Imperial College Healthcare's cardiovascular prevention and rehabilitation programme (CPRP) comprises a hospital-based programme at Charing Cross Hospital and a community-based programme (MyAction) in Westminster.
The dedicated full-time multidisciplinary team offers a comprehensive menu-based rehabilitation programme that meets the needs of its local community as well as that of a leading tertiary referral centre for coronary revascularisation, heart failure and implantable devices.
It serves 400,000 people living in Hammersmith, Fulham and Westminster, where over a quarter of people are from black and minority ethnic groups and receives referrals for over 1,300 people annually.
This example was originally submitted to demonstrate implemention of NICE CG172. This guidance has now been updated and replaced by NICE NG185. The example has been reviewed and its content continues to align generally with the updated guidance. The latest NICE guidance should be referred to if replicating any aspect of this example.
- Acute coronary syndromes (NG185)
Aims and objectives
Uptake of cardiac rehabilitation is still low, with only 44% of people starting an outpatient cardiac rehabilitation programme in England, Northern Ireland and Wales after an MI. People also wait an average of 53 days to start an outpatient rehabilitation programme.
Therefore two of the key priorities for implementation are:
1). To offer cardiac rehabilitation programmes designed to motivate people to attend and complete the programme. Explain the benefits of attending.
2). Begin cardiac rehabilitation as soon as possible after admission and before discharge from hospital. Invite the person to a cardiac rehabilitation session taking place within 10 days of their discharge from hospital.
Our cardiac prevention and rehabilitation programmes aims to provide patients with cardiovascular disease with a high quality comprehensive cardiovascular prevention and rehabilitation programme. The programme includes an emphasis on healthy lifestyle change (smoking cessation, adhering to a cardio-protective diet and increasing physical activity levels), managing medical risk factors such as blood pressure and lipids and ensuring patients are prescribed evidence-based doses of cardio-protective medications. The programme also addresses psychosocial health.
The programme is delivered by a full multidisciplinary team as per the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) Core Components and Standards (2012) which includes cardiovascular specialist nurses, dieticians, physical activity specialists supported by psychologists and a consultant cardiologist.
Reasons for implementing your project
The Imperial College Healthcare NHS Trust Cardiovascular Prevention and Rehabilitation programme (CPRP) was started over 10 years ago but only had its funding formalised in 2011. A business case was presented at the time to Hammersmith and Fulham PCT which was accepted based on the excellence of the programme's clinical outcomes and also due to the costs savings associated with the substantially lower cardiac readmission rate in Hammersmith and Fulham compared with the rest of NW London (which can be attributed to the CPRP).
The MyAction Westminster programme was commissioned directly by NHS Westminster in 2009 and is an integrated prevention programme including patients with all manifestations of atherosclerotic disease (including TIA/PAD) as well as patients at high multifactorial risk of developing CVD.
NICE guidance (CG48) published in May 2007 (MI - secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction) had a key priority for implementation that "Cardiac rehabilitation should be equally accessible and relevant to all patients after an MI, particularly people from groups that are less likely to access this service. These include people from black and minority ethnic groups, older people, people from lower socioeconomic groups, women, people from rural communities and people with mental and physical health comorbidities." Both programmes have been developed following this guidance as well as the relevant guidelines and targets as set out by the NSF and the Joint British Societies' recommendations on prevention of coronary heart disease in clinical practice and the BACPR Standards and Core Components for Cardiac Rehabilitation 2012. The programmes are now designed to deliver the standards set out in the updated guidance NICE NG185 for acute coronary syndromes.
These have reinforced the importance of offering cardiac rehabilitation programmes designed to motivate people to attend and complete the programme, and to begin cardiac rehabilitation as soon as possible after admission and before discharge from hospital.
How did you implement the project
Patients are admitted to the trust from across North West London for investigation and treatment. There is a robust identification and referral system in place ensuring that patients who have had a cardiovascular event are offered access to one of the Imperial CPRPs or referred to their local cardiac rehabilitation service if this is their preference. This is referred to as the Phase 1 service and all such patients see a dedicated CPRP nurse.
The phase 1 intervention is particularly important as it plays an important role in a patient's recovery. This consists of a clinical evaluation including risk factor assessment and education and specific tailored advice with regards to activities of daily living. It is also an important time point for early initiation of cardiac rehabilitation. Patients being referred to Imperial CPRP are then sent an individual letter of invitation for their initial assessment stating that their consultant cardiologist has recommended they attend and that the programme is part of their medical treatment. An appointment is offered within the target 10 days. Both programmes place a strong emphasis on equity of access and all cardiac patients are eligible irrespective of revascularisation status.
In Westminster, the programmes are delivered in three community hubs, two of which are located in the borough's most deprived wards (with a high prevalence of BME groups) so that these patients who are often underrepresented in cardiac rehabilitation have ease of access. The starting point for the outpatient CPRP is the multidisciplinary assessment where patients are seen by each member of the MDT. During this assessment the patient's needs are identified and a tailored, patient-centred programme is devised.
All participants are offered a choice of a 12-16 week structured programme with supervised group exercise sessions and educational workshops (hospital or community-based) or an individually tailored home programme. The programme also includes a low functional capacity class with a higher staff to patient ratio (1:3) to allow patients e.g. with heart failure or other comorbidities such as COPD, arthritis, to attend. The team recently introduced a dedicated ICD (implantable cardiac-defibrillator) rehabilitation programme and an intensive weight management programme. In 2010, the Westminster community programme began a Phase 4 cardiac rehabilitation service which ensures a seamless transition of patients from the Phase 3 programme.
In 2012-2013, over 98% of eligible patients were offered a CP&R programme and over 80% of these attended a subsequent initial assessment. This figure is nearly double the national average of 43%.
The programme has a dedicated database and a strong emphasis is placed on audit and evaluation. Audit includes all clinical outcomes including lifestyle (smoking, diet, physical activity/fitness), blood pressure, lipids, glycaemia, cardio-protective medication and psychosocial measures (hospital anxiety and depression scores, quality of life measures).
In comparison with National Audit of Cardiac Rehabilitation, the programmes clinical outcomes are substantially better and show improvements across all these domains.
Patient satisfaction rating are measured using a hand held tablet device and are very positive with ratings that are in the top 5% of Imperial's services.
The Imperial cardiac and rehabilitation programme was recognised as one of the top three in the UK in the 2011 British Heart Foundation Celebrating Cardiac Rehab award. The MyAction Westminster programme was also shortlisted for a NHS Innovation and Improvements Award in 2010, by the HSJ (Health Service Journal) awards 2012 in the primary care and community service redesign category and also for an I Care Integration award in 2013. It was also commended in the BUPA Foundation Healthy Lives prize in 2011.
Key learning points
We have developed a service that has managed to tackle and achieve our targets through having:
- a dedicated business case so that funding is appropriate to deliver a quality service.
- a robust identification and referral service for in patients delivered by a core member of the Cardiac Prevention and Rehabilitation programme multi-disciplinary team.
- a full multi-disciplinary team as recommended by the British Association for Cardiovascular Prevention and Rehabilitation Standards 2012 with adherence to the seven standards advocated within.
- a strong emphasis on audit and evaluation to show clinical benefit and value for money.