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Telecardiology speeds referrals

Dr Amol Kelshiker and Dee Hannah describe a community-based service that delivers rapid diagnostics.

Harrow PCT serves a population of nearly 250,000 in a busy commuter-belt, suburban area of north-west London. In 2005, an audit of cardiology outpatients at Northwick Park Hospital revealed an average waiting time for appointments of more than 12 weeks, giving rise to considerable distress to anxious patients.

Restricted capacity for specialist tests (for example, echo, ECG, BP and cardiac event monitoring) led to additional delays and consultation appointments with a cardiologist were being wasted because patients were either inadequately investigated or referred inappropriately.

GPSIs and specialist nurses
There was ample evidence that these investigations could be carried out more effectively and quickly in primary care, and in many cases eliminate the need for referral to secondary care.

The PCT decided to improve the local service by developing a highly trained mobile cardiac team involving trained GPSIs and specialist nurse practitioners, specialist nurses, and healthcare assistants all supported by hospital-based cardiologists.

The result was an electronic, paper-free, primary care-based diagnostic service accessible online by all the PCT's 37 practices. The service was established early in 2006 and the PCT invested in state-of-the art equipment for ECG and BP recording. The service now includes 24-hour ECG and cardiac event monitoring.

Waiting times slashed
Every practice is connected via PCs to a central email server, allowing ECG and BP data to be requested by individual GPs with the results returned to them electronically.

Alternatively, GPs can undertake their own ECG and BP tests and have them analysed by the assessment and diagnostic service.

Either way, the time from the GP requesting an ECG or ECG interpretation to the patient receiving a clear idea of their cardiac management has been slashed from weeks or months to hours or days.

There is a fast track to secondary care when abnormal ECGs dictate that a referral to a cardiologist is warranted. A patient pathway makes clear which patients are suitable for primary care management and which are not.

The assessment service is now taking on a significant diagnostic workload. Between April and June 2007, for example, Harrow PCT carried out 123 24-hour ECGs, over 70 24-hour BPs, 138 resting ECGs and dealt with 14 cardiac events. Secondary referrals to outpatient clinics fell by up to 40 per cent.

Self-assessment satisfaction questionnaires that patients attending the community cardiology service complete indicate a 95 per cent satisfaction rate.

Mobile service
In 90 per cent of cases the GPSI or specialist nurse practitioner can make a diagnosis and create a management plan. Practices without ECG machines send their patients to one of the PCT's cardiac diagnostics specialists for the ECG and the analysis is emailed back to the GP.

As a completely paper-free system the risk of lost reports or having to interpret poor quality recordings and copies is minimised.

As the equipment is highly mobile healthcare professionals can take ECG readings in the homes of housebound patients, bringing the data back for interpretation and analysis.

The main aim has been to provide direct access to diagnostic ECGs and ambulatory BPs for local GPs to improve patient outcomes. The service maximises the skill mix to allow primary care specialists in cardiology to interpret the data and advise GPs accordingly.

Much needed improvement
It is unacceptable for patients to wait sometimes months for what are relatively simple investigations to establish diagnosis, enable onward management or exclude serious illness and allow patients to get on with their lives reassured. This was a service that was crying out for change and we have succeeded in delivering much-needed improvements to locally-based cardiac diagnostic services.

Harrow PCT's implementation of this sophisticated diagnostic initiative was aided by the support and training back up provided by Welch Allyn, the firm supplying the diagnostic equipment and computer software to link local practices to the central server.

- Cardiology GPSI Dr Kelshiker and cardiac nurse consultant Ms Hannah work in Harrow PCT's primary care-based cardiology service.

Community-based cardiac diagnostics service

  • Uses Welch Allyn's CardioPerfect PC-based Resting ECG: a mobile, menu-driven ECG system, automatically storing and analysing recorded ECG data via existing computer hardware.
  • A 12-lead ECG device, with pre-trigger recording connecting to CardioPerfect Workstation software and installed in 37 GP practices.
  • Can store/retrieve thousands of ECGs, and compare different ECGs on the same monitor. Extended ECGs can be recorded for up to five minutes on all 12 leads.
  • Healthcare professionals can record ECGs at the bedside or during home visits.
  • Hard copy printouts can be produced directly on any Windows-compatible printer or by remote fax.
  • Networking facilities and integrated transmission features for telemedicine applications.
  • EMR-ready system, with the capacity to integrate with other patient information systems (medical records, for example).
  • Enables PCTs to manage all cardiopulmonary test data within one software package without disrupting GP practices' routine work, via stand-alone or networked PCs.
  • Quick, easy retrieval and analysis of data, eliminating the need for repeat ECGs by reviewing a complete 12-lead pre-print report on screen.
  • Can change or add a diagnosis and compare with previous ECGs using the on screen ECG report editor function.

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