The Cardiac Rehabilitation (CR) service at University Hospitals South Manchester sees 1000+ inpatients post-myocardial infarction. However, with the introduction of a primary angioplasty service, and its' associated short length of stay it became apparent that our five day service model was missing patients admitted at the end of the week or over the weekend. Although patients were subsequently picked up through phone calls or referrals to their local CR service it was apparent that take-up of CR was lower in this group of patients. The development of the service is relevant to NG185 Recommendation 1.8 Cardiac rehabilitation after a myocardial infarction (MI).
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 This guidance has now been updated and replaced by NICE NG185.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
The aim was to improve CR take-up by ensuring all short stay myocardial infarction (MI) patients had face to face contact with a CR specialist.
This was linked to the following objectives:
- A designated CR Nurse Coordinator on site seven days a week.
- Robust identification and coordination of in-patients requiring CR.
- Training a core team of Cardiology Liaison Nurses to provide a range of specialist cardiology services including CR.
- Provision of timely, early contact with patients and their families as soon as possible after admission and before discharge.
- Provision of individual patient education with appropriate supportive verbal and written information (comprehensive CR information pack is currently being developed).
- Explanation and discussion of the benefits of attending a CR programme as an essential part of recovery.
- Completion of standardised CR referral documentation (currently electronic version under development).
- Ensure systematic processes for timely transfer of information to out-patient CR services.
- Motivation of individuals to attend and complete outpatient CR (uptake and adherence targets).
- Offering programmes designed to meet the needs of a diverse local population by provision of the following options:
o Hospital-based programme.
o Community-based programme (to target specifically those with significant health inequalities).
o Home visits for individual patients as required.
Reasons for implementing your project
The quality of cardiac rehabilitation provision was adversely affected for acute MI patients, following primary angioplasty, due to a reduced hospital stay (from 7 days reduced to 2 - 3 days). There was a risk that patients would be discharged before face to face early intervention by the Cardiology Liaison Nurse team was possible. An informal baseline assessment was carried out to ascertain the size of the problem.
Opportunities were identified to improve efficiency and save costs, namely:
- Improve patient flow.
- Reduce length of stay.
- Target all eligible patients therefore potentially reducing readmission rates.
- Increase the pool of specialist cardiology nurses trained to provide in-patient CR.
- Enhance quality of CR referral form completion to support NACR information and audit.
How did you implement the project
We aimed to achieve the objectives by implementing the following changes:
- Remodelling of inpatient Cardiology Specialist Nurse Service from 5 to 7 day service in line with 'Changes to Working Practice' policy, and in consultation with Human Resources.
- Agreement reached from staff side regarding proposed changes to practice i.e. seven day service.
- Period of training to ensure whole team of Cardiac Liaison Nurses could provide in-patient CR.
- Facilitation of team working and cross cover to ensure best patient experience at all times.
- Refinement of robust systems to identify in-scope patients.
- Provision of comprehensive high quality verbal and written patient information post cardiac event and detailing CR programme.
- Improved liaison and communication between the Cardiology Liaison Nurse team, administration personnel and outpatient Cardiac Rehabilitation Therapy teams.
- Development of systems to optimise uptake and completion with motivational letters and programme literature.
- Enhancement of administration systems linking inpatient and outpatient CR.
- Robust triage system and follow-up of patients once discharged (contacted within 2-3 days), including those who initially state whilst in hospital, that they are not interested in attending CR.
- Agreement of the individual's CR assessment appointment from 1 - 4 weeks post discharge dependent on clinical status and preference.
- Robust system for follow-up of patients, who do not attend assessment or fail to continue to attend, using motivational phone calls and letters.
- Setting up of a CR Operational Group to link key personnel from the cardiac liaison nurse team, hospital-based and community-based CR teams.
Barriers which were overcome were in relation to historic working practice, e.g. no weekend working, no cross-cover with the cardiology liaison nurse team, and a lack of understanding of the different roles and responsibilities within that team.
We evaluated results using:
- Data from the advancing quality for myocardial infarction (AQ MI) Advancing Quality is the flagship programme of AQuA. It aims to improve standards of healthcare provided in NHS hospitals across the North West of England and reduce variation.
- NACR data.
- Patient reported experience measure.
- Consistently 90% of eligible patients post MI offered cardiac rehabilitation.
- Completion rates for out patient cardiac rehabilitation service was up to 82% (this includes all in-scope patients and not solely MI).
- Patient satisfaction; 93% of patients report their overall CR experience as excellent or very good (DOH target 85%).
What impact did the changes have on patient outcomes?
The changes negated the potential adverse effects of the reduced hospital stay associated with primary angioplasty following acute MI. The overall impact of theses changes ensured that the high quality CR service was maintained.
Key learning points
- Ensure ALL in-patients are seen by a designated cardiac rehabilitation professional.
- Provide a seven day in-patient service to ensure patients are seen in a timely manner and provided with written and verbal information prior to discharge.
- Engage staff in the service redesign through describing the positive impacts for patients.
- Ensure appropriate consultation takes place prior to the implementation of new rosters and cross-training.
- Standardise CR referral form and ensure systematic processes of referral.
- Achieve good communication with primary care (e.g. CR discharge form READ-coded).
- Organise CR operational meetings to include key personnel involved in all the CR stages.