interim evaluation 17092010 - nhs wales...acute chest pain patient management; c/o canolfan...

Title

Primary Care Acute Chest Pain Awareness Project Interim Evaluation

Authors

Alison Turner, Clinical Project Manager Marc Thomas, Project Manager

Owner

Mid & South West Wales Cardiac Network

Document Reference

MSWCN/1000/80/10/11/Interim

Associated Documents

Pre-Implementation Staff Awareness Questionnaire; Record of Calls/Visitors to Practice Redirected to Emergency Services; Acute Chest Pain Management (Clinical); Acute Chest Pain Patient Management

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Introduction The majority of General Practice (GP) practices have now been accessed across the Mid and South West Wales region. Educational sessions have been delivered in a variety of forums, including Protected Learning Time for Primary Care, Practice Managers meetings, and organised regional evening meetings. It has been challenging to access educational forums, particularly with the aim of targeting a mixed audience of clinical and non-clinical GP practice staff. Counties that have been accessed to date are Bridgend, Carmarthenshire, Ceredigion and Pembrokeshire. Areas that have yet to be accessed are Neath Port Talbot, Swansea and Powys. Method As in the pilot study (appendix A) the educational sessions started with a pre-education questionnaire, to enable further examination of baseline knowledge and confidence regarding acute chest pain and its timely treatment. The chest pain guidance flowcharts (appendix B) and other resources were given out. Everyone attending the sessions completed a pre-education survey (appendix C). These were also given to those who were going to disseminate the education within their practices, to enable further evaluation of everyone receiving the education/resources, be it within the formal setting or at a more local level. Post education and implementation questionnaires are currently still being sent out to all sites that have received the education, to evaluate how practice has developed and to discern whether confidence in dealing with acute chest pain calls has improved. Following the educational sessions, non-carbon copy forms to report cases where the call handler has utilised the project guidance have been submitted to allow further analysis on some outcomes for patients who have been diverted away from assessment in primary care, to direct paramedic/hospital assessment. This was fed back to the Mid and South west Wales Project team anonymously, where the cases could be traced and followed up on the Myocardial Ischaemia National Audit Project (MINAP) database. Alongside this, the MINAP dataset has been examined to note the year-by-year trends in admission routes for those patients who are ultimately discharged with an acute cardiac event. Results Questionnaire results The pilot study displayed overwhelming improvements in administration group with confidence gained in dealing with acute chest pain calls/presentation. The project team were keen to see if this trend continued in both clinical and administration groups in the project regional roll-out phase, and, with increased numbers and a more longitudinal

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examination of data, if this in turn improved appropriate admission routes to hospital for acute chest pain patients.

1 2 3 4 5 6 7 8 9 10

0%

5%

10%

15%

20%

25%

30%

35%

40%

Confidence Level

Administrative Staff Confidence LevelsChest Pain Presentation in Person to GP Practice

Pre % (n=110)Post % (n=120)

Chart 1

1 2 3 4 5 6 7 8 9 10

0%

5%

10%

15%

20%

25%

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35%

40%

Confidence Level

Administrative Staff Confidence LevelsTelephone Call to GP Practice Reporting Chest Pain

Pre % (n=110)Post % (n=120)

Chart 2

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1 2 3 4 5 6 7 8 9 10

0%

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45%

Confidence Level

Clinical Staff Confidence LevelsChest Pain Presentation in Person to GP Practice

Pre % (n=110)Post % (n=120)

Chart 3

1 2 3 4 5 6 7 8 9 10

0%

10%

20%

30%

40%

50%

60%

Confidence Level

Clinical Staff Confidence LevelsTelephone Call to GP Practice Reporting Chest Pain

Pre % (n=110)Post % (n=120)

Chart 4 Demonstration of this confidence needed to be reflected in the patient admission routes. Again, a vast improvement was seen in the number of people stating that they would call 999 rather than allocate time within a clinic or organise a home visit. This was then verified by examining the trends in admission route by MINAP data results (charts 9 & 10) to ensure that this was actually being put into practice.

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Method of Admission - Administrative Staff

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40%

50%

60%

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90%

100%

To be seen byGP; GP then calls

999 afterassessment

Patient advisedto call 999 (or

surgery call 999if patient

presents inperson)

bypassing GP

To be seen byGP; GP advises

patients to makeown way to

hospital

Patient is triagedto attend surgeryfor assessment

at next availablesame day

appointment

Method of Admission

Perc

en

tag

e

Pre % (n=110)Post % (n=120)

Chart 5

Method of Admission - Clinical Staff

0%

10%

20%

30%

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80%


999 afterassessment

Patient advised tocall 999 (or

surgery call 999 ifpatient presents

in person)bypassing GP



hospital

Patient is triagedto attend surgeryfor assessment at

next availablesame day

appointment

Method of Admission

Perc

en

tag

e

Pre % (n=110)Post % (n=120)

Chart 6 Very few GP practices had existing written guidance specifically for handling acute chest pain cases. There was some general guidance on treatment of emergency conditions, but little rationale for the specific need and timescales relating to acute chest pain treatment. Qualitative feedback, mainly verbal by informal discussion after the educational sessions, suggested that the guidance was particularly effective as the rationale and evidence base for the guidance had been explained.

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Awareness of Written Guidance - Administrative Staff

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Yes No Unsure

Aware of Written Guidance?

Perc

en

tag

e

Pre % (n=110)Post % (n=120)

Chart 7

Awareness of Written Guidance - Clinical Staff

0%

10%

20%

30%

40%

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Yes No Unsure

Aware of Written Guidance?

Perc

en

tag

e

Pre % (n=110)Post % (n=120)

Chart 8

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MINAP data analysis

Method of Admission

2005-2006 (n=455)

2006-2007 (n=444)

2007-2008 (n=371)

2008-2009 (n=418)

2009-2010 (n=358)

Called 999 276 306 238 287 264 Called GP who called emergency service then saw patient 5 6 3 1 4 Called GP who saw patient then called emergency services 59 38 28 25 24 Called GP - told to make own way to hospital 18 15 10 13 7 Made own way to hospital (did not call anyone) 69 55 74 67 46 Other 28 24 18 25 13

Source: MINAP (Accessed: 07 September 2010) Examination of the MINAP dataset to look at the regional trends for admission routes was also carried out for all STEMI patients on admission. The data looks at 2 years pre-project to date. Only ST elevation myocardial infarction (STEMI) patients were followed up at this stage, as the main objective of the study was to reduce Call-to-Needle (CTN) times. With emerging evidence supporting the early assessment and revascularisation of non-STEMI (NSTEMI) patients, the final evaluation will include, where possible, the evaluation of this cohort of patients.

Chart 9

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Chart 10

Chart 11

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Chart 12 Discussion Following on from the pilot evaluation, we were expecting a replication of the improvement in staff confidence levels with the structured approach, which was achieved and in fact surpassed. With the poor reporting of case-by-case information in the pilot study, we were unsure how this area of the project would develop. What we had not looked at with the pilot study were the year-on-year trends in chest pain admission routes, as the project had low numbers and a relatively short duration to have had a significant impact on outcomes. The results showing such a vast improvement were welcomed and having had the project in place for over 12 months and we hope to be able to attribute this to the project. To demonstrate this further, in the final analysis we hope to compare our region to another similar geographical/population region that has not had this education or structured guidance. There is also a demonstrable decrease in the numbers of GPs asking patients to make their own way to hospital, which was not shown in the pilot evaluation. This could be that the numbers dealt with were very small with the pilot group, and also that the duration of the pilot did not allow for the impact of the education to be demonstrated on the MINAP database. Again, this was a pleasing result, although the project team are aware that this should be at zero. Conclusions Further analysis will enable the final project evaluation to demonstrate the potential for wide dissemination of the education and written guidance developed through this project. Emphasis must be place on the need for the educational support needed to implement the guidance effectively and enable those using the resources - both clinical and non-clinical – to put

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the guidance into practice to improve time to treatment. There is scope to evaluate outcomes more effectively, but also scope to realise the difficulty in accessing forums in Primary care to educate and target the whole ‘team’ dealing with the patient journey. With the interim results in mind and the demonstrable results, the project education and resources could be disseminated to a wider audience with confidence that the final project outcomes will be positive, but reinforcing the need for the hand-in-hand approach of brief education alongside provision of written resources being the most effective way of implementing the structured approach to practice. Those wishing to disseminate the project could make use of the current Powerpoint presentation (appendix D) to enable this, bearing in mind the difficulty in targeting the wider audience that the current project team have encountered.

Appendix A

Primary Care Acute Chest Pain Awareness Project Pilot Evaluation (October 2009)

Title

Primary Care Acute Chest Pain Awareness Project Pilot Evaluation

Authors

Alison Turner, Clinical Project Manger Marc Thomas, Project Manager

Owner

Mid & South West Wales Cardiac Network

Acknowledgements

With thanks to staff at: Adfer Medical Group, Llanelli Coach & Horses Surgery, St. Clears Furnace House Surgery, Carmarthen Llanfair Surgery, Llandovery Margaret Street Surgery, Ammanford Meddygfa Tywi, Nantgaredig

Document Reference

MSWCN/1000/80/10/11/Pilot

Associated Documents

Pre-Implementation Staff Awareness Questionnaire; Record of Calls/Visitors to Practice Redirected to Emergency Services; Acute Chest Pain Management (Clinical); Acute Chest Pain Patient Management;

c/o Canolfan Gwasanaethau Busnes GIG Cymru, Canolfan Henffordd, 36 Stryd y Berllan, Abertawe, SA1 5AQ c/o NHS Wales Business Services Centre, The Oldway Centre, 36 Orchard Street, Swansea, SA1 5AQ Ffôn/Telephone • 01792 607284 Ffacs/Facsimile • 01792 607204 Ebost/Email • [email protected] Rhyngrwyd/Internet • http://www.mswcardiacnet.wales.nhs.uk/

mailto:[email protected]

http://www.mswcardiacnet.wales.nhs.uk/

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Primary Care Acute Chest Pain Awareness Project

Pilot Evaluation

Introduction

All Carmarthenshire GP practices (n=27) were approached to participate in the

pilot; 6 sites agreed to participate:

• W92055 – JL Richards & Partners (Llanfair Surgery, Llandovery) Practice

population c. 5,700

• W92030 – AI Harries & Partners (Adfer Medical Group, Llanelli) Practice

population c.15,500

• W92007 – HI Wilding & Partners (Coach & Horses Surgery, St. Clears)

Practice population c. 7,600

• W92016 – GH Lewis & Partners (Furnace House, Carmarthen) Practice

population c. 14,300

• W92040 – MJ Griffiths & Partners (Margaret Street, Ammanford) Practice

population c. 8,300

• W92063 – DA Davies & Evans (Meddygfa Tywi, Nantgaredig) Practice

population c. 3,300

Sites were visited during November and December 2008 by project staff,

receiving an educational presentation about the background to the project,

resources that would be available and had the opportunity to ask questions. The

project was received positively in general, with only one site voicing reservations

about inappropriate admissions with their ‘known’ abusers of their current triage

system. Rationale was that there was probably an argument for offering a 999

call for such people, who would probably refuse the offer, as the motive was to

access a GP, not usually to gain hospital admission.

Method

At the beginning of the set-up visit, a pre-implementation staff awareness

questionnaire (appendix 1) was completed by all attendees to assess prior

knowledge and resources currently in place. Sites were also given pro-formas to

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complete and submit to the Cardiac Network (appendix 2) to log chest pain calls

that were subsequently admitted to hospital, although automated telephone

messages advising those with chest pain or any other emergency to dial 999 were

still in place and encouraged. Should callers still access the primary care

telephone system, or self-present to the surgery, the calls were backed up with

the evidence based flow-charts (appendix 3), to assist the decision making

process. The flow charts were developed in collaboration with the British Heart

Foundation, Welsh Ambulance Service NHS Trust, Carmarthenshire LHB and Mid &

South West Wales Cardiac Network. The clinical flow-chart is based on the

Suspected ACS pathway of the Map of Medicine. Surgeries were contacted at the

end of the initial 3 month pilot, to encourage dissemination of the project within

the surgery and promote a good response rate. The pilot was extended for a

further 2 months in order to gain more results.

Results

Staff confidence

47 pre-implementation questionnaires were completed and returned.

31 post-implementation questionnaires were completed and returned.

There was a greater proportion of non-clinical staff attending the education

sessions and subsequently completing the questionnaires.

The results demonstrated greatly improved confidence in dealing with people

presenting with chest pain, both directly to the surgery or telephoning for advice.

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0

10

20

30

40

%

1 2 3 4 5 6 7 8 9 10

Staff Confidence level

Chest pain presenting in person to Surgery - Administrative Staff

Pre %

Post %

Graph 1

Source: Pre-Implementation Staff Awareness Survey

0

10

20

30

40

%

1 2 3 4 5 6 7 8 9 10

Staff Confidence level

Chest pain telephone calls to Surgery - Administrative Staff

Pre%

Post %

Graph 2


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Method of admission - Administrative Staff

0

20

40

60

80

100

To be seen byGP; GP then

calls 999 afterassessment

Patient advisedto call 999 (orsurgery call

999 if patientpresents in

person)bypassing GP

To be seen byGP; GP

advises patientto make own

way to hospital

Patient istriaged to

attend surgeryfor assessment

at nextavailable same

dayappointment

Method of Admission

Pe

rce

nta

ge

Pre %

Post %

Graph 3


Awareness of written guidance - Administrative Staff

0

20

40

60

80

100

Yes No Unsure

Awareness

%

Pre %

Post %

Graph 4


Chest pain calls

9 chest pain admission responses were received from the 6 sites as follows:

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W92055: 6

W92030: 2

W92007: 1

W92016: 0

W92040: 0

W92063: 0

This was then followed up by tracing the admission on the MINAP database. One

admission was logged onto MINAP, initially suggesting that these admissions were

ultimately not acute coronary syndrome (ACS) causes of chest pain. Further

examination of the MINAP dataset revealed that not all ACS patients are entered –

one Carmarthenshire hospital only enters data for definite ST elevation MIs

(STEMI), not all patients with an ACS. Although the project was initially driven by

examination of method of admission for STEMI treatment, and hence speedy

access to thrombolysis, it would have been helpful to know if the chest pain calls

had been for an ACS, who may subsequently have undergone urgent

revascularisation.

A MINAP database search was performed for the same time period, specifically

looking at those patients (with all ACS causes of admission) who had contact with

primary care prior to their admission. These fell into 3 categories:

• Patients who called their GP, who called 999 then saw patient

• Patients who called their GP, GP saw the patient then called 999

• Patients who called their GP and were then told to make their own way to

hospital

‘W numbers’ were obtained to link these cases to the surgery that admitted the

patient, maintaining anonymity. Several cases originated from pilot sites, with no

pro-forma received from the pilot site.

Discussion

Several points emerged from the pilot evaluation. Informal discussions with the

surgery staff have suggested that the structured approach with the supporting

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documentation has greatly assisted the decision-making process and in turn this

has improved confidence in dealing with chest pain patients. Perhaps more

regular telephone follow-up by project staff would have produced better feedback

of all chest pain cases admitted. Again from informal discussion, there may have

been misconceptions with staff that they were only reporting on cases that had a

999 admission, rather than all admissions for chest pain that had received care in

the Primary Care setting. This may explain the disparity between the pro-formas

received and the MINAP data, as several cases reported on MINAP were cases

where patients were told to make their own way to hospital. This is unfortunate,

as it is these cases in particular that the project is trying to target, but this can

also be used to underpin the rationale for the project. Comparing MINAP data for

2007-8 to that of 2008-9, there has been no decrease in the number of cases in

the Mid & South West Wales region where the GP has asked the patient to make

their own way to hospital. There has, incidentally, been a significant rise in the

number of patients calling 999, and reduction in numbers of patients making their

own way to hospital, perhaps demonstrating the impact of campaigns such as

‘BHF Doubt Kills’.

Although the initial concept for the project outcomes was expected to principally

be the discharge diagnosis of patients admitted with chest pain, the educational

sessions to describe the management of acute chest pain have emerged as having

a greater impact. The disparity between sites in approach to chest pain

management has reflected well in the positive responses received to the

structured though not prescriptive approach gained by the implementation of the

guidance at user-level, whether that be clinical or non-clinical. This has helped

inform our approach to rolling the resources and the project across the Mid &

South West Wales region in the first instance, but with scope for the resources

being able to be used nationally.

Conclusions

The pilot project changed the emphasis on the outcome data, to include patient

outcomes, but to emphasise the importance of the education and structured

approach to chest pain management in Primary Care. Cascading the project to all

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GP sites in the Mid & South West Wales area will be challenging due to the rural

and large geographical area to be covered, but by piloting the project and

receiving feedback, both formal and informal, we can make the educational

sessions informative and useful. As we have been working in collaboration with

the British Heart Foundation, the project will be evaluated in full when all areas

have received their education and resources and when feedback has been

received. We then hope that the information and resources can be utilised widely.

Marc.Thomas

Typewritten Text

Appendix 1

Marc.Thomas

Typewritten Text

Appendix 2

Further History Call emergency

services and upgrade call to 999

HistoryPatient complains of acute chest pain

* Risk Factors • Smoking • Hyperlipidaemia • Hypertension • Diabetes • Existing CHD • Family history of CHD • Recent cocaine use

Examination should not delay

transport of patient to secondary care

Examination

Diagnosis of acute

coronary event

Emergency Support Equipment (where available):

• Defibrillator • Oxygen • Suction • Airway • Bag Valve Mask

Acute Chest Pain Management (Clinical)

Ask Patient: • Character/severity/location/

radiation of pain • Time of onset • Is pain continuous? • Factors relieving pain • Past history of similar pain • Risk Factors* • Related to activity or exercise• Is pain related to trauma/injury?

Examination • General appearance - pallor/

clammy/cyanosed• Vital signs – Pulse/BP/

Resp. rate/O2 Saturation/JVP • Auscultate chest • Abdominal examination – for

suspected aneurysm • ECG

Treatment • Aspirin 300mg• Oxygen • GTN spray • Opiate analgesia/antiemetic • If not already called, call ambulance.

Remember:For every minute delay in thrombolytic treatment 11 days survival is lost

Registered Charity Number 225971

* Associated Symptoms • Shortness of breath • Nausea/vomiting • Sweating • Feeling light-headed • Pallor

Patient may complain of associated

symptoms*

Marc.Thomas

Typewritten Text

Appendix 3

Rhif Cofrestru’r Elusen 225971

Efallai bydd y claf yn cwyno o

symptomau cysylltiol*

Hanes

Mae’r claf yn cwyno o boen y frest llym

Hanes PellachFfoniwch

gwasanaethau argyfwng ac uwchraddiwch yr

alwad i 999

Archwiliad

Diagnosis o ddigwyddiad

coronaidd llym/ cychwyniad cyflym

* Symptomau Cysylltiol • Diffyg Anadl • Cyfog a Chwydu • Chwyslyd • Pendro • Gwelwedd

* Ffactorau Risg • Ysmygu • Colesterol Uchel • Pwysedd Gwaed Uchel • Clefyd Melys • Clefyd Coronaidd y Galon • Hanes Teuluol o Glefyd

Coronaidd y Galon • Defnydd Cocên yn

ddiweddar

Ni ddylai yr archwiliad oedi

cludo y claf i ofal eilaidd

Cofiwch:Am bob munud o oedi yn nhriniaeth thrombolytic, mae 11 diwrnod o oroesiad yn cael eu colli

Offer Cymorth Argyfwng (Os ar gael):

• Defibrillator • Ocsigen • Sugnedd • Llwybr Anadlu • Mwgwd Bag Falf

Rheolaeth Poen y Frest Llym – Cychwyniad Cyflym (Clinigol)

Gofynnwch i‘r Claf: • Nodwedd/llymder/

lleoliad/ymledu o boen • Amser cychwyn • Ydy’r boen yn parhaol? • Ffactorau sy’n cynorthwyo’r boen • Hanes o boen debyg • Ffactorau Risg*• Ydy’r boen yn berthnasol i weithgaredd/

gweithgarwch corfforol/trawma/anafiad?

Archwiliad • Golwg cyffredinol – gwelwedd/

oerwlyb/afliwiad glas y croen• Arwyddion bywiol – curiad/pwysau

gwaed/cyflymdra anadl • Dirlawnder O2/Pwysau Gyddfol

Gwythїen (JVP)• Gwrandewch ar y frest • Archwiliad yr abdomen – am aneurysm • ECG

Triniaeth • Aspirin 300mg• Ocsigen • Chwistrell GTN • Analgesia cysglyn/gwrthgyfogydd • Os nad yw’r ambiwlans wedi cael ei

alw, ffoniwch nawr.

Patient complains of chest pain or discomfort and/or has collapsed

Telephone In practice

If patient is aloneCall 999 then alert

doctor or nurse Immediately

Somebody is with the patient

• Ask for brief details (name, DOB, address)

• Note date/time • Transfer the call to

a doctor or nurse immediately

• Ask for brief details of patient (name, DOB, address)

• Ask caller to redial 999

Dial 999 and ask for ambulance for

chest pain to attend at patient’s address

Inform doctor of the call

• Sit patient down• Reassure help is

on the way • Stay with patient

until help arrives

Acute Chest Pain Patient Management



Mae’r claf yn cwyno o boen y frest neu anghysur a/neu wedi ymollwng

Ffôn Yn y Feddygfa

Os yw’r claf ar ben ei hunan

Mae rhywun gyda’r claf

• Gofynnwch am fanylion (Enw, Dyddiad Geni, Cyfeiriad)

• Nodwch dyddiad ac amser

• Trosglwyddwch yr alwad i feddyg neu nyrs ar unwaith

• Gofynnwch am fanylion y claf (Enw, Dyddiad Geni, Cyfeiriad)

• Gofynnwch iddyn nhw ffonio 999

Ffoniwch 999 a gofynnwch am

ambiwlans i boen y frest i fynd i gyfeiriad y claf

Dywedwch wrth y meddyg am yr alwad

• Eisteddwch y claf i lawr• Dywedwch wrth y claf

fod help ar y ffordd • Arhoswch gyda’r

claf tan fydd y help yn cyrraedd


Poen y Frest Llyn – Cychwyniad Cyflym Rheolaeth y Claf

• Ffoniwch 999• Gofynnwch i unrhywun

i chwilio am feddyg neu nyrs ar unwaith


Appendix B

Chest Pain Guidance Flowcharts

Further History Call emergency

services and upgrade call to 999

HistoryPatient complains of acute chest pain

* Risk Factors • Smoking • Hyperlipidaemia • Hypertension • Diabetes • Existing CHD • Family history of CHD • Recent cocaine use

Examination should not delay

transport of patient to secondary care

Examination

Diagnosis of acute

coronary event

Emergency Support Equipment (where available):

• Defibrillator • Oxygen • Suction • Airway • Bag Valve Mask

Acute Chest Pain Management (Clinical)

Ask Patient: • Character/severity/location/

radiation of pain • Time of onset • Is pain continuous? • Factors relieving pain • Past history of similar pain • Risk Factors* • Related to activity or exercise• Is pain related to trauma/injury?

Examination • General appearance - pallor/

clammy/cyanosed• Vital signs – Pulse/BP/

Resp. rate/O2 Saturation/JVP • Auscultate chest • Abdominal examination – for

suspected aneurysm • ECG

Treatment • Aspirin 300mg• Oxygen • GTN spray • Opiate analgesia/antiemetic • If not already called, call ambulance.



* Associated Symptoms • Shortness of breath • Nausea/vomiting • Sweating • Feeling light-headed • Pallor

Patient may complain of associated

symptoms*


Efallai bydd y claf yn cwyno o

symptomau cysylltiol*

Hanes

Mae’r claf yn cwyno o boen y frest llym

Hanes PellachFfoniwch

gwasanaethau argyfwng ac uwchraddiwch yr

alwad i 999

Archwiliad

Diagnosis o ddigwyddiad

coronaidd llym/ cychwyniad cyflym

* Symptomau Cysylltiol • Diffyg Anadl • Cyfog a Chwydu • Chwyslyd • Pendro • Gwelwedd

* Ffactorau Risg • Ysmygu • Colesterol Uchel • Pwysedd Gwaed Uchel • Clefyd Melys • Clefyd Coronaidd y Galon • Hanes Teuluol o Glefyd

Coronaidd y Galon • Defnydd Cocên yn

ddiweddar

Ni ddylai yr archwiliad oedi

cludo y claf i ofal eilaidd


Offer Cymorth Argyfwng (Os ar gael):

• Defibrillator • Ocsigen • Sugnedd • Llwybr Anadlu • Mwgwd Bag Falf

Rheolaeth Poen y Frest Llym – Cychwyniad Cyflym (Clinigol)

Gofynnwch i‘r Claf: • Nodwedd/llymder/

lleoliad/ymledu o boen • Amser cychwyn • Ydy’r boen yn parhaol? • Ffactorau sy’n cynorthwyo’r boen • Hanes o boen debyg • Ffactorau Risg*• Ydy’r boen yn berthnasol i weithgaredd/

gweithgarwch corfforol/trawma/anafiad?

Archwiliad • Golwg cyffredinol – gwelwedd/

oerwlyb/afliwiad glas y croen• Arwyddion bywiol – curiad/pwysau

gwaed/cyflymdra anadl • Dirlawnder O2/Pwysau Gyddfol

Gwythїen (JVP)• Gwrandewch ar y frest • Archwiliad yr abdomen – am aneurysm • ECG

Triniaeth • Aspirin 300mg• Ocsigen • Chwistrell GTN • Analgesia cysglyn/gwrthgyfogydd • Os nad yw’r ambiwlans wedi cael ei

alw, ffoniwch nawr.

Patient complains of chest pain or discomfort and/or has collapsed

Telephone In practice

If patient is aloneCall 999 then alert

doctor or nurse Immediately

Somebody is with the patient

• Ask for brief details (name, DOB, address)

• Note date/time • Transfer the call to

a doctor or nurse immediately

• Ask for brief details of patient (name, DOB, address)

• Ask caller to redial 999

Dial 999 and ask for ambulance for

chest pain to attend at patient’s address

Inform doctor of the call

• Sit patient down• Reassure help is

on the way • Stay with patient

until help arrives

Acute Chest Pain Patient Management



Mae’r claf yn cwyno o boen y frest neu anghysur a/neu wedi ymollwng

Ffôn Yn y Feddygfa

Os yw’r claf ar ben ei hunan

Mae rhywun gyda’r claf

• Gofynnwch am fanylion (Enw, Dyddiad Geni, Cyfeiriad)

• Nodwch dyddiad ac amser

• Trosglwyddwch yr alwad i feddyg neu nyrs ar unwaith

• Gofynnwch am fanylion y claf (Enw, Dyddiad Geni, Cyfeiriad)

• Gofynnwch iddyn nhw ffonio 999

Ffoniwch 999 a gofynnwch am

ambiwlans i boen y frest i fynd i gyfeiriad y claf

Dywedwch wrth y meddyg am yr alwad

• Eisteddwch y claf i lawr• Dywedwch wrth y claf

fod help ar y ffordd • Arhoswch gyda’r

claf tan fydd y help yn cyrraedd


Poen y Frest Llyn – Cychwyniad Cyflym Rheolaeth y Claf

• Ffoniwch 999• Gofynnwch i unrhywun

i chwilio am feddyg neu nyrs ar unwaith


Appendix C

Pre Education Awareness and Confidence Survey

Appendix D

Education Sessions Powerpoint Presentation

Primary Care Acute Chest Pain Awareness Project

Background

• Report from MINAP (Myocardial Ischaemia National Audit Project)–2005-6 Data–Higher proportion of people in Wales

called/visited GP rather than calling 999 with chest pain

Background

•MINAP Analysis – Network LevelMethod of Admission

2007-2008n=361

Called GP - 9%

Called 999 - 64%

NHS direct - 0.3%

Made own way - 20%

Local Helpline - 1%

Called GP and told to make ownway - 3%

Already an in-patient - 2%

Other/Missing - 1%

Background

Cardiac Networks Co-ordinating Group: Call-to-Needle Subgroup–Need to raise awareness of symptoms

and a clear message of what to do if symptoms occur1

–Need ongoing innovative campaigns to raise awareness1

1 Recommendation for improving call-to-needle times in Wales; recommendation 1.5

Background• Annual Operating Framework Target 12(2008-9)

