Clinic Phase
4 Establishment of CPR training for carers and
patients Review of long term maintenance
goals Established links with Leisure and
Community Services to provide the BACR phase 4
training
12
Spread Links established with all projects and
other agencies to establish the best referral and
care pathways for all patients with heart
problems and to establish overall spread of
project Closer links to Primary Care to establish
the best way this service can be provided. Closer
links with all Tertiary Centres need to be
established using the format already in existence
to Walsgrave Hospital. Contact with other
rehabilitation units within the Black Country
Collaborative
Sustainability Building on established links
between Walsall PCT and Walsall Cardiac
Rehabilitation Trust (Heart Care) Continuation of
established management structure within both
organisations. Developing the Cardiac
Rehabilitation Service within new larger
premises. Although there is some funding for the
basic rehab service, we need to obtain additional
funding to provide a service for all types of
heart disease, including services within the
community.
13
Black Country CHD Collaborative
Revascularisation Project
Contact Details Clinical Lead Dr John
Pidgeon The Royal Wolverhampton Hospitals 01902
643177 Project Manager Mr Thomas Jinks C/o St
Johns Medical Centre High Street Walsall
Wood WS9 9LP 01543 372552 Mobile07946
702544 E-mail Jinkst_at_gp.walsall-ha.wmids.nhs.uk
Aim statement Optimise management, access to
Angioplasty and Coronary Artery By-pass Surgery
for emergency and urgent patients at Manor
Hospital Walsall and elective patients of City
and Walsgrave Hospitals Provide early
intervention for high risk patients with non
infarct syndromes Inpatient Angioplastyto reduce
delay to 75 within five days (reduced from 15
days) from decision to angioplasty until
performance. Inpatient CABGto reduce delay to
75 within 31 days from date of referral to
Cardiac surgeon until performance
14
Improvement Changes (Patient slice All Walsall
patients) Troponin I introduced to give earlier
and more sensitive identification of myocardial
damage Acute Coronary Syndrome Protocol now
establishedgreater uptake of angiography In
patient transfers for angiography and angioplasty
communication system established by devising
proforma, checklist, patient leaflet explaining
procedure and risks and process chart. Now four
days from decision on ward round (DGH) to
discharge from tertiary centre Communication
systems for angiography / angioplasty
consistently identifies patient to be offered
rehabilitation and the scheduling of OPD
appointments appropriately In patient transfers
for CABG communication system established by
devising proforma, patient leaflet and process
chart. Patient now clinically optimised at DGH
to prevent bed blocking at Tertiary Centre. Now
28 days from decision on ward round (DGH) to
discharge from tertiary centre Development of
Fast Track system for patients awaiting an early
CABG. Patients discharged home for six to eight
weeks with a provisional date for CABG operation
if they meet clinical guidelines. Patients are
monitored at home by Community CHD nurses and
given a leaflet on what to do if their clinical
status changes. PDSA being undertaken. Benefits
are free up DGH beds, patient should be less
tired and anxious being at home and knowing a
likely date for surgery Elective CABG patients
now offered (trial basis presently) exercise and
education programmes prior to surgery Electronic
transfer of angiogram between DGH and tertiary
centre being piloted
15
Spread In patient transfer communication
system for angiography and angioplasty now
established with Walsgrave Hospital as well as
City Hospital. New Cross Hospital now refers to
Walsgrave using system. Future development will
be for all referring DGH s using either or both
Tertiary centres to adopt communication system at
their DGH Inpatient transfer communication system
for CABG patients now used by City Hospital to
refer their patients for heart surgery. Future
development will be for all referring DGHs to
adopt the communication system who refer to
Walsgrave Hospital Fast Track system for
patients awaiting an early CABG with patient
being discharged home for six to eight weeks with
a provisional date for heart surgery being
customised with New Cross Hospital and City
Hospital currently
Sustainability Communication systems established
for angiography /angioplasty, CABG and Fast
Track. Education sessions undertaken with
nursing and medical staff at patient slice
hospitals and spread areas
16
Black Country CHD Collaborative
Heart Failure
Contact Details Clinical Lead Dr. Mark
Payne Walsall Hospitals NHS Trust 01922
721172 Project Manager Miss Joanne
Gutteridge C/o St Johns Medical Centre High
Street Walsall Wood WS9 9LP Office 01543
362025 Fax [phone] Mobile 07946
702536 E-mail GutteridgeJ_at_gp.walsall-ha.wmids.nhs
.uk
17

• Aim statement
• We aim to improve experience and outcomes for
  patients diagnosed with heart failure by
• Developing a systematic pathway for the inpatient
  and outpatient management of heart failure,
  incorporating the setting up of a dedicated heart
  failure clinic - target of 80 of suitable
  patients attending with confirmed LVSD
• Improving patient / carer experience through
  education and re-enforcement during the
  inpatient, outpatient and domestic review -
  target of 100 of patients assessed by Hospital
  and Community Cardiac Nurses
• Involving patient / carers in their management by
  developing patient hand held records - target of
  80 of patients attending heart failure clinic
  using and keeping of weight charts
• Optimising the use of treatments that improve
  morbidity and mortality - target 90 of patients
  receiving ACEI, 80 of suitable patients
  receiving max tolerated dose of B-Blockers and
  75 receiving Spironolactone
• Developing of a flexible booking service system
  (to include direct GP booking) facilitating the
  patient care pathway - target of 90 of patients
  attending OASIS Clinic choosing the date for
  their Echo and 100 of patients attending booking
  their GP review
• Providing on going review in the Community
  coordinated by Community Cardiac Nurses - target
  of 100 of patients having 1,3,6 and 12 month
  reviews which is tailored to the patients
  individual needs.

Improvement Changes Providing a structured /
sustainable service for the diagnosis, management
and follow up of all patients with suspected /
confirmed Heart Failure / LV dysfunction in
Walsall. Dramatically reducing and sustaining the
access time to Echocardiography for both
inpatients and outpatients. Systems have been put
in place to ensure the optimal dosing of ACE
inhibitors, Diuretics, Spironolactone and
B-Blockers. Patients are also monitored for any
required adjustments during follow-up. Nationally
recognized booking systems have been applied to
the whole service.
18
Spread Presentations given to organisations
within and outside the Collaborative on the work
achieved, including National Collaborative,
National NSF, Department of Health and National
PDQ (Partnership in Developing Quality)
meetings. Involvement in the development of
regional guidelines for establishing a Heart
Failure service. Involving patients and carers
from across the borough in the ongoing work of
the project, enabling them to see themselves as
part of the same system by development of a hand
held record and contact list for patients and
carers, through an established Patient and Carer
Forum. Establishing links with other projects and
creating new care pathways for patients with
Coronary Heart Disease. Networking with new
Collaboratives and clinicians from Wolverhampton
and Dudley in the spread area, through the
Cardiac Network forum and project team meetings,
to enable spread of the methodology and
experiences of setting up a Heart Failure Service.
Sustainability Providing a District wide service
to all patients that attend Walsall Manor
Hospital. All key personnel providing the Heart
Failure service have secured / permanent
positions within the organization. An Integrated
Care Pathway has been established from Primary to
Secondary and back to Primary Care. Regular team
meetings established involving all key personnel
to constantly review the working practices of the
service. Database to support the service to allow
continuous audit. All protocols used have been
agreed by the Specialist Medical Group and Local
Medical Committee. Education programmes
established for both Secondary and Primary Care
personnel to facilitate Continued Personal
Development programmes. Links established with
other Regional Hospitals to develop provision for
biventricular pacing of appropriate patients.
19
Black Country CHD Collaborative
Angina
Contact Details Clinical Lead Dr. Paul
Giles Walsall Hospitals NHS Trust 01922
721172 Project Manager C/o St Johns Medical
Centre High Street Walsall Wood WS9 9LP Office
01543 362025 Fax [phone] Mobile E-mail
Aim statement To improve the experience and
outcomes of all patients with established
coronary heart disease by engaging them in a
comprehensive and systematic programme of
appropriate preventative care. This will be
achieved by optimising access to and use of
primary care based services on the Walsall Post
MI clinic model. Initially working with 2
test-bed practices, rolling out to ten practices,
5 in south and 5 in east PCGs and then on to the
wider community. Strategies for achieving this
will be to ensure that 100 of practices in the
slice will have a register established according
to the standard. 85 of patients on the register
have been offered and attended an annual review
with 90 of suitable patients under 75 years
being prescribed aspirin and 90 of suitable
patients under 75 being prescribed a statin.
Targets for patient and carer experience agreed
at 80.
20
Improvement Changes The strength of the
secondary prevention project lies in its
integration with Primary Care Subgroup of the CHD
Local Implementation Team (LIT), the LMC and the
commissioning teams. The integration has been
important because there has been very little
additional funding for the work, ensuring
mainstreaming from the start of the project. This
will be important to sustainability of the
improvements. Registers There has been a great
deal of time spent on populating validating
practice-based CHD registers, and implementing
strategies to ensure their maintenance. This was
seen as fundamental to all other measures and is
the gateway to the patient annual review. All
practices within the patient slice now have
validated and maintained registers. All
practices have appointed a guardian of the
register to ensure register maintenance. Reviews
All practices now carry out annual reviews and
have developed a call/recall system to ensure
pre-scheduling of annual reviews. This will
enable practices to plan capacity and demand. A
variety of models of annual review is in place,
using the widest possible range of skill mix in
the practice teams. The patient birthday model
has been popular as a means of organising the
work but other methods of scheduling have also
been used successfully. The standard for the
review is set by the EMIS template devised in
collaboration with the LIT Primary Care
Sub-Group. House-bound patients are visited by
the practice nurses, with phlebotomy in some
areas carried out by health care assistants prior
to the nurses visit. Clinical Effectiveness Both
measures have improved independently of the
annual review process. Aspirin prescribing
increased due to telephone triage, a strategy
previously used by the Primary Care
Collaborative, but supported by an
aspirin-decision chart to exclude all
contra-indications thereby improving safety for
the patient. Statin prescribing has improved
through better use of practice clinical computer
systems. Practices did not always record
cholesterol results on their systems and needed
to develop the skills to build searches. By
correctly identifying those who should be on
statins, the prescribing rate has increased.
Also, the identification of key groups who may
have been overlooked e.g. the over 75 age group
and those who had a CHD diagnosis many years ago,
have enabled some quick wins. The statin
measure may need review in light of new evidence
from the Heart Protection Study. Mapping of
samples sent to the laboratory showed a delay in
turn around of cholesterol results. This has not
been addressed within Phase One. However, all
Walsall practices will have Lab-Links within the
next year, enabling clinicians to view results as
soon as they are entered by the
laboratory. Patient and Carer Despite the
problems with the questionnaires-poor sample
size, flawed design, respondents, scores not
reflecting the new work - there has been some
positive spin-offs. The names and addresses
volunteered by the respondents have enabled some
useful forums to be organised and have provided
the Collaborative with a rich arena to design and
test the hand-held record, and other aspects of
service redesign. The discovery interviews have
given a rich source of information about the
pathway. This work will help to ensure that any
changes are patient- centred. As a result of
comments on questionnaires, patients are asked to
bring a relative with them to their annual
review, if they wish. Other carer support systems
discussed are a telephone help-line at Heart Care
(rehabilitation centre) or a drop in service at
the local Walk-in Centre.
21
Spread The strategies for register population,
validation and maintenance are already used
Walsall-wide and most practices have begun the
annual review process, supported by the EMIS
template. Links into Wolverhampton and Dudley
have been developed since the beginning of the
project. Spread into these two areas will depend
on the local resources available and willing to
undertake process, starting with mapping and
demand/capacity assessment. There is a need to
highlight local problems and then use the
Collaborative resources to support local
solutions, there being no single right solution
applicable in all circumstances.
Sustainability As there has been little
additional funding for this work, practices have
had to find individual solutions to their
capacity problems. This has ensured the
sustainability of register maintenance, annual
reviews and the implementation of clinically
effective treatments. This will enable Primary
Care to weather the peaks and troughs of other
important initiatives, which occur each year e.g.
Influenza Vaccine Campaigns and staff Holidays.
In future, measures requiring patients to be
entered on the practice CHD registers within a
defined period of a qualifying CHD event may help
keep registers up to date. Clinical effectiveness
sustainability will depend on the budgets set by
the new Primary Care Trust. There is already
pressure on the drug budget due to statin
prescribing and, as all practices move towards
their targets, this may be unsustainable without
additional extra funding.