Shared learning database

Leeds Teaching Hospitals NHS Trust
Published date:
November 2013

The 2011 NICE guidance emphasises the importance of providing CHD patients with advice about how to use sublingual GTN (Recommendation 1.3.3). Our 5 phases project ran over 18 months. We assessed patients' knowledge of GTN use & their opinion of current advice & written info provided. Based on the feedback, we worked with patients to develop a suitable credit card sized GTN card containing readily accessible & practical instruction on how & when to use GTN during a chest pain episode. We piloted & user tested the card. 230+ patients found it very useful for managing their angina and knowing when to call 999. Our national survey of 135 Trusts across the country revealed that advice about GTN wasn't consistent, GTN use was not routinely assessed by healthcare professionals, and all participants wanted a national GTN advice card. We have now developed a national GTN card (version 2) that will be made available to all healthcare professionals who have patients with stable angina.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of the project was to evaluate and improve the advice given to patients with CHD about sublingual GTN use. The project was conducted in 5 phases: Phase 1 - exploratory phase:
a) Assess if CHD patients who were admitted with chest pain knew / used their GTN correctly when chest pain was experienced.
b) Opinion of patients of advice provided and leaflets supplied by our Trust.
Phase 2 - develop a suitable approach and written information about how to use GTN in collaboration with patients who have CHD.
Phase 3 - Evaluate / user testing of the new credit card size GTN card (version 1).
Phase 4 - National picture - Conduct a national survey to evaluate:
a) What advice and leaflets are used nationally about GTN
b) Do practitioners routinely assess patients with CHD's understanding of how and when to use their GTN.
c) Are health care professionals interested in a national GTN Card.
Phase 5 - Develop a national GTN card (version 2) and make available to all healthcare professionals who have patients with stable angina.

Reasons for implementing your project

Before the project started patients were provided with booklets which contained information about medicines including how to use GTN. Advice was mainly provided by cardiac rehabilitation team. Our baseline audit revealed that many patients who have been prescribed GTN and have been previously admitted to our Trust did not know how to use their GTN correctly. Patients did not find that the GTN written information was readily accessible and as GTN use tends to be on when required basis, patients could not easily find the information on how to use GTN when they most needed it. Therefore, patients either used their GTN incorrectly or did not use at all. This resulted in sometime unnecessary admissions, or extensive delay in calling 999 after experiencing chest pain. Only 17% of patients showed full knowledge of how to use GTN. We consulted and involved patients throughout this project; in trying to understand the quality of the current service and its impact, ways to improve the service and evaluation of the new service. In the new approach, all patients prescribed GTN were:
1) Given a GTN card
2) Verbally advised on how to use GTN
3) Their GTN use and knowledge evaluated during admission or clinic review.

Better approach and tools in advising patients on GTN use means:
1) Better angina self-management
2) Shorter wait for 999 calls, when chest pain is not resolving. (time = muscle)
3) Less unnecessary admissions (angina)
4) Better informed patients
5) Well trained and informed healthcare professionals
6) Better use of written information, tailored to patients' needs

How did you implement the project

As explained earlier, we used the following methods:
1) Audit 1- evaluating current understanding and use of GTN by patients with established CHD who were already prescribed GTN and admitted with chest pain.

2) Consultation through surveys and patient comments on problems with current advice and written information about GTN.

3) Consultation with patients and healthcare professionals on a new approach to advice patients about GTN use and make it readily accessible and practical. Development of appropriate written information.

4) Piloting and evaluating the new written information and asking patients to comment and provide feedback on new approach.

5) Using a national electronic survey targeted at cardiology specialists, to evaluate national practice, advice given and interest in a national consistent approach in line with NICE recommendations.

6) Developing a national card.

Key findings

The approach we used to advice patients about GTN use was not effective. Only 17% of patients showed full knowledge of how to use GTN. Despite supplying our patients a wide range of written information about GTN, the majority do not seem to remember reading that information and cited that they did not think written information was readily accessible. Written advice should support verbal advice and not be given on its own without emphasis.

GTN written information should be readily accessible and practical, so it can be used at the point of needing GTN.

Involving patients in the development of patient information is invaluable. It enables the design and provision of information which is tailored to patients' needs and helps healthcare professionals better understand the practical issues related to medicines use.

Patient satisfaction was very evident. 80% of patients found the card useful. 83% said that it was easy to understand the information provided on the card and 81% agreed that idea of a small card that can be carried by those who use GTN is a good one.

Our survey showed that there was no consistent advice given about GTN use nationally. Some followed NICE's advice (10 minute), others used 15 min or more before advising their patietns to call 999. The majority of healthcare professionals did not routinely assess patients' understanding and ability to use their GTN when reviewed their medicines and 93% were interested in a national GTN card to make the advice provided more consistent.

We will be measuring further outcomes (reduced symptoms to 999 call time, unnecessary admissions etc.) before and after introducing the GTN advice card. The advice card is always provided with a verbal advice by nurses, pharmacists and pharmacy technicians. Doctors in outpatient clinics have also been using them. GPs were very interested in them and asked for national use and NICE's endorsement.

Key learning points

Never underestimate the simple interventions that are mistakenly taken for granted. The use of GTN is thought to be simple! but out project revealed that we are assuming too much. Neither the information we provided was effective, nor the patients were satisfied. Patients were missing on a simple intervention which could impact positively on their life and help them manage their condition better.

It is important to evaluate if the advice and information given to patients are suitable and effective. Do not assume, audit and check with patients.

When developing information leaflets, always involve expert patients, they provide invaluable insight into how and what to include. Simple recommendations and practicalities that are faced by patients can easily be missed by healthcare professionals.

Written information should always be supported by verbal advice.

Always assess patient's understanding of how to use their medicines.

Conflicting advice can confuse patients. Strive to have national consistent approach.

Share your experiences nationally to benefit patients across the whole country.

Contact details

Dr Rani Khatib
Senior Cardiology Pharmcist and Lecturer
Leeds Teaching Hospitals NHS Trust

Secondary care
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