University Hospital of Wales,
Acute Coronary Syndrome
(ACS)Unit.
Innovation and Research-Innovative models of care.
Victoria Williams Cardiology Nurse Practitioner
Louise Birch Cardiology Nurse Practitioner
Michelle Ball Cardiology Nurse Practitioner
Sarah Barnett Cardiology Nurse Practitioner
Aims of the presentation
• To outline the expanding role of the
nurse practitioner within Cardiology at
University Hospital of Wales (UHW)
• To Describe and illustrate the
development of the role through the
establishment of a nurse led Acute
Coronary Syndrome (ACS) service,
demonstrating innovative ways of
working to improve patient care.
Learning Outcomes
• To illustrate the role of the
advanced practitioner within
Cardiology at UHW
• To understand how the ACS
service is run and how successful
outcomes have been achieved
• To consider how the role and the
service will evolve and develop in
the future.
Background of the NP role within
Cardiology
• Established in 2010
• In response to European work Time
Directive (EWTD)
• To streamline the patient Journey
• Improve multi-disciplinary
communication
• Improve patient outcomes and
satisfaction
• Cardiology Co-ordinator
established role since 2004
• Roles merged 2010
• Both practitioners undertaking
MSC Advanced Practitioner
Pathway
• Team has expanded to include 2
further Part-time positions
• ACS service launched in
September 2010.
University Hospital of Wales
• Tertiary Cardiology centre
• Contracted to provide tertiary
services to District General
Hospitals within south east
Wales
Aims of ACS service
• Reduce patient length of stay
in both DGH & tertiary centre
• Reduce waiting times for
intervention
• Meet European and NICE
guidelines
• Improve patient outcomes
• Improve patient journey
Collaborative working
District General Hospitals
Electronic referral within strict criteria
Training and education re: ACS protocols
Pre-operative workup and investigations
Repatriation of patients awaiting
follow on services
Cardiac Catheter Theatre
Cardiology Nurse
Practitioners
Central point of
contact.
Co-ordinating the care
pathway from point of
referral to discharge.
Electronic referral
system
Telephone triage of
ACS/Complex
transfers.
Advanced Clinical
Assessment Skills.
Cardiology Ward
Protected beds within ward area
High turnover of ACS patients
Increased workload and expertise.
Collaborative approach between nursing
staff, NPs & Medics
Nurse-led discharge protocols.
Allocated catheter slots
Re-organisation of consultant rota
Flexi sessions to back fill for
annual leave/study leave
UniversityHospital
Hospitalof
ofWales
Wales
University
Acute
Coronary
SyndromeInpatient
InpatientReferral
Referralform
form
Acute
Coronary
Syndrome
Electronic Referral
Please
complete
and
save
with
patients
nameas
asfile
filename
name
Please
complete
and
save
with
patients
name
Email
with
patient
name
SUBJECTheading
heading
Wales.ACS@wales.nhs.uk
Email
with
patient
name
in in
SUBJECT
Wales.ACS@wales.nhs.uk
PLEASE
NOTE:
You
are
sending
confidential
patient
information,
thisform
formshould
should ONLY
ONLY be
be sent
sent from
from an
PLEASE NOTE: You are sending confidential patient information, this
an NHS
NHS email
email address
address
PATIENT
DETAILS
PATIENT
DETAILS
Surname
Surname
Forename(s)
Forename(s)
DoB
DoB
NHS no.
NHS no.
Hosp no.
Hosp no.
Gyna
Pain
Anne
Mike
09/12/1958
09/12/1978
123456789
123456789
A123456
A123456
Ref Hosp
Ref Hosp
Ref Con
Ref Con
Ward
Ward
Ward tel
Ward tel
Weight Kg
Weight Kg
Address:
Address:
21 River St, Cardiff, CF123AB
32 craze Rd. Cardiff, CF321ba
Llandough Hospital
Llandough Hospital
Dr C Pain
Dr C Pain
CCU
CCU
5645
5645
79Kg
79Kg
PRESENTATION DETAILS
PRESENTATION DETAILS
Condition for transfer
Condition
for transfer
Major complications
Major complications
Previous interventions
Previous interventions
NSTEACS
NSTEACS
Tachyarrythmia (not AF) (echo mandatory)
CABG (Please include graft details)
DD/MM/YYYY HH:MM
DD/MM/YYYY HH:MM
08/11/2011 10:00
08/11/201113:00
10:00
08/11/2011
08/11/201113:20
13:00
08/11/2011
08/11/201111:00
13:20
09/11/2011
09/11/2011 11:00
SYMPTOM ONSET
SYMPTOM ONSET
CALL FOR HELP
CALL FOR HELP
LOCAL HOSP ARRIVAL
LOCAL
HOSP
REFERRAL
TOARRIVAL
UHW
REFERRAL
TO UHW
History/Co-m orbidities
ECHO
History/Co-m
orbidities chest pain, initially on exertion, last episode @ ECHO
2/7 hx of intermittent
awaited
Chest
rest pain.
raditing to Lt arm assoc SOB. ECG inferior TWI. PMH: Nil
RISK
RISK
Age
Age
BP
BPST deviation
STHypertension
deviation
Family Hist
Hypertension
Family Hist
50 to <60
70
toto
<80
110
<120
130 toYES
<140
NO
YES
YES2
2
Creat
Creat
Heart Rate
Troponin
Heart
Rate
Troponin
Smoking
Smoking
awaited
35 to 70
141
176
60 to <70
90Elevated
to <100
Elevated
Previous
Previous
CHF
CHF
Arrest
Diabetes
Arrest
Elevated
Diabetes
Cholesterol
Elevated
Cholesterol
I (no CHF)
III (Pulmonary
NO oedema)
No
YES
No
NO
YES
GRACE RISK SCORE
Risk of Death (%) GRACE RISKRisk
of Death/MI (%)
SCORE
15.0
Risk of Death/MI
(%)
In Hospital
In Hospital
To 6 months
1.0 (%)
Risk of Death
49.0
4.0
62.0
23.0
76.0
86.0
To 6 months
RESULTS & TREATMENT
RESULTS & TREATMENT
BLOODS
BLOODS
14.8
Hb
260
Plt
10
Hb
9
Wbc
260
Plt
2.65
Trop I/T
9
Wbc
MRSA status
unknown
2.65
Trop I/T
(if known)
MRSA status
<3
CRP
unknown
(if known)
64
Creatinine
45
CRP
REFERRERS DETAILS
155
Creatinine
Antiplatelets
300mg loading + 75mg maintenance
Aspirin
Clopidogrel 300mg loading + 75mg maintenance
600mg loading + 75mg Maintenance
Clopidogrel
Prasugrel 300mg loading + 75mg Maintenance
None given
Prasugrel
Other
None given
Other
REFERRERS
ASSESSEDDETAILS
AND REFERRED BY? (Full Name)
A Doctor
ASSESSED AND REFERRED
BY? (Full Name)
For UHW use
A Doctor
Accepted by
ForDate
UHWand
use
time tranferred
Accepted
Ward by
Date
and time tranferred
Consultant
Ward
Date on Ladder
Consultant
Date and time procedure performed
Date on Ladder
Date and time procedure performed
Anticoagulation
Antiplatelets
Aspirin
Anticoagulation
Type given
Type given
Clexane
dose
Clexane
adjustment
dose
for renal
adjustment
function?
for renal
function?
CONTACT DETAILS (Hosp switch and bleep)
02920
744744
(6565)
CONTACT DETAILS
(Hosp
switch
and bleep)
02920 744744 (6565)
Free text:
Free text:
DATE (DD/MM/YYYY)
09/11/2011
DATE (DD/MM/YYYY)
©drf reeman.com
09/11/2011
©drf reeman.com
Advanced clinical skills
• All members of the team are at
different stages of their Msc
pathway
• We all utilise advanced clinical
skills as part of the role to
enhance the service.
• Undertaking regular competency
based training and assessment
Wider components of the NP
role within cardiology
• Co-ordination and organisation
of complex patients
• Organisation of in-patient and
outpatient pacing calendar
• Reviewing A&E admissions with
the Cardiology SPR.
• Assist the junior medical team
and nursing staff with ward
duties as necessary.
Successful outcomes
• Reduced bed days in DGH and tertiary
centre
• Reduced waiting times for intervention
• A more streamlined service for patients
• Improved communication between all
members of the team
• Improved patient satisfaction and less
complaints
Comparative information for ACS patients referred to UHW from
DGHs Within the South East Cardiac Network. (Aug 2010/June
2011)
20
18
16
14
no of Days
12
Aug-2010
10
Jun-2011
8
6
4
2
0
Average total pre
Averagetotal
ref erral days
ref erral to transf er
days
Average total
UHW bed days
Average total bed
days
The future of the ACS service
• Plans to develop a cardiology
assessment ward utilising 19
beds within the directorate
• accommodating all cardiology
admissions and transfers
• Development of an assessment
tool and pathway to be utilised
in A&E by both NPs and SPR
• To streamline in house service
Future of the NP role
•
•
•
•
Independent prescribing
Post intervention clinics
Ultimately all Msc trained
first point of contact for the
assessment acute and sick
patients
• Incorporated into the junior
doctor rota.