– All patients with MI suitable for thrombolysis will have a CTN time < 60 minutes

• ‘The Golden Hour’ and ‘One minute delay = 11 days loss of life’1

• Standard 3 National Service Framework for Coronary heart disease (June 2009)– Point 3.10 ‘If a GP is called for symptoms suggestive of

acute coronary syndromes, the GP should call 999 for an ambulance prior to attending to give assistance’

1 Boersma E, Maas ACP et al early thrombolytic treatment in AMI: reappraisal of the golden hour; Lancet 348: 771-775

Aims

• To raise awareness within Primary Care of importance of immediate admission of suspected MI (heart attack)

• To reduce pain-to-call time / pain-to-needle time

Project Outline• Provide poster pathway and education to

Primary care for– clinical staff to support management of acute

MI (heart attack)– admin staff to support management of calls

from patients with acute chest pain– Assess pre and post education outcomes

• Provide workshops in primary care to ‘roll-out’ project and raise awareness

Timeframe

• Pilot project in Carmarthenshire November 2008-June 2009

• Evaluate pilot October 2009• Full implementation – November

2009• Interim evaluation – September

2010

Measurement of Expected Benefits

• MINAP Data comparison

• Project Evaluation

• Pre/Post project staff survey

Interim Analysis 1

• Increased confidence by both administration and clinical staff in dealing with acute chest pain calls/presentation

1 2 3 4 5 6 7 8 9 10

0%

5%

10%

15%

20%

25%

30%

35%

40%

Confidence Level

Administrative Staff Confidence LevelsChest Pain Presentation in Person to GP Practice

Pre % (n=110)Post % (n=120)

1 2 3 4 5 6 7 8 9 10

0%

5%

10%

15%

20%

25%

30%

35%

40%

Confidence Level

Administrative Staff Confidence LevelsTelephone Call to GP Practice Reporting Chest Pain

Pre % (n=110)Post % (n=120)

1 2 3 4 5 6 7 8 9 10

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Confidence Level

Clinical Staff Confidence LevelsChest Pain Presentation in Person to GP Practice

Pre % (n=110)Post % (n=120)

1 2 3 4 5 6 7 8 9 10

0%

10%

20%

30%

40%

50%

60%

Confidence Level

Clinical Staff Confidence LevelsTelephone Call to GP Practice Reporting Chest Pain

Pre % (n=110)Post % (n=120)

Interim analysis 2

• Fewer patients told by staff to make their own way to hospital

Interim analysis

• Stated change in practice towards advising 999 call rather than arranging same day appointment/home visit.

• Verified change in practice demonstrated through MINAP data

Method of Admission - Administrative Staff

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


999 afterassessment

Patient advisedto call 999 (or

surgery call 999if patient

presents inperson)

bypassing GP



hospital

Patient is triagedto attend surgeryfor assessment

at next availablesame day

appointment

Method of Admission

Perc

en

tag

e

Pre % (n=110)Post % (n=120)

Method of Admission - Clinical Staff

0%

10%

20%

30%

40%

50%

60%

70%

80%


999 afterassessment

Patient advised tocall 999 (or

surgery call 999 ifpatient presents

in person)bypassing GP



hospital

Patient is triagedto attend surgeryfor assessment at

next availablesame day

appointment

Method of Admission

Perc

en

tag

e

Pre % (n=110)Post % (n=120)

Conclusions• Improved patient care by

accelerating admission appropriately to paramedic/secondary care

• Structured, evidence-based resources, generic and universally suitable for use in GP surgeries

• Reduce call to needle times and accelerate care of all ACS patients

?If you would like any

further information please contact:

Marc [email protected]

01792 607353

Alison [email protected]

01437 773737