Design and implementation of a new pathway to improve cardiac outcomes

Non-ST Elevation Myocardial Infarction (NSTEMI) pathway redesign

RightCare works with local health systems to identify innovative practice and share learning. Information briefs are a way of communicating early views of emerging practice. They are designed to raise interest and demonstrate good practice in the development of transformative change across the country.

Summary

This information brief is based on the work to redesign the non-ST elevation myocardial infarction (NSTEMI) pathways at Royal Papworth Hospital NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust and East Kent Hospitals University NHS Foundation Trust. To date, 10 trusts and one large health system in England have redesigned their NSTEMI pathway to reduce unwarranted variation, supported by the programme.

Diagnose: What’s the problem?

  • NSTEMI is a leading cause of emergency hospitalisation in Europe and accounts for over 50,000 hospital admissions per year. It is associated with significant mortality and morbidity risk in the long term.
  • NICE guidelines (CG94) and quality standards (QS68) are frequently not being met for NSTEMI. The guidelines recommend coronary angiography, with follow-on percutaneous coronary intervention (PCI) if indicated, within 72 hours from first admission in adults with an intermediate or higher risk of future adverse cardiovascular events. The procedures are undertaken within tertiary centres and their performance against this standard is monitored. The data shows poor attainment of the standard and significant variation between NHS tertiary providers.
  • Patients are often admitted to a District General Hospital and can wait up to an average of approximately five days before being transferred to a tertiary centre for the diagnostic angiogram (and PCI if required). This leads to a poor patient experience and is demoralising for staff who constantly have to explain delays to patients. It also represents an inefficient use of limited resources.

Develop: What they changed

  • Development of meaningful data- a key to this initiative has been the development of meaningful data that follows the patient journey from first admission through to procedure. Previously, the available data only captured the time from when the patient was admitted to the tertiary centre, missing the in-patient days prior to transfer.
  • Through collaborative working, The Cardiovascular Partnership Programme* has been able to link relevant spells of care in the Hospital Episode Statistics (HES) data to generate a more complete picture of the patient journey.
  • Understanding of the current NSTEMI pathway through a multi-disciplinary workshop, facilitated by Consultant Cardiologist Richard Jones, which brought providers and commissioners together to discuss the pathway and required changes.
  • Re-design of the NSTEMI pathway through implementation groups who discussed and agreed decisions with professional colleagues outside the meetings. Research was undertaken on other sites that have successfully redesigned their NSTEMI pathway and who were able to share resources to facilitate the re-design (Glasgow and Portsmouth).
  • A pathway booklet was developed and shared with all partners involved in delivery of the pathway.

Deliver: What does the local health system say changed

  • More patients access the right service at the right time, improving performance against the NICE standard. Trusts that have redesigned the pathway as part of the programme have increased the proportion of patients receiving the procedure within the required 72 hours from admission.
  • 40% more patients discharged to their usual place of residence direct from the cardiology centre, avoiding a subsequent admission and freeing up bed capacity (Blackpool).
  • Reduced length of stay from first admission to intervention (angiography/PCI), releasing bed days. Figure 1 below shows the projected reductions in length of stay resulting from the changes to the NSTEMI pathway at Royal Papworth Hospital.  It illustrates a reduction of 3,080 bed days per 1000 admissions.
  • ·Reduction in unwarranted variation in relation to:
    • access to the service, especially variation related to geography (Blackpool in particular, where different DGHs had different transfer times due to differing transport solutions)
    • availability of cardiologists for review (related to which day within the week patients are admitted)
    • catheter laboratory availability (especially at weekends).
  • Self-reported improved job satisfaction as staff can provide prompt treatment and do not need to explain delays in transfer to the cardiac centre to patients.
  • High levels of patient satisfaction reported with results of qualitative surveys being analysed.

What next? Learning points from the local system

The next steps to be taken by the three NHS Trusts to further develop their redesigned NSTEMI pathway include:

  • improving the electronic referral system to allow more efficient referral, communications and reporting
  • patient involvement pre- and post-pathway journey to evaluate experience and inform refinements to the pathway
  • facilitating a cardiology network to further develop relationships and develop the pathway (in Blackpool).

Useful resources

To find more RightCare resources on cardiovascular services please visit our website.

With thanks to:

  • Dr Richard Jones, Consultant Cardiologist and Clinical Director of the Wessex Cardiovascular Clinical Network
  • Royal Papworth Hospital NHS Foundation Trust
  • Blackpool Teaching Hospitals & East Kent Hospitals University NHS Foundation Trust
  • The Cardiovascular Partnership Programme (CPP)

For more information please contact rightcare@nhs.net