1. Integration of Primary and Secondary Care Cardiology
Dr Peter O Callaghan, Consultant Cardiologist and Clinical Director,
Cardiff and Vale University Health Board
Context and Problem
Effects of Changes
Historically, the only route available for GPs to refer non urgent patients to a cardiologist at Cardiff and Vale University Health Board was by referral to a consultant cardiologist outpatient clinic. Cardiologists would see the patient in clinic and then send a letter back to the GP with a diagnosis, investigation and treatment plan.
GPs complain that consultant cardiologists are too remote and waiting times too long. Cardiologists complain that the quality of some patient referrals is poor with a significant number of inappropriate referrals. The absence of early advice and reassurance can result in symptoms worsening and anxiety levels increasing.
Between January and July 2016, 2,226 GP requests for a cardiology out-patient visit were received. Traditionally all referrals were accepted and sorted into clinics. Since the introduction of HeRS2 31% referrals no longer require a consultant clinic appointment. 21% are redirected to physiologist and nurse led clinics. 10% of requests are now declined with advice. In contrast to paper based systems. This 31% reduction in patients attending cardiology OPD clinics has had a dramatic effect on the total number of patients waiting to be seen by a cardiologist as shown. For example in August 2015, 1,223 patients were waiting for cardiology outpatient appointment. By March 2016 this had dropped substantially to 117 patients. It is now maintained and stabilised at < 500 as of Aug 2017.
Strategy for Change
Through a growing recognition that the status quo was no longer able to cope, a different model of care needed to be developed based on collaboration between primary (GP) and secondary (cardiologist) care.
Cardiology was identified as a pilot site for a Hospital based electronic referral system (HeRS2). Four questions helped to shape the model:
Why do GPs refer patients?
Do all patients referred need to be seen by a cardiologist?
Could visits be avoided by timely feedback and advice?
What steps are involved in getting the patient booked into a specific clinic?
4,000 new patients are referred annually and the number of referrals is increasing at >10% per year. The high volume of referrals resulted in long delays and challenges in achieving ‘referral to treatment’ (RTT) targets. Historically, achievement of RTT targets has relied on waiting list initiative clinics. This quality improvement project alters the focus from the traditional emphasis on increasing supply (hiring more staff, additional clinics etc) to focusing on managing demand. HeRS2 was tailored to meet the needs of cardiology, with interaction between cardiologists and the IT team. 3 PDSA (Plan, Do, Study, Act) cycles were run over a 2 month period. These PDSA cycles led to new proposals of how patients should be redirected to new specialist nurse and physiologist clinics. Consultants would deal with referrals electronically on their desk-top and referral to a general cardiology clinic would no longer be the default position. In addition a new eAdvice system provided the ability to communicate directly, quickly and effectively with GPs – often with advice only thereby avoiding outpatient clinic allocation.
Week waiting
Aug
Mar
Sept 2016
0-4
157 56
145
5 - 9
201 37
179
10-14
162 12 24
15-19
187 7
20-24
151 4 3
25-29
222 1
30-35
130
>36 13
eAdvice started in September 2015 and the number of GPs requesting eAdvice has grown monthly. This service grew slowly – initially confined to two GP clusters and within these clusters was mainly used by select GPs. Between September 2015 and January 2016 an average of 4 eAdvice requests a week were received from GPs. Awareness has increased and by August 2016 an average of 14 eAdvice requests/week are handled by the cardiology service. A prospective audit of eAdvice outcome shows that in 2/3 cases (66%) eAdvice resulted in advice only or a request to adjust medication. The eAdvice turn around time of less than 4 days was achieved in 75% cases. In August 2017 requests average 30/week.
In summary the combination of clinic reorganisation, electronic clinic referrals and eAdvice has resulted in a dramatic reduction in numbers of patients waiting to see a cardiologist and a significant reduction in referral to treatment times.
eAdvice has grown in popularity and is being rolled out across directorates. In September 2016 discussion started to incorporate eAdvice into the Welsh Clinical Portal, which enables e-Advise to be available across the NHS in Wales; the roll-out is now underway.
Measurement of Improvement
SMART measures included:
Total number of patients waiting to see a cardiologist.
Proportion of patients diverted to physiologist or nurse led clinics
Proportion of patients declined an outpatient assessment with advice given instead.
No of eAdvice requests per week.
4 day turn around target > 90%
Continuous GP assessment of the service - after each eAdvice the GP is prompted to answer an audit question to facilitate analysis of the outcome of eAdvice.
A questionnaire for GPs & consultants provided qualitative feedback
Lessons Learned
The project relied on clearly expressing a vision, engaging the wider multi-professional team, primary care colleagues, IT, communications team and medical records.
An unplanned consequence of eAdvice has been an increase in consultant work-load. To resolve this issue, 4 cardiologists have taken over providing eAdvice and this time commitment is now incorporated into job plans.
Contact information:
Dr Peter O Callaghan, Consultant Cardiologist and Clinical Director,
Cardiff and Vale University Health Board: