State-wide Cardiology Project

Rapid Assessment and Access for Patients Presenting with Chest Pain

South Eastern Sydney Illawarra Area Health Service

Abstract

The State-Wide Cardiology Project (SWCP) was implemented successfully at Wollongong Hospital in October 2006. The aim of the project was to ensure that all patients presenting with chest pain were assessed and treated according to best practice guidelines and provided with access to diagnostics and treatment plans that would improve their flow through Cardiology and Emergency.

The project has exceeded expectations which are evidenced by an 11.6% improvement in access. This has been achieved despite a 7% increase in cardiology admissions. Further outcomes from the project include a reduction in waiting times for Myocardial Perfusion Scanning, of 4 days for in-patients and 10 days for out-patient appointments and a saving in excess of 700 bed days since the implementation of the Chest Pain Evaluation Area (CPEA).

Aim

The aim of the project was to implement appropriate site specific solutions to enhance the patient journey, improve access to cardiology beds, reduce bed days and improve timeliness and access to appropriate diagnostics.

Nature of the Problem

NSW Health Clinical Services Redesign Program recognised the need to improve the journey for patients presenting to the Emergency Department with chest pain. The project was designed to support clinicians and managers to redesign and improve a range of patient services to enhance the patient journey.

The solutions designed by NSW Health were prioritised for immediate implementation in order of their importance to improve access to cardiology services.

NSW Health recognised that patients presenting with chest pain represented one of the highest access block challenges.

The evaluation conducted by NSW Health clearly reflected the situation at Wollongong Hospital (WH). The pre-implementation data demonstrated poor access to cardiology beds and appropriate diagnostic procedures.

Extent of the Problem

WH pre-implementation data demonstrated that patients requiring admission for Acute Coronary Syndrome (ACS) spent and average of 8.4 hours in the Emergency Department and only 69% accessed a bed in the Cardiology Unit within 8 hours from presentation. There was no consistent approach to managing patients presenting with chest pain and patients were not stratified as low, intermediate or high risk as recommended under best practice ACS guidelines.

TWH data demonstrates that time from admission to Myocardial Perfusion Scan (MPS) was on average five days for in-patients and out-patients waited on average twelve days.  Access to treadmill testing was inconsistent due to competing demands on medical staff time. This was confirmed by review of Cardiac Diagnostics Services throughput data, which revealed a dramatic decline in treadmill stress testing during the preceding three years and changes in practice with the advent of invasive diagnostic procedures.

Average length of stay for ACS patients was 4.6 days according to data supplied by NSW health.

Strategic Importance

A primary focus of NSW Health SWCP 2006 was to improve access for all patients requiring inpatient treatment with a particular focus on those patients presenting with ACS. The SWCP solutions were aimed at improving the journey for this group of patients. The project also aligns itself with the NSW State Health Plan 2010; creating a better experience for people using health services. 

Planning and Implementing Solutions

SESIH Clinical Redesign Unit (CRU) was responsible for ensuring that local teams were formed and timelines for implementation decided.

Governance structure was established under the leadership of SESIH CRU. This involved the appointment of an Area Executive Sponsor to oversee the project across all sites. Each site was required to nominate a local Implementation Officer and Executive Sponsor.

The Implementation Officer, with support from the Southern Hospital Network (SHN) CRU and Executive Sponsor, formulated a team to implement the solutions chosen from the list of solutions offered by SWCP. The implementation team consisted of, Implementation Officer, Executive Sponsor , Clinical Redesign Manager , Director of Cardiology and Director of Emergency.

Stakeholders identified that would be critical for the smooth implementation of the project which included representatives from relevant diagnostic services, Department of Cardiology and Emergency Medicine inclusive of multidisciplinary members.

The initial meeting included a presentation from NSW Health Senior Project Officers detailing all potential solutions. These officers’ assisted with solutions applicable for implementation.

Weekly meetings occurred to guide the implementation process. The engagement of other stakeholders took place by means of direct face to face meetings, emails and formal education sessions. Communication was considered to be critical therefore numerous tools were utilised to disseminate information including: flyers, posters and newsletters. 

Solutions selected and implemented at Wollongong Hospital included chest pain pathway, CPEA and timely access to relevant diagnostic services. There were two locations that were considered to accommodate the CPEA, Emergency Department (ED) and Sub Acute Coronary Care (SACCU). It was determined that the CPEA was best co-located in SACCU due to space constraints within the ED.
Solution descriptions attached as appendix

Weekly reports were compiled for SESIH Clinical Redesign Unit for submission to NSW Health. Reporting included access data and ongoing risks and issues. Internal reporting mechanisms included weekly reports to the General Manager, monthly reports to the Patient Flow Committee and Wollongong Access Redesign Program Committee.

Outcomes and Evaluation

Local outcomes demonstrate that access for intermediate and high risk ACS patients has improved and has consistently out performed the previous year. The data shown below in Graph 1 clearly demonstrates improved access to beds by 11.6%, recognising that within the same time period admissions increased by 7%.

Graph 1

Use of a consistent best practice pathway to manage these patients through the process has ensured that cardiology patients are admitted to the right bed first time, with appropriate utilisation of diagnostic resources.

Graph 2 outlines the number of patients admitted to the CPEA from the time the unit opened.  Business rules established at implementation of the CPEA requiring all patients admitted to the unit to be on a pathway with clear stratification to ensure the philosophy of the unit is maintained. This graph demonstrates that in excess of 400 patients have been admitted to the CPEA since the 30th October 2006 and 300 have been discharged home safely within 24hrs.

Graph 2
 

Graph 3 reflects this as a percentage of total admissions.  This translates to a saving of in excess of 700 bed days as outlined in graph 4.

 
Use of the pathway for the treatment of intermediate and low risk patients ensures cardiology patents are adequately evaluated and referred for appropriate diagnostics. Post implementation low risk outpatient access to MPS is an average of 2 days. Intermediate risk inpatient access is less than 24hrs as displayed in graph 5.

It should be noted that low risk patients are now referred directly to the Nuclear Medicine Department for a MPS greatly improving patient safety.

Sustaining Change

It was determined that prior to commencing the project it was essential to appoint an Implementation Officer to take ownership and drive of the project. Appointment of an Executive Sponsor to pass on issues of concern was also an important function to support sustainability

Key performance indicator data were defined and collected to measure the effectiveness and sustainability of the change.

Post implementation cardiology access data is reported and discussed routinely as a standard agenda item for the Department of Cardiology, Emergency Dept and Clinical Design and Innovation Committee meetings.

A CNC Cardiac Assessment Nurse has been approved to act as a conduit between ED and Cardiology inpatient and diagnostic services. This role will oversee and drive the process at WH. Continuing education is provided to all relevant stakeholder groups in the Cardiology and Emergency Departments.

Future Scope

The project solutions will be implemented across the SHN with assistance from the CANC.
Implementation has commenced at Shellharbour, Shoalhaven and Milton Hospitals. Solutions selected for implementation are site specific taking into account available resources.

Project Team

Tony Tiberio and Chris Masters 

Contact

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