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Coronary Heart Disease and Stroke in Scotland
5 Access to Treatment and Care: CHD
Strategy Recommendation
Each NHS Board will have a local cardiac services Managed Clinical Network in operation with a Quality Assurance programme agreed with the Quality Standards Board for Health in Scotland. The Network will cover all aspects of CHD from primary prevention to cardiac rehabilitation by April 2004.
Improving access to treatment and care
5.1 The recent fall in premature mortality rates from CHD has been impressive. But there is no room for complacency. As Section 1 of this Report indicates, other parts of the world show us that it is possible to reduce mortality rates even further, and doing so remains a key clinical priority for the Scottish Executive. Section 2 highlights the need to reduce the number of people developing CHD in the first place through changing lifestyles and behaviours. In order to make the most of our opportunity to reduce mortality, we must continue to seek ways to improve the treatment and care of CHD patients.
Waiting Times for Investigation and Treatment
5.2 Timely referral for investigation and treatment is a key component of a modern health service. Reducing waiting times can often have a direct impact in making the treatment more effective. It is also important to patients to help them map out the major milestones as they embark on their various patient journeys. Patients need to be confident that their diagnosis and treatment is well-planned, reliable and available within reasonable timescales.
5.3 Up until now, the Scottish Executive has set waiting time guarantees that no patient would wait more than 12 weeks between seeing a specialist and having angiography, and that no patient would wait more than 24 weeks between angiography and receiving surgery or percutaneous coronary intervention (PCI). At September 2004, only sixteen patients were recorded as waiting for more than 12 weeks for angiography and none recorded as waiting for more than 24 weeks for surgery or PCI.
5.4 From the end of this month, the targets are being tightened. No patient will wait more than 8 weeks between seeing a specialist and having angiography, and no patient will wait more than 18 weeks between angiography and receiving surgery or PCI. This will make a real difference for patients; in September 2004 patients routinely had to wait longer than these times for treatment.
5.5 By the end of 2007 no one will wait more than 16 weeks from specialist referral to treatment for cardiac intervention of any kind. This 16 week maximum waiting time standard includes waiting time to both angiography and any subsequent surgery or PCI. The total maximum waiting time from specialist referral to treatment for CHD will therefore have been cut by more than a half when compared with the targets in place until December 2004. In addition, the waiting time standard will cover not just the patients going on to have surgery and PCI, but cover all forms of cardiac intervention.
Rapid Access Chest Pain Services
5.6 It is important that patients experiencing new chest pain or a sudden increase in their symptoms are seen as soon as possible. Rapid Action Chest Pain Clinics (RACP Clinics) provide a 'one stop shop' to confirm or exclude the likelihood of CHD. A number of models have developed for chest pain assessment and these have been driven by local circumstances and examples of good practice in other centres. Strategy funds to a total of 2.3m have been used to support the development and implementation of RACP services. The majority of NHS Boards either now offer this service or are working towards their implementation.
Treatment of Acute Myocardial Infarction
5.7 As treatment of heart disease has improved, heart attacks are becoming less common in Scotland. In 1990-91 there were 20,399 hospital admissions for acute myocardial infarction (AMI) and this decreased to 17,141 in 2003-04. But there have also been developments in the treatment for AMI.
5.8 Thrombolytic treatment has been the established method of treating AMI since the 1990s and is the benchmark against which new therapies and interventions are measured. Trials have demonstrated that, particularly in patients who present within the first hour of the onset of symptoms, thrombolysis reduces heart muscle damage; preserves left ventricular function and offers a better chance of survival.
5.9 A number of innovative strategies have been devised to ensure that treatment is administered promptly. Several studies have demonstrated that administering therapy in the community (pre-hospital thrombolysis) produces results that are superior (17% relative reduction in short-term mortality) to hospital thrombolysis, particularly when the transfer time to hospital is greater than thirty minutes.
5.10 Scotland has a population of over 5 million, of whom over 3 million live in the central belt and 1.38 million live in the cities of Glasgow, Edinburgh, Aberdeen or Dundee. The benefits of pre-hospital thrombolysis are less clear cut in urban settings and if the journey time to hospital is short most clinicians advocate a "scoop and run" policy. Even in rural and remote areas pre-hospital thrombolysis has not been widely adopted for logistical reasons. Nevertheless, the newly acquired ability to fax or telemeter ECGs from an ambulance to a cardiac centre and the development of thrombolytic drugs that can be administered as a single bolus injection have made this form of therapy much easier to deliver.
CASE STUDY
The Scottish Ambulance Service Pre-hospital ECG telemetry & administration of thrombolysis The Scottish Ambulance Service is on target to have all its paramedics trained and equipped to provide pre-hospital coronary care and the delivery of thrombolysis by the end of March 2005. Training has been provided at multiple venues involving staff from all Health Boards in Scotland with training addressing the needs of heart attack patients, the diagnosis of acute coronary syndromes, the use of thrombolytic agents and the interpretation of the 12 lead ECG. A major contribution to the programme has been the roll-out of the service's new 'Lifepak' defibrillator/monitors and ECG recorder. Linked to this is the development of five telemedicine decision support centres which can transmit the pre-hospital ECG to the receiving hospital. A joint venture between the Scottish Ambulance Service and Lothian University Hospitals Division has resulted in the 885,000 people of South East Scotland having access to pre-hospital transmission of a 12 lead ECG to the Coronary Care Unit in the Royal Infirmary of Edinburgh. Furthermore, in East/Mid Lothian and the Scottish Borders, patients may also receive pre-hospital administration of thrombolytic therapy. The provisional results of this initiative are greatly encouraging. In the first two full months of the project over 500 successful transmissions were made. Of these, 22 patients were fast tracked direct to a Coronary Care Unit where staff were ready to continue the care in a seamless manner. 16 patients were thrombolysed prior to arrival at CCU. |
5.11 Percutaneous coronary intervention (PCI) - formerly known as coronary angioplasty - is a very effective treatment for both angina and AMI. PCI can restore the blood flow to the heart for more than 95% patients with no residual narrowing to the artery and a much lower risk of further heart attack.
Next Steps
5.12 The National Advisory Committee for CHD has established a working party to draw up an integrated strategy for the management of AMI in Scotland. The Scottish Ambulance Service, the Scottish Cardiac Society, and the SIGN CHD Steering Group will be included in the working party, which has been asked to produce a final report by March 2005. This will include specific guidance on the indications for, and the provision of, pre-hospital thrombolysis, hospital thrombolysis, primary PCI, and rescue PCI.
Revascularisation Rates
5.13 The 2001 Task Force Report on CHD and Stroke proposed a target of 1,400 revascularisation procedures per million population. As anticipated, the rates for PCI have continued to increase annually by approximately 7.5%, while rates for CABG have remained stable. The CHD and Stroke Strategy recommended that rates be increased progressively with aim of reducing and ultimately eliminating waiting lists. This is consistent with all the evidence about the benefits of early intervention and the approach taken by the National Waiting Times Unit. Figures from Scottish Revascularisation Register for 2003-04 show the current rate of revascularisation to be 1,318 per million of population. If the rate of PCI in Scotland continues to increase at the present rate, we will exceed our target of 1,400 interventions per million of population in 2004-05.
Adults with Congenital Heart Disease
5.14 A national programme for the surveillance and treatment of adults who have ongoing health problems attributable to congenital heart disease has been proposed and is being considered by the National Services Advisory Group. The proposal is sponsored by NHS Greater Glasgow and NHS Lothian and strongly supported by the Scottish cardiology community.
5.15 The ongoing clinical needs of this group of patients are well recognised and there have been significant advances in trans-catheter and surgical interventions for patients with congenital heart defects. Certain operations are life saving in infancy or childhood but have the potential to lead to later complications requiring further surgery in adulthood. The number of patients in this group is increasing as a consequence of the success of paediatric intervention in recent times. Several individual elements of the service are already in place but work is still needed on the co-ordination of the supervision and care of the patient population by a core multi-disciplinary specialist team. The National Services Advisory Group is on track to agree a recommendation by April 2005.
CASE STUDY Revascularisation Capacity Review In December 2003, the Scottish Executive and the Chairs of the three Regional Planning Groups commissioned a short piece of work around capacity planning for revascularisation services in Scotland. The work arose from a lack of clarity surrounding available capacity within NHSScotland and the likely future requirements, given the anticipated reductions in waiting time guarantees. The group reported in April 2004; its recommendations included: Percutaneous Coronary Intervention PCI has demonstrated considerable growth over the last four years and this continued growth is unlikely to change in the near future there was wide variation in the efficiency (patient through-put) of catheter laboratories additional capacity will be required to cope with the projected growth in PCI additional catheter laboratories may need to be commissioned at some sites laboratory equipment at several sites will need to be replaced in the next three years consideration should be given to a networked approach to attract consultant staff to regional centres consideration should be given to using the Regional Planning Groups to develop and sustain referral patterns for cardiac investigation and intervention
Cardiac Surgery the number of bypass grafts has fallen or become stable over recent years theatre capacity does not need to increase but neither should it decrease at this time if waiting times are to be decreased further current theatre capacity needs to be supported by increased ICU capacity to accommodate the more complex needs of patients and longer lengths of stay consideration should be given to an agreed substantive short-term workload for the Golden Jubilee National Hospital to support the achievement of waiting times guarantees
The recommendations are now being translated into a costed implementation plan. |
Heart Failure
5.16 Improvements in heart failure management mean patients live longer and have a better health related quality of life. Heart failure is a complex condition in which the heart can no longer pump blood around the body adequately. There are a number of causes of heart failure, the most common of which is CHD. The risk of heart failure increases with age and with an aging population, the management of heart failure is an important element of the CHD and Stroke Strategy. The Strategy suggested that each MCN should work with its NHS Board to establish a local Heart Failure Group and develop an implementation strategy.
5.17 In terms of diagnosis, echocardiography remains the gold standard investigation. It is relatively expensive, but costs and practicalities of carrying out the test in primary care have become an option as equipment has become smaller and cheaper. Other advances in heart failure diagnosis include a blood test for elevated brain naturetic peptide, a marker for heart failure. Together, these advances have made it possible to develop nurse-led heart failure initiatives in primary care. The role of the nurse specialist is now well established in the management of this group of patients, their interventions focusing upon: early diagnosis, optimisation of medical therapy; symptom control; psychological support and patient education. To date over 1m has been invested in heart failure services from Strategy funds and seven MCNs have nurse-led heart failure programmes in place. The remainder are in the advanced stages of planning the service.
5.18 In July 2004, the Minister for Health and Community Care announced an additional 450,000 to support the development of a National Centre for the Treatment of Advanced Heart Failure. The case mix of the National Centre is expected to be as follows:
specialist assessment and advice on management
cardiac resynchronisation therapy
advanced complex heart surgery
liaison with cardiac transplantation service
5.19 The creation of this centre of excellence means that Scotland will have a comprehensive heart failure service ranging from the care provided by specialist nurses in patients' own homes to the most complex interventions provided by the National Centre.
5.20 But even with the best of treatments, few patients survive more that 5 years with a diagnosis of 'severe' heart failure and this condition has a prognosis that is worse than that for most cancers. As the Strategy reported, the Scottish Partnership for Palliative Care had established a working group to make proposals for end-stage heart failure. A draft report will be issued for consultation in late 2004/early 2005 and the final report is expected in summer 2005.
Cardiac Rehabilitation
5.21 Cardiac rehabilitation is an essential service for patients recovering from cardiac illness. It has been shown to produce physical, psychological and survival benefits for patients who have experienced a heart attack or undergone heart surgery. MCNs are responsible for developing and implementing local plans for cardiac rehabilitation in line with the recommendations set out in SIGN 57. In developing these plans, MCNs have been asked to ensure the participation of excluded groups such as ethnic minorities, women, older patients and those from areas of socio-economic deprivation. Over 1m of Strategy funding has been committed to cardiac rehabilitation to date.
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