Seeking your views

CA R D I O L O G Y A N D CA R D I A C

SU R G E RY RE V I E W S –

Seeking your views

October 2001

Department of Health, Social Services and Public SafetyAn Roinn Sláinte, Seirbhísí Sóisialta agus Sábháilteachta Poiblí

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Consultation Paper

CARDIOLOGY AND CARDIAC SURGERY REVIEWS -

SEEKING YOUR VIEWS

This consultation pack has been prepared to provide the public, relevant

interest groups and health service staff with information on the outcome of

the cardiology and cardiac surgery reviews and to invite comments on the

reviews and their recommendations.

This consultation process, which will run until 4th January 2002, is being

undertaken to assist the Minister in reaching final decisions on the

implementation of the reports’ recommendations.

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CARDIOLOGY AND CARDIAC SURGERY

Background

Heart disease remains a major cause of illness and death here. Whilst the numbers of

deaths from this disease continue to fall, rates of coronary artery disease remain higher

than in most European countries.

The best way to deal with the incidence of heart disease in the long term is to assist

people to take life decisions that will reduce their risk of developing the disease. This

preventative approach complements the cardiology and cardiac surgery services,

provided to deliver the necessary range of diagnostic, therapeutic and treatments to

manage and deal with heart disease when it arises.

Our service aim is to provide efficient and effective clinical services, which dovetail

to meet the full range of patients’ needs at the onset of the disease and as it progresses.

It is important that services work as part of a seamless system, a ‘managed clinical

network’ of care, to ensure that patients receive the best possible care in a timely and

sensitive way to minimise the impact of the disease on their lives.

Reviews of Cardiology Services and Cardiac Surgery

Recognising that cardiology and cardiac surgery are rapidly changing clinical fields,

the Department commissioned reviews of both clinical areas, and is now consulting on

the outcome of the reviews.

Cardiology Review

The cardiology review was a professional review, led by Dr Campbell, the Chief

Medical Officer, and completed in 1999. The goal of that professional Review was to

help shape the strategic direction of future services here, including: standards of care

with regard to treatment; location of facilities; and maximization of professional

skills.

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The cardiac surgery review, also chaired by Dr Campbell, was commissioned in

response to the recent decreasing throughput of patients in cardiac surgery. That

review was completed in September 2001.

The Cardiology Report was written by professionals and primarily aimed at clinicians

working in the field of Cardiology. It was circulated to clinicians at the time, and has

already informed developments in the areas of cardiology intervention.

Recent policy developments have focused on building acute services underpinned by

effective clinical networks. This is now considered crucial to the provision of

modern, clinically and cost effective cardiology services that are accessible to those

who require them. There have also been major developments in the field of

interventional cardiology since the review was first commissioned in 1998.

These factors coupled with other recent initiatives, including the Acute Hospitals

Review, the Ambulance Review and the Review of Cardiac Surgery, have underlined

the transitional nature of the 1999 professional review and highlighted the need for a

further review of adult cardiology services in the next 2-3 years.

The Review of Cardiology Services Report was initially circulated to Boards and

Trusts in 1999. Reflecting the views expressed by the Boards and others, the review

was subsequently linked with a parallel review of Cardiac Surgery, which was

commissioned in 2000.

Cardiac Surgery Review

The Minister commissioned the Cardiac Surgery Review, in response to concerns at

the decreasing numbers of patients undergoing surgery at the regional cardiac surgery

unit in the Royal Victoria Hospital. This reduction could be explained in part by the

increased demand on intensive care facilities in the post-operative period. A

consequence of this has been that fewer people have been able to access surgery and

waiting times have increased significantly.

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The Review report identifies the significant factors contributing to the decreased

throughput in cardiac surgery. It recommends a number of measures that should be

taken to improve services and to alleviate some of the current pressures. It also looks

forward and anticipates the future demand for cardiac surgery over the forthcoming

years.

This consultation paper brings together the products of the two reviews. The key

principles, outlined in the Cardiac Surgery Review Report, apply to both service areas.

They are that future services must:

• Be patient focused

• Ensure quality outcomes;

• Facilitate timely access

• Ensure equity of access

• Make appropriate use of resources

Subsequent Developments in Cardiology

Since the Report was completed in 1999, there have been significant developments in

both interventional cardiology and provision of service. These include:

• the capacity for coronary angiography has been increased by the establishment

of an Angiography Suite at Altnagelvin Hospital(due to open Autumn 2001);

• the opening of a 3rd Cardiac Catheterisation laboratory at the RVH;

• a regional audit of the provision of Thrombolytic drugs is under way and is due

to report early in 2002;

• an number of initiatives have been taken by Boards, GPs and the NI Chest,

Heart and Stroke Association to increase the availability of defibrillators in the

community;

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• progress has been made in the utilization of existing cardiac catheterisation labs

to make full use of the existing capacity;

• a number of initiatives have been introduced by General Practitioners to

support people with cardiac disease and promote good health. These include

chronic disease management clinics, smoking cessation clinics, and local

rehabilitation programmes.

Consultation Pack

The Department is now consulting on the findings of the reviews and the

recommendations. To facilitate this process, this paper and the attached documents

have been issued widely as a consultation pack. The pack includes:

Appendix 1 An updated summary of the Cardiology review and revised and

updated recommendations.

Appendix 2 Executive summary of the Cardiac Surgery Review and its

recommendations.

Appendix 3 Joint action Plan, drawing on the key recommendations of the

two reviews.

Appendix 4 An ‘equality issues’ paper

Appendix 5 Glossary

The full documents, outlining the terms of reference of the reviews, their method and

details of the background to their recommendations are available on the Department’s

website: www.dhsspsni.gov.uk.

Consultation process

The Department would welcome comments on the outcome of the two reviews and

the recommendations of the joint Action Plan for their implementation. Recognising

that some of the recommendations have significant resource implications, it should be

http://www.dhsspsni.gov.uk/

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noted that the speed and approach to implementation will be influenced both by the

outcome of the consultation process and the availability of resources in 2002-03 and

beyond. With this in mind, it would be helpful for comments to cover the relative

priority of recommendations, where appropriate.

Commenting on the Way Forward

In line with its commitment to assess the equality implications of proposals for service

changes, the Department would particularly welcome any comments on the potential

impact of the proposals and Action Plan on those groups of potential service users

identified in equality legislation.

In particular, you may wish to consider the following questions:

• Do you think that the two Reviews have covered the necessary ground?

• What do you feel are the priority areas for action?

• Are there additional actions/recommendations that need to be included

to improve services?

• Are there other actions to improve access to services that should be

taken?

• Is there anything else that can or should be done to promote equality of

access regardless of age, gender or geographic location?

• If the recommendations are implemented what is their potential impact

on other services within the hospital and community sectors?

Any comments should be sent to Tom Reid, Room 111, Dundonald House, Upper

Newtownards Road, Belfast BT4 3SF or e-mailed to him at

[email protected]. Comments should be received by 4th January 2002.

mailto:[email protected]

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If you have any queries about the consultation process or require any further

information, please write to Tom Reid at the above address or ring him tel. 028

90524947.

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Appendix 1

REVIEW OF CARDIOLOGY SERVICES

EXECUTIVE SUMMARY

&

RECOMMENDATIONS

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REVIEW OF CARDIOLOGY SERVICES

EXECUTIVE SUMMARY

(i) Cardiovascular disease, primarily coronary heart disease, has been a major

cause of death here for many decades and remains the major cause of death

today. Significant efforts to prevent disease and to treat established disease

have, however, resulted in a decrease in the death rates from coronary heart

disease over the past two decades.

(ii) Cardiology is that branch of medicine which deals with the diagnosis and

treatment of heart disease. Many recent developments within cardiology have

improved the treatment of patients with heart disease. In particular, recent

advances in stenting have improved the outlook for patients with blocked

coronary arteries. Public expectations of successful treatments are now higher

than ever.

(iii) Advances in treatments are taking place in tandem with demographic changes.

The number of older people here has been increasing and will continue to do

so. As age is the major risk factor for heart disease, an ageing population will

undoubtedly result in increasing pressures on cardiology services.

(iv) This report sets out recommendations for the strategic direction of future

cardiology services here, including standards of care with regard to treatment,

location of facilities and maximisation of professional skills. It recommends

that a network of cardiology services should be developed and that research

into cardiovascular disease should be strengthened by co-ordinating actions and

developing a database of all research work.

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CURRENT PROVISION OF SERVICE

Pre Hospital Intervention

(v) Prompt and effective treatment of patients suffering a heart attack can help save

lives and improve long-term outcome. We have a responsive mobile coronary

care service that covers most locations. It provides first line emergency

medical service to patients with acute chest pain. This includes pain relief,

resuscitation and the administration of thrombolytic (clot-busting) drugs.

There has been no regional evaluation of mobile coronary care services.

Non-invasive investigations / Outpatient care

(vi) Non-invasive investigations form a key element in the accurate diagnosis and

management of all forms of cardiac disease and are therefore of critical

importance.

(vii) No patient should have to wait longer than 8 weeks for a cardiology outpatient

appointment. All hospitals providing acute services here conduct a range of

non-invasive cardiology investigations. Demand for cardiology investigations

has increased in recent years and is expected to continue to increase.

(viii) All cardiology units here should provide the range of investigations necessary

to confirm the diagnosis and inform treatment options. Investigations requiring

advanced technology or specialised expertise should be concentrated on sites

where a sufficient number of investigations are conducted and the clinical

expertise is available to support the service.

(ix) Open access to investigations for general practitioners exists in most hospitals.

General practitioners should have managed direct access to a range of

cardiology investigations. Protocols for managed direct access should be

agreed between locally based general practitioners and cardiologists.

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Interventional Cardiology

(x) Interventional (or invasive) cardiology consists of angiography, the dye test

that is used to view the coronary arteries and percutaneous intervention (PCI),

the treatment of blocked coronary arteries. Treatment may consist of balloon

angioplasty or angioplasty plus the insertion of a stent, designed to keep the

coronary artery open.

(xi) Despite increased activities, waiting times for many procedures continue to

grow, with clear evidence of geographical variation in access to invasive

procedures. Referring doctors should be given details of waiting times by

individual cardiologists and patients should be given the opportunity to join the

shortest waiting list. Following diagnostic angiography, no patient should wait

more than three months for a PCI.

Cardiac rehabilitation

(xii) All patients who suffer a heart attack should be offered cardiac rehabilitation.

Cardiac rehabilitation services are aimed at all patients with established heart

disease, to facilitate physical, psychological and emotional recovery and enable

patients to achieve and maintain better health.

(xiii) Rehabilitation programmes should adopt a multi-disciplinary approach and

opportunities should be maximised for the voluntary and statutory sector to

work collaboratively to deliver rehabilitation programmes.

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THE FUTURE OF CARDIOLOGY SERVICES

(xiv) A managed clinical network should be developed for cardiology services The

network should emphasise partnership, effective use of resources and

maximising the quality of service to patients. The use of information

technology should be maximised within a network, particularly where it

improves patient access to a rapid diagnosis (for example when cardiologists

assess ECGs transmitted electronically and provide advice to primary care

professions).

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UPDATED RECOMMENDATIONS 1 PRE-HOSPITAL INTERVENTION

1.1 An effective first line emergency medical service to patients with acute chest pain must be in place. This service must be regularly monitored, audited and evaluated.

1.2 The relative benefits and drawbacks of dispatching medical staff on a MCCU while depleting available cover for inpatients must be analysed and evaluated.

1.3 All staff providing a first line emergency medical service must have appropriate training in advanced life support.

1.4 New technology should be maximised to facilitate the transfer of information from peripheral locations to a CCU where cardiology expertise is available.

1.5 A unified programme for activating and dispatching ambulances should be employed.

1.6 Public education should alert people to the significance of chest pain and reinforce the message that emergency services should be called promptly.

1.7 The teaching of resuscitation skills within communities should be given priority.

2 NON-INVASIVE/OUTPATIENT CARDIOLOGY

2.1 Direct Managed Access clinics should be available to GPs and physicians. Their use should be

determined by locally agreed protocols.

2.2 The development of a tertiary referral service for the investigation and management of syncope should be explored by means of a thorough needs assessment.

2.3 Investigative facilitates must be adequately staffed and equipped. Equipment should be regularly maintained and updated as appropriate and all staff should receive appropriate training.

2.4 Additional training should take place to ensure staff using new equipment or reporting on new tests have necessary skills.

2.5 No patient should have to wait longer than 8 weeks for a cardiology outpatient appointment.

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3 INTERVENTIONAL CARDIOLOGY

3.1 Referral guidelines for the management of patients with heart disease should be explored.

3.2 Clinical care pathways for percutaneous intervention and CABG should be agreed and

implemented.

3.3 A regional audit of angiography and PCI services should be conducted regularly.

3.4 The role of a chest pain clinic to facilitate the rapid assessment of patients should be further explored.

3.5 The current inequities in access to invasive procedures need to be addressed. GPs, referring cardiologists and physicians with an interest in cardiology should be given details of waiting times. Patients should be given the opportunity to join the shortest waiting list.

3.6 No patient should wait longer than 3 months for angiography and no longer than a further 3 months for PCI.

3.7 The capacity for PCIs should be increased to accommodate an anticipated level of about 1400 by 2005.

3.8 Details of waiting times by individual cardiac surgeon must be made available to all referring doctors.

4 CARDIAC REHABILITATION

4.1 Rehabilitation programmes here should adopt a standardised approach and utilise similar protocols and guidelines.

4.2 All patients should be offered cardiac rehabilitation. For each individual, consideration should be given to their age, risk stratification and level of fitness in recommending the nature of their programme.

4.3 Cardiac rehabilitation programmes will usually commence in the hospital setting. The focus for ongoing rehabilitation should be within primary care.

4.4 Cardiac rehabilitation should adopt a multi-disciplinary approach in both the design and implementation of the programme. Partnerships between the voluntary and statutory sector should be encouraged and facilitated.

4.5 Rehabilitation programmes should be evidence-based, audited and thoroughly evaluated.

4.6 A Directory of Rehabilitation Programmes should be developed. This will help to support discharge planning and communication between rehabilitation professionals and with primary care teams.

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5 RESEARCH IN CARDIOLOGY

5.1 A database on all cardiovascular research should be developed and held at a central location

5.2 The R&D office should put in place arrangements to coordinate and strengthen cardiovascular research in Northern Ireland.

6 AN INTEGRATED SERVICE

6.1 A Clinical System of Care should be developed for cardiology services here.

6.2 A multi-disciplinary Advisory Forum should be formed to develop the system. The Advisory

Forum should be supported by a project manager.

6.3 The Advisory Forum should embrace the issues of research and development within the parameters of the Managed Clinical Network.

6.4 There should be sufficient investment in IT to facilitate network development.

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Appendix 2

CARDIAC SURGERY REVIEW

EXECUTIVE SUMMARY

&

RECOMMENDATIONS

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REVIEW OF CARDIAC SURGERY

EXECUTIVE SUMMARY

(i) Heart disease remains a major cause of death and illness here, where rates are

higher than almost all other places in Europe. For a proportion of patients with

heart disease surgery provides a means to relieve symptoms and improve

quality of life.

(ii) Developments in the field of cardiology and cardiac surgery now mean that

much more can be done to treat people with heart disease. In turn, public

expectations of successful treatments are now higher than before.

(iii) Cardiac surgery services at the Royal Victoria Hospital (the Royal) have, for

the past few years, been under considerable pressure. Much of this pressure is

due to an increased demand on intensive care facilities in the post-operative

period. This has in turn resulted in fewer people being able to access surgery

and consequently the waiting time for surgery has been increasing.

(iv) This report identifies the significant factors contributing to the decreased

throughput in cardiac surgery. It recommends a number of measures that

should be taken to improve services and to alleviate some of the current

pressures. It also anticipates the future demand for cardiac surgery over the

forthcoming years.

(v) Cardiac surgery is provided by a dedicated and committed team of highly

skilled professionals at the Royal Victoria Hospital. Without exception

patients spoke highly of the care they received and commended staff for their

hard work and dedication to the service. Building on the strengths of the

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current service is a key principle in striving for excellence within cardiac

surgery.

IMPROVING CURRENT SERVICES

(vi) Cardiac surgery should be a patient-centred service. Measures to ensure that

patients are well informed partners in the decision-making process are

recommended. For example, patients referred for or awaiting surgery should

be kept fully informed of waiting time and expected date for surgery. Clearly

designated responsibility for the management of the waiting list, admission

procedures and follow up is recommended.

(vii) A patient’s pathway to cardiac surgery is relatively complex, typically

involving a number of hospital visits and several investigations before they are

placed on the waiting list for surgery. The referral mechanism needs to be

simplified with direct referral from cardiologist to cardiac surgeon replacing

current procedures. It is important that all patients are prioritised on agreed

clinical criteria and undergo surgery within the waiting time appropriate to

their clinical need.

(viii) No patient should wait longer than 8 weeks for a cardiac surgery outpatient

appointment and by 2003 they should have had surgery within 12 months of

attending outpatients. Regularly updated and accurate waiting times for each

cardiac surgeon should be made available to referring cardiologists.

(ix) Following surgery, patients are transferred to the cardiac surgery intensive care

unit (CSICU). A number of steps, some of which have already been initiated,

are recommended that would improve both the efficiency and effectiveness of

patient care in CSICU. These include the application of agreed clinical

protocols for patient management the introduction of fast tracking for suitable

patients and improving medical cover especially anaesthetic cover to the unit.

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(x) Staffing levels, particularly nurse staffing, are the major underlying problem in

the cardiac surgery unit and are directly responsible for the unit’s difficulty in

functioning at optimal capacity. Recruiting and retaining nurses presents a

major challenge. Stressful work load, long working hours, poor morale and

inadequate levels of remuneration all contribute to recruitment and retention

problems. This report recommends immediate action to enhance nurse staffing

levels, review remuneration, and strengthen medical support to the cardiac

surgery unit.

(xi) A multidisciplinary team (MDT) approach is critical in cardiac surgery. The

MDT should meet regularly to provide the opportunity for staff to share

information, discuss relevant issues and review practices and procedures.

(xii) Other factors will also play a role in strengthening the service. Integrating

cardiac and thoracic surgery would provide opportunities to improve patient

management and this should be actively pursued. Overcoming some of the

physical obstacles such as having intensive care and high dependency care

facilities adjacent to one another would make services more manageable.

FUTURE SERVICES

(xiii) Our cardiac surgery rates and in particular our rates of coronary artery

bypassing (CABG) were close to the European average of 429 per million in

1999. Intervention rates, however, vary from country to country. This poses

the question as to the appropriate level of surgery. In England the National

Service Framework for Coronary Heart Disease (NSF) have proposed an

increase in CABG to 750 per million. We will need to keep under constant

review the surgical provision indicated for our population.

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(xv) The rapid developments within cardiology will undoubtedly influence the

demand for cardiac surgery. The percutaneous intervention (PCI) rate will

continue to increase over the next few years with little change anticipated in the

need for CABG surgery.

(xvi) As a priority the number of CABG procedures must be increased to the current

target of 800 and waiting times for surgery must be decreased. While the

Royal are increasing the number of CABG procedures there will remain a need

to send patients elsewhere for surgery in the short to medium term if the

waiting list is to be brought under control.

(xvii) This report does not address the provision of paediatric cardiac surgery in

detail. Decisions regarding this will be deferred until the National Review of

Paediatric and Congenital Cardiac Services has been completed. Any changes

in the provision of PCS will have an impact on adult services, which will then

need to be reassessed in light of developments. This will include the need to

explore opportunities for North South collaboration in the delivery of care.

(xviii) Data collection, rigorous local audit and participation in national audit is

essential in ensuring a high quality service. The results of audit should be

made widely available.

(xix) A high quality of cardiac surgery is provided at the Royal. Recommendations

contained in this report aim to strengthen the quality of current services and to

ensure that, as a highly respected regional service, cardiac surgery will

continue to meet the needs of the community.

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RECOMMENDATIONS 1 FUTURE NEED FOR CARDIAC SURGERY

1.1 The total number of cardiac surgery procedures should be increased and maintained at the

agreed target level of 1100, of which 800 should be CABGs.

1.2 Until the target number of procedures is achieved at the Royal additional operations should be

purchased from other units to prevent waiting lists growing.

1.3 The future need for cardiac surgery should be regularly reassessed every 3 years in light of

national and international intervention rates, advances in clinical practice and outcome based

data.

1.4 Existing angiography facilities and those anticipated to become operational in the next year

should be utilised for investigative procedures so that additional capacity for PCIs is freed up

at the RVH and BCH sites.

2 ACCESS TO SURGERY

2.1 A simpler and more efficient referral mechanism should be designed and implemented.

Following angiography, cardiologists should refer directly to the appropriate cardiac surgeon

and their outpatient clinic. Referring cardiologists must have access to information on the

waiting times for each cardiac surgeon.

2.2 All patients awaiting surgery should be given an assigned status by the cardiac surgeon,

according to clinical criteria based on an agreed, standard assessment tool.

2.3 No patient should wait longer than 8 weeks for a cardiac surgery outpatient appointment.

2.4 There should be a maximum waiting time of 12 months from the first outpatient’s appointment

to the date of surgery by 2003, working towards a target of 6 months by 2005.

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3 INFORMATION WHILST WAITING

3.1 All patients awaiting surgery should receive clear and accurate information at regular intervals

regarding their treatment. This information should also be copied to the referring clinician

and the patient’s GP.

4 CARDIAC LIAISON NURSE

4.1 The existing post of cardiac liaison nurse should be funded as part of the cardiac surgery unit.

The liaison nurse should work collaboratively with cardiology and rehabilitation nurses to

provide a network of care.

5 WAITING LIST AND ADMISSION MANAGEMENT

5.1 The patient’s waiting time for surgery, admission and subsequent inpatient stay must be

managed with maximum efficiency. This responsibility should be clearly assigned within the

unit and the process audited at regular intervals.

5.2 All patients awaiting elective cardiac surgery should be invited to attend a preoperative

assessment clinic.

5.3 All patients awaiting surgery should be given a provisional date for admission.

5.4 Patients awaiting urgent surgery must be clearly identified, prioritised on clinical criteria, and

tracked to ensure they undergo surgery without undue delay. This will ensure equity of access,

regardless of geographical location.

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6 CLINICAL PRACTICE

6.1 Protocols for clinical management in CSICU should be agreed and applied.

6.2 A consultant anaesthetist should be present in CSICU during weekday working hours as the

lead clinician.

6.3 Clinical responsibility in CSICU for uncomplicated postoperative patients should be shared

between the cardiac surgeons and the anaesthetists. For patients remaining in CSICU beyond

24 hours, clinical management should be co-ordinated by the consultant anaesthetist as the

lead clinician.

6.4 The decision on whether to operate on high risk patients must be taken by the multi-

disciplinary clinical team responsible for their care in full consultation with the patient and

their family.

6.5 Residential medical cover must be available at all times to CSICU. This must be provided by

individuals skilled in the management of resuscitation and intensive care, including paediatric

resuscitation.

6.6 The practice of fast tracking should be expanded through the use of agreed and applied

protocols, with the provision of designated and appropriately staffed beds to support suitable

patients.

6.7 The HDU and CSICU should be next to each other to facilitate more effective and efficient use

of facilities and staff.

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7 DISCHARGE, FOLLOW UP AND REHABILITATION

7.1 All patients who undergo cardiac surgery should be offered a programme of cardiac

rehabilitation.

7.2 Discharge plans to include follow up and rehabilitation arrangements must be in place and

communicated clearly to patients and their families, their cardiologist and general practitioner.

7.3 When patients who have had their operation elsewhere return to Northern Ireland for follow up

and rehabilitation, arrangements must be in place to ensure a co-ordinated approach to

postoperative care.

8 INFORMATION

8.1 A theatre management system should be installed in cardiac theatres to allow staff to monitor

efficiency and theatre utilisation.

8.2 Data on patient management must be collected, rigorously analysed, and shared with

commissioners. It should also be made available to patients. Contributing data to the National

Adult Cardiac Surgical Database is an essential element of external quality assurance and must

continue. The electronic database purchased to support contributions to the national audit must

be adequately supported

9 EQUIPMENT

9.1 There should be a programme for the planned replacement and maintenance of equipment

within the unit. Needs should be prioritised immediately.

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10 THE CARDIAC SURGERY TEAM

10.1 A multi-disciplinary team should be established and meet regularly. The sub-director of the

Cardiology Directorate would be the most appropriate individual to act as lead clinician of the

MDT

10.2 Action must be taken to ensure that nursing levels are at the agreed complement and that

current CSICU and HDU beds are adequately staffed. Staffing should be increased on a

planned basis, with a training programme and systems in place to support new staff members..

10.3 There should be temporary or overlapping appointments of staff where feasible so that the

running of the unit is not interrupted by foreseeable staff vacancies.

10.4 The grading and remuneration of nurses should be reappraised in the light of changes in

practices in specialist areas such as intensive care and specialist theatre nursing.

10.5 Accredited training programmes for anaesthetic technicians and perfusionists, supported by

supernumerary posts should be made available if staff are to be recruited, trained and retained

within the service. The disparity in grading between Northern Ireland and GB should be

addressed.

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11 PROFESSIONAL DEVELOPMENT

11.1 Staff training and professional development must be planned and adequately resourced. The

position of the clinical education facilitator in CSICU should be permanent and mainstreamed.

11.2 Training opportunities should be identified and attendance at appropriate courses encouraged

as part of professional development.

11.3 Cardiac surgery staff should have access to the full range of educational opportunities

applicable to their speciality area. Professional links with the surgical directorate should be

strengthened to facilitate this.

11.4 Consideration should be given to the creation of a nurse practitioner position within the cardiac

surgery unit.

11.5 Consideration should be given to creating a role of trained theatre support worker.

12 PAEDIATRIC CARDIAC SURGERY

12.1 Paediatric cardiac surgery must be examined in detail after the publication of the Bristol

Inquiry and the report of the Review of Paediatric and Congenital Cardiac Services currently

being undertaken in England, Wales and Northern Ireland.

13 LINKS WITH THORACIC SURGERY

13.1 A small working group should be established to consider the integration of cardiac and

thoracic surgery services.

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Appendix 3

CARDIOLOGY

&

CARDIAC SURGERY

JOINT ACTION PLAN

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1. EMERGENCY CARDIAC SERVICES Lead Responsibility

Resource Implications

1.1

The Department will commission an audit of first line emergency medical services, including Mobile Coronary Care Units, to patients with acute chest pain and report by April 2003. Cardiology Review: recommendations 1.1,1.2

DHSSPS

To be met from existing resources

1.2

Trusts should ensure that by 2003, all staff providing a first line emergency medical service have appropriate training in advanced life support. Cardiology Review: recommendation 1.3

HSS

Trusts


1.3

The teaching of resuscitation skills should be developed in schools and the workplace. Boards should jointly commission a pilot programme in schools by 2003. Cardiology Review: recommendation 1.7

HSS

Boards


2. OUTPATIENT MANAGEMENT Lead

Responsibility Resource

Implications 2.1

No patient should have to wait longer than 8 weeks for a cardiology or cardiac surgery outpatient appointment and no longer than 13 weeks for diagnostic angiography. Cardiac Surgery Review: recommendation 2.3

HSS Boards & Trusts


2.2

Waiting times for outpatient appointments, invasive procedures and cardiac surgery should be published and regularly updated for each consultant. Cardiology Review: recommendation 3.5, 3.8

Cardiac Surgery Review: recommendation 2.1

HSS Trusts


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3. INPATIENT MANAGEMENT Lead


Implications 3.1

A subgroup of CREST should be established to develop clinical care pathways for the referral and management of patients with heart disease. Cardiology Review: recommendation 3.1, 3.2

DHSSPS &

CREST


3.2

The existing chest pain clinic at the RVH should be evaluated as a model for service development. Cardiology Review: recommendation 3.4

EHSSB


3.3

All patients awaiting surgery should be assigned a priority status and given a provisional date for surgery by the cardiac surgeon, according to clinical criteria. Cardiac Surgery Review: recommendations 5.3, 5.4

HSS Trusts


3.4

Patients awaiting PCI or surgery should receive clear and accurate information at regular intervals regarding their treatment. This information should also be copied to the referring clinician and the patient’s GP Cardiac Surgery Review: recommendation 3.1

HSS Trusts


3.5

The relevant clinical director should be directly responsible for ensuring that patients’ waiting time, admission and subsequent inpatient stay is managed efficiently. Cardiac Surgery Review: recommendation 5.1

Relevant Clinical Director


3.6

All patients awaiting elective cardiac surgery should be invited to attend a preoperative assessment clinic. Cardiac Surgery Review: recommendation 5.2

HSS Trusts


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4. FUTURE CAPACITY FOR CARDIAC SURGERY/INTERVENTIONAL CARDIOLOGY

Lead Responsibility


4.1

The total number of cardiac surgery procedures should be increased to the target level of 1100, including 800 CABGs, by increasing staffing (7.2 below), replacing necessary equipment (6.1 below) and by reviewing the linkage between cardiac surgery and thoracic surgery (9.1 below) Cardiac Surgery Review: recommendation 1.1, 10.1, 9.1, 13.1

DHSSPS

Refer To 6.1 & 7.2 Below

4.2

No patient should wait longer than 12 months for surgery. Until the target number of procedures is achieved at the Royal and waiting time for surgery has decreased, additional operations should be purchased from other units to prevent waiting lists growing. Cardiac Surgery Review: recommendation 2.4, 1.2

HSS Boards

2002/03 - £1.5m

2003/04 - £1.5m

2004/05 - £1.5m

4.3

Following angiography, no patient should wait longer than 3 months for PCI. The capacity for PCIs should be increased to accommodate an anticipated level of about 1400 by 2005. Cardiology Review: recommendations 3.6, 3.7

DHSSPS

Revenue:

2002/03 - £0.1m

2003/04 - £0.2m

2004/05 - £0.3m

4.4

All recommendations in the Cardiac Surgery review relating to clinical practice should be implemented as soon as possible.

Cardiology Review: recommendations 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7

HSS BOARDS & TRUSTS

Capital:

2002/03 - £0.2m

Revenue:

Recurring from 2002/03 - £0.25m

5. DISCHARGE, FOLLOW-UP AND

REHABILITATION Lead


Implications 5.1

Boards should commission cardiac rehabilitation for patients following a heart attack or cardiac surgery. Cardiology Review: recommendation 4.2

HSS BOARDS


5.2

Trusts and voluntary sector service providers should work collaboratively to develop multi-disciplinary cardiac rehabilitation. Cardiology Review: recommendation 4.4

HSS TRUSTS


33

6. EQUIPMENT Lead


Implications 6.1

Boards should commission a programme for the planned replacement and maintenance of equipment within the unit. Cardiac Surgery Review: recommendation 9.1

HSS BOARDS

Capital:

2002/03 - £0.7m

2003/05 - £2m

7. THE CARDIAC SURGERY TEAM Lead


Implications 7.1

A multi-disciplinary team in cardiac surgery should be established and meet regularly. The sub-director of the Cardiology Directorate should act as lead clinician of the MDT. Cardiac Surgery Review: recommendation 10.1

RGH HSS TRUST


7.2

Boards and Trusts should ensure that nursing, perfusionists and technician levels are at the agreed complement and that current CSICU and HDU beds are adequately staffed. Staffing should be increased on a planned basis, with a training programme and systems in place to support new staff members. Cardiac Surgery Review: recommendations 10.2, 10.3, 10.4

HSS BOARDS & TRUSTS

Revenue:

Recurring from 2002/03 - £0.7m

7.3

Accredited training programmes for anesthetic technicians and perfusionists, supported by supernumerary posts should be made available if staff are to be recruited, trained and retrained within the service. The disparity in grading between Northern Ireland and GB should be reviewed. Cardiac Surgery Review: recommendation 10.5

HSS BOARDS & TRUSTS


7.4

The existing post of cardiac liaison nurse should be funded as part of the cardiac surgery unit. The liaison nurse should work collaboratively with cardiology and rehabilitation nurses to provide a network of care. Cardiac Surgery Review: recommendation 4.1

HSS BOARDS

Revenue:

Recurring from 2002/03 - £50,000

34

8. PAEDIATRIC CARDIAC SURGERY Lead Responsibility


8.1

Paediatric cardiac surgery must be examined in detail after the publication of the Bristol Inquiry and the report of the Review of Paediatric and Congenital Cardiac Services currently being undertaken in England, Wales and Northern Ireland. Cardiac Surgery Review: recommendation 12.1

DHSSPS

To be determined in light of outcome of review.

9. LINKS WITH THORACIC SURGERY Lead


Implications 9.1

A small working group should be established to consider the integration of cardiac and thoracic surgery services. Cardiac Surgery Review: recommendation 13.1

HSS BOARDS & TRUSTS


10. IMPLEMENTATION OF

RECOMMENDATIONS Lead


Implications 10.1

The Royal Group of Hospitals Trust should set up a multi-disciplinary implementation group to take forward the necessary cardiac surgery service developments within the agreed time-frame

The Department should set up a key stake-holders group to monitor progress towards implementation of the Action Plan.

RGH Trust

DHSSPS etc.



35

Appendix 4

CARDIOLOGY

&

CARDIAC SURGERY

EQUALITY ISSUES

36

Equality Obligations

The Northern Ireland Act, 1998, has placed new statutory equality obligations on each

of the bodies within the HSSPS family. From 1 January 2000, the Department and all

of its associated bodies must, in carrying out their functions, have due regard to the

need to promote equality of opportunity:

• between persons of different religious belief, political opinion, racial group, age,

marital status or sexual orientation;

• between men and women generally;

• between persons with a disability and persons without; and

• between persons with dependants and persons without.

Without prejudice to these obligations, a public authority is also required, in carrying

out its functions, to have regard to the desirability of promoting good relations

between persons of different religious belief, political opinion or racial group.

While the Department will undertake a full equality impact assessment on the

recommendations contained within this report, with regard to equity of access to

cardiac surgery services there are a number of issues which it may be useful to

highlight at this stage.

Age

The risk of heart disease increases with advancing age. Older people are more likely

to suffer from more severe cardiac disease which has the potential for substantial

improvement using modern day cardiac surgery interventions.

While chronological age is not a barrier to treatment, there is a perception, often

highlighted in the media and medical literature, that ageism exists in relation to access

to cardiac interventions. The age range of those who undergo cardiac surgery here

37

demonstrates that the majority are aged over 50 years, with a small number aged over

80 years.

Gender

Nationally and internationally, cardiac heart disease is much more common in men

than in women. At any age the absolute risk of a coronary event in women is about a

fifth of that for men.

Relatively few studies in this area have concentrated specifically on women.

However, national and international patterns suggest that women are proportionately

under represented among patients undergoing cardiac surgery.

Deprivation

Although deprivation does not fall within the range of issues which the Department

must consider under its equality impact assessment, there is a clear relationship

between coronary heart disease and social deprivation which must be taken into

account by those who plan and deliver the service.

Internationally, there is a substantial body of research evidence which clearly

demonstrates the relationship between socio-economic deprivation and high levels of

coronary heart disease. While the overall death rates from coronary heart disease have

been falling for the last two decades, the death rate for men aged under 65 in the most

deprived communities continues to rise. Much of this variation in mortality rates by

deprivation can be explained by differences in risk factor prevalence rather than

access to cardiology services and cardiac surgery.

As highlighted in 'Investing for Health', the Department and the Executive is

committed to addressing inequalities in health. In this regard and with reference to its

statutory equality obligations, the Department would welcome views on the potential

equality implications of the recommendations outlined in this report.

38

39

Appendix 5

CARDIOLOGY

&

CARDIAC SURGERY

GLOSSARY

40

Acute myocardial infarction

Heart attack. Refers to the death of heart muscle (myocardium) which follows sudden reduction in or cessation of the flow of blood down the coronary arteries, e.g. narrowing due to atheroma of the vessels, leading to thrombosis in the coronary arteries. Advanced life support Attempt to restore spontaneous circulation following cardiac arrest using basic life support, defibrillation, advanced airway management and drugs. Angina, angina pectoris

Literally pain in the chest. Usually gripping or crushing in nature in the chest and/or left arm and jaw felt when there is insufficient blood supply to the heart muscle.

Stable angina is the term used for angina (pectoris) which is relatively predictable and the intensity and frequency of which remains similar over long periods.

Unstable angina is angina (pectoris) which is severe and unpredictable and which threatens to progress to an acute myocardial infarction.

Angiogram

A procedure in which a fine catheter is inserted via a blood vessel to inject x-ray opaque dye into the coronary arteries to obtain an x-ray image of the anatomy of the coronary arteries. Angioplasty

A procedure in which a small balloon on the end of a catheter is inserted into an artery (in CHD the coronary arteries) and inflated to widen a narrowed artery.

41

Arrhythmia

An abnormal rhythm of the heart. Artery

A blood vessel that carries blood away from the heart. Atheroma

Deposits of fatty material and cholesterol inside the walls of arteries. Atherosclerosis

Narrowing and thickening of arteries due to the development of fibrous tissue in the wall and sometimes calcium deposits. Usually associated with atheroma. CABG

Coronary artery bypass grafting. An open-heart operation in which blockages to the coronary arteries are bypassed by grafting on a length of artery or vein to bring a fresh blood supply to the heart muscle. Cardiac arrest

Complete cessation of the heart beat. Cardio-pulmonary resuscitation (CPR) The techniques of treating arrest of the heart by artificial respiration and cardiac compression.

42

Cardiothoracic

Of the heart and chest contents e.g. oesophagus and lungs. Catheter, cardiac

A long, narrow tube which, when passed through the veins or arteries into the heart cavities is used for measuring pressures or injecting x-ray opaque dye for outlining the heart and blood vessels. Catheterisation laboratory

The x-ray laboratory in which an angiogram is performed. Coronary angiogram

An angiogram of the coronary arteries. Coronary arteries

The arteries that supply the heart muscle with blood. Coronary heart disease

Narrowing or blockage of the coronary arteries by atheroma, leading to angina, coronary thrombosis or heart attack, heart failure, and/or sudden death. Defibrillator

An instrument for delivering an electric shock in an attempt to terminate ventricular fibrillation.

43

Electrocardiogram (ECG) A recording of the heart’s electrical activity obtained from electrodes positioned on the chest wall and limbs. An exercise (stress) ECG is taken before and during exercise (usually using a treadmill or stationary bicycle) to obtain objective and quantitative recording of myocardial ischaemia on exertion. Echocardiogram

An image and measurement of the heart obtained using ultrasound. Embolism

The migration through the bloodstream of a blood clot from one part of the body to another where it causes an occlusion. Infarction

Death of tissue following interruption of the blood supply. Ischaemia

Blood supply inadequate for tissue needs especially during exercise. Perfusionist

Specially trained staff who manage the heart-lung bypass equipment used during open heart surgery. Primary care

The conventional first point of contact between a patient and the National Health Service.

44

Primary prevention

The prevention of the development of a condition e.g. CHD, by avoidance of factors known to contribute to its development e.g. smoking, lack of exercise. See also secondary prevention. Protocols

A plan detailing the steps that will be taken in the treatment of a patient or in a research study. Percutaneous intervention A composite term that includes PTCA and stenting Percutaneous transluminal coronary angioplasty (PTCA) Angioplasty of the coronary arteries i.e. the introduction of a balloon on a catheter through the skin (percutaneous), into a blood vessel (transluminal) and into the coronary arteries to widen them. Revascularisation

A procedure to improve the blood supply. In the case of CHD these include CABG and PTCA. Secondary prevention

In the case of CHD, interventions such as lifestyle changes or drugs aimed at slowing or reversing the progression of disease.

45

Stent

An artificial structure inserted into a coronary artery following PTCA to support the vessel wall and reduce the risk of re-occlusion. Tertiary centre

A major medical centre providing open-heart surgery and PTCA, which receives referrals from both primary and secondary care. Thrombolysis

The lysis (dissolving) of blood clots by the use of thrombolytic drugs. Thrombolytic therapy

A class of drugs used to achieve thrombolysis. Thrombosis

The process of clot formation (thrombus – clot). Unstable angina pectoris

Angina which threatens progression to heart attack. Ventricles

The two main pumping chambers of the heart.

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