OUTREACH PAEDIATRIC CARDIOLOGY
The role of paediatricians with a special interest in cardiology
A model for networked service provision.
August 2004
The increase in referrals to tertiary paediatric cardiac services emphasises the need for
increased local cardiology expertise outside tertiary cardiac centres. The need for
consultant paediatricians with an interest (and appropriate training) in cardiology is
beginning to be recognised by Trusts and PCTs. This document aims to set out simple
guidelines for consultant paediatricians with an interest in cardiology such that the
recommendations of the recently published DH document The Paediatric and Congenital
Cardiac Services Review (PCCSR) relating to maximising local care of patients with
congenital heart disease might be fulfilled alongside important issues of clinical
governance. The principal clinical governance issues relate to maintenance of expertise,
CPD and avoiding occasional practice.
Maintenance of expertise
Most paediatricians with an interest in cardiology will be the only consultant in their
hospital holding such a post. In such circumstances close links with the tertiary paediatric
cardiology service will be essential for purposes of peer review and keeping up to date.
CPD links to tertiary centres should involve jointly held outreach clinics where individual
patients’ future shared care is planned by the cardiologist and the paediatrician such that
the patient or parents have a clear understanding of what levels of care should take place
locally and at the tertiary centre. For all but the busiest outreach services, it would be
appropriate for the paediatrician with an interest in cardiology to have regular periods of
time spent visiting the tertiary centre (say, two weeks per year) to refresh their experience
of tertiary care. This CPD activity should be a formal part of the consultant’s job plan.
CPD should also include regular attendance at relevant specialist symposiums and
academic meetings. The consultant’s annual appraisals should include an assessment of
evidence of continuing fitness to practise with a special interest in cardiology. Avoidance
of occasional practice is obviously of prime importance.
Balancing local hospital and tertiary centre care
The PCCSR recommends that as much care as possible should be carried out locally, the
patient only having to travel to the tertiary centre for specialised investigations and
treatment. Investigations which should be available locally, supervised or carried out by
the paediatrician include ECG, ambulatory ECG and event recording, exercise stress
testing (perhaps with the exception of high risk cases such as symptomatic long QT
syndromes or severe hypertrophic cardiomyopathy) and transthoracic echocardiography.
Specialist procedures which should be restricted to tertiary cardiac centres include
transoesophageal echocardiography, specialist cardiac imaging such as tertiary level fetal
cardiac imaging (and subsequent parental counselling), radionuclide imaging, MRI or
cardiac CT, cardiac catheterisation and pacemaker implantation and follow up.
Deciding which patients should see a cardiologist
Simple guidelines rather than complex algorithms are essential. Parental expectation and
clinical governance suggest that any child seen by the paediatrician with an interest in
cardiology and deemed to have a cardiac abnormality should be seen by a cardiologist on
at least one occasion. After that, for some minor anomalies it may be sufficient for further
follow up to be undertaken purely by the paediatrician with an interest in cardiology. A
joint decision on the need for and planning of follow up should be made for each
individual patient at the joint outreach clinic, the parents being fully informed of these
plans in writing.
There are many new referrals for a cardiac opinion which could be dealt with,
particularly in the first instance, by the paediatrician with an interest in cardiology. These
include assessment of asymptomatic murmurs, children with family history of potentially
inheritable cardiac disease (such as cardiomyopathy, Marfan’s syndrome or sudden
cardiac death), and investigation of palpitations, dizziness, intermittent cyanosis or chest
pain.
Transition through adolescence to adult congenital cardiac care
Joint outreach clinics for adolescents should include the cardiologist arranging future care
for patients who will continue to need specialist follow up for congenital heart disease
into adult life. This must include the patient having a clear understanding of what level of
shared care will take place between local adult cardiologists and the tertiary centre adult
congenital cardiac service. As these patients move from paediatric to adult care they and
their general practitioners should be given written information explaining future follow
up arrangements, along with contact details for the tertiary centre and (if appropriate) for
the local adult cardiac service.
Audit
Local clinical governance arrangements should include regular audit of the
paediatrician’s practice, including workload and patient referral patterns.
John Gibbs FRCP
Consultant paediatric cardiologist
Leeds General Infirmary
This document was unanimously supported at the Yorkshire, Humberside and Northern Trent paediatric
cardiac network meeting held in York in March 2005. It was supported and adopted on a National basis by
the British Congenital Cardiac Association Council in May 2005 and by the Royal College of Paediatrics
and Child Health in April 2006.