Sláintecare is a ten-year programme to transform the Irish health and social care services, finding, supporting, and scaling innovative new ways of providing care. In 2019 a ring-fenced integration fund looked for initiatives that support the delivery of integrated care to ‘shift care to the community in new and innovative ways, helping to reduce and prevent hospital visits and providing hospital avoidance measures’ (Government of Ireland, 2020:8).
The Integrated Community Chest Pain Clinic (ICCPC) is a natural expansion of the innovative advanced nurse led chest pain service in Tallaght University Hospital (TUH) (Ingram et al, 2017), to the community for low risk patients. There are no similar clinics in Ireland. The clinic is led by an advanced nurse practitioner (ANP).
Tallaght University Hospital, Dublin, has one of the largest emergency departments (ED) nationally, with 50,000 adult attendances per year. Chest pain is a principal presenting symptom of coronary heart disease and places a significant burden on the ED. Patient presentations with chest pain to Tallaght University Hospital ED rose from 5% of all ED presentations in 2009 to 9% in 2019 (n=4567); 31% (n-1446) of which were referred after an initial visit to the general practitioner (GP).
In the primary care setting chest pain is a common presenting complaint with an over diagnosis/suspicion of stable angina, however GPs lack access to a cardiac specialist in a timely fashion, hence the referral to ED. As 78% of these GP referrals are low risk, this leads to prolonged patient experience time (PET) in ED and adds to the already overcrowded nature of the department, especially in a time of social distancing.
In 2020 the full impact of the COVID-19 pandemic on cardiology services became evident (Fersia et al, 2020). The usual chest pain care pathways had been cut, with the staff of the hospital nurse-led chest pain service redeployed to critical care, chest pain follow up clinics cancelled and cardiology diagnostics severely curtailed. As hospital resources were re-prioritised access to cardiovascular services was decreased (ESC, 2020), with evidence of ‘collateral damage’ on patients with cardiovascular disease, especially as patients became very apprehensive about attending hospitals in particular emergency departments. We recognised that a new pathway to address the needs of patients with chest pain was required.
Integrated Community Chest Pain Clinic (ICCPC)
The Integrated community chest pain clinic (ICCPC) commenced in September 2020. This ANP led clinic aims to provide an alternative avenue to which GPs can directly refer patients with non-acute chest pain, thereby shifting the focus of care and providing hospital avoidance as per the Slaintecare vision. The clinic can be accessed by all GPs in the Tallaght University Hospital catchment. The clinic is run by an advanced nurse practitioner (ANP) who has 10 years of advanced chest pain assessment experience, with 0.5 cardiology physiologist and 0.5 clerical admin support.
The clinic is based in a local primary care centre adjacent to the main hospital campus. The referral process was set up in collaboration with the local integration committee which includes both hospital representative (medical, nursing, and managerial) and over 200 local GPs. Suitable patients are those who present to the GP with non-acute chest pain which may be indicative of coronary heart disease > 25 years of age.
Over time the clinic has demonstrated unforeseen benefits, accepting referrals redirected from the hospital cardiology outpatient waiting list as well as direct GP referrals. During lockdown number 3 in early 2021 ED referrals were managed in the community in lieu of the Tallaght Hospital Chest Pain Service as all staff were re-deployed. This was on a temporary basis for six weeks, enabling a discharge pathway for 50 patients discharged from ED with non-acute chest pain to continue.
As the ANP who runs this clinic I can say that the last six months has been very professionally rewarding, allowing me to provide uninterrupted care during a pandemic to patients who need it. My practice is strengthened by utilisation of the ESC pre-test probability score guidelines (Knuuti et al, 2019) and patient assessments are carried out either Face to Face (F2F) or by telephone. At each F2F the patient receives a comprehensive health history, advanced physical assessment, and ECG/ Vital signs. After the assessment, a differential diagnosis is formulated and an exercise stress test (EST) scheduled if required. The EST takes place in the hospital by the designated physiologist and ECHO is available at the visit if required. My autonomy an ANP is further enabled by medicinal prescribing and referral for chest x-ray in the community if required. Health promotion regarding cardiovascular risk modification is offered, ‘Making every contact count’ (HES 2021).
If a diagnostic test or symptom review is required, the patient receives a telephone appointment follow up from myself explaining the results. If the EST is abnormal the case may be managed in collaboration with the Consultant cardiologist and the patient may be referred for further diagnostic testing such as CTCA or Coronary angiogram. Most patients to date have been discharged to the referring GP with a detailed letter sent to the GP by myself.
The first 6 months
From September 2020 to February 2021, 252 referrals have been received from 112 individual GPs. The average waiting time for the apt. was 5 days. There were 178 F2F clinic and 153 telephone clinics carried out by the ANP, a total of 331 episodes of ANP care. The average patient age was 50.5 years with a range of 25-87 years. Exercise stress testing was performed on 91 patients (50%) and ECHO on 23 (13%), with 37% not requiring any cardiology diagnostics.
Most patients (59%) were discharged to primary care after ≤ 2 assessments with non-anginal chest pain whilst 25 patients were referred on for coronary angiography, 22 of whom were diagnosed with coronary artery disease. Chest pain presentations to the ED are 11% less compared to the same period last year. I managed 74% of all patients autonomously (Fig.1), with benefits to the patient and busy cardiology consultants.
This new way of working presented a timely response to the management of the patient with chest pain during the COVID-19 pandemic. The clinic is enabled by ANP autonomy, clinical experience, and clinical governance provided by the consultant cardiologist. Integration and teamwork are further demonstrated with a funded physiologist enabling cardiology diagnostics and consultant collaboration when needed. Local GP support allows true integrated care from community to hospital allowing patients to access the same evidence-based care whilst avoiding the hospital setting.
Patient experience feedback has been extremely positive and a formal research study on this and GP experience has ethical approval. Patients are seen ‘by the right person, in the right place, at the right time’ and we continue to engage and empower individuals to manage their own health in an ever-changing healthcare environment.
- “I think the location of the clinic outside, and away from the hospital is such a good idea. Hope it can continue. My visit to the clinic was a pleasure and I give it top marks”
- “I could not believe the service I received and how quickly I was seen and tested it felt like a very personal service. Why do we not have this type of outreach clinic for other expertise in our hospitals I think it's the future”
- “The treatment I received was excellent and within a few days the problem I presented with was sorted out for me. I am extremely grateful for the care and kindness I received from the team and I feel this is a wonderful service and I thank all involved for setting this service up which was very much needed”
- “Thank you for the recent update. You are providing a wonderful and much needed service and I'd like to thank you + colleagues for same."
Written by Shirley Ingram, advanced nurse practitioner, registered nurse prescriber (Cardiology) -Tallaght University Hospital, Dublin, Ireland.