Cardiology ACPs @ ULTH

Transcript

1. Advanced Clinical Practitioners at ULTH Cardiology
2. Team composition; Lincoln County Hospital “Acute” service 24/7/365 Heart failure 8-6, 7/7/365 + Outpatient activity & ward rounds Boston Pilgrim Hospital “Acute” service 8-7, 7/7/365 Heart failure 8-6, 7/7/365 + Outpatient activity & ward rounds 4 consultant-level practitioners 15 “acute” ACPs 5 heart failure ACPs A wide range of professional backgrounds & experience, including allied health professionals such as paramedics. All are trained to MSc level & are non-medical prescribers. Pan-Trust cover w/ a base site
3. Overall team clinical activity; >400 life-saving emergency PCI procedures ~4500 pan-trust acute cardiology reviews >800 pan-trust inpatient heart failure reviews ~2700 heart failure clinic reviews ~1800 chest pain clinic reviews >520 arrhythmia clinic reviews >900 post ACS clinic follow-ups >190 outpatient cardioversions ~5500 CSSU consultant ACP reviews >300 CCU consultant ACP reviews & more not captured by this data
4. Acute service activity; PPCI & other emergent activity service Rapid access chest pain clinic Arrhythmia clinic Post ACS clinic Cardioversion clinic Emergency department reviews Out of hours ward rounds Cardiology inpatient reviews OOH MET/cardiac arrest calls Anything/ everything else Educational activity (hierarchy of priority) Admin/reporting results 3 weekly @ LCH 2 weekly @ Pilgrim 1 weekly @ LCH 1 monthly @ LCH/GDH 1 weekly @ LCH 1 weekly @ Pilgrim
5. Appropriate “shop-floor”referrals; Acute & chronic coronary syndromes - STEMI, NSTEMI & the angina “spectrum” Chest pain suspected to be cardiac in origin (often not - see next slide) Arrhythmia & cardiac arrest Acute heart failure / chronic decompensations Valvular dysfunction Endocarditis Pericarditis & Myocarditis Cardiac syncope (as opposed to undifferentiated)
6. Undifferentiated Chest Pain; The Cardiology ACP’s “bread & butter”
7. Cardiology “core” pharma; Angina (CCS); Aspirin 75mg Atorvastatin 20mg Anti-angial therapy GTN PRN Acute Coronary Syndrome; Dual antiplatelet therapy for 12/12, single APT thereafter Atorvastatin 80mg Bisoprolol Ramipril Fondaparinux GTN PRN Anti-anginals; Beta blocker Calcium channel blocker (rate limiting vs non-rate limiting) Nitrate Ranolazine Ivabradine (sinus rhythm only, HR>70, normal QTc) Nicorandil
8. Cardiology ACP “bread & butter”; SOCRATES mnemonic - allows for a structured approach Chest pain assessment; Severity - “mild”, “severe”, “worse pain ever”. Prefer score out of 10 than 3 or 5. Be consistent with scale. Onset - Rest vs exertional? Woke the patient from sleep? Whilst straining/lifting/pushing? Character - sharp, stabbing? Dull ache, tight? Squeezing? Tearing, crushing? Burning? “Sitting on my chest”. Some patients unable to characterise. Radiation - Arm, neck, back, jaw? None-radiating? Associated symptoms - Dyspnoea, nausea, diaphoresis, dizziness, syncope/presyncope. Focal neurology? Time - how long did/does the pain last? Is it ongoing? How long has the symptom been evident/is this a new symptom? Exacerbating & relieving factors - What makes the pain worse? Movement? Inspiration? Exertion? What makes the pain better? Sitting forward? GTN? Site - Where is the pain? All across the chest, specifically left sided? Central? Axilla/flank? Xiphisternum?
9. Cardiology ACP “bread & butter”; Chest pain assessment; Most important factor is whether the symptom is exertional in pattern.
10. Activation of cath lab team Procedure The PPCI pathway; ED / UTC EMAS/ Helimed Inpatient GP PPCI phone Further assessment Ischaemic symptoms Coronary Care
11. Undifferentiated ST elevation; Determining the clinical signficance - not always clear!
12. The 4 Pillars of Advanced Practice; As described above Forms the bulk of our role Formal; ALS, University modules, ECG workshop, departmental training, insight visits Informal teaching; nursing staff, medical colleagues, students, other MDT members Senior members of the MDT & the senior cardiology clinician on site OOH Band 7-8c (4 Consultant Nurses); We lead by example trust-wide in clinical practice & behaviours Linked to Leicester CTU & involved in variety of projects; MINAP Strong emphasis on evidence based practice
13. Working as an ACP in cardiology; Positives; Autonomous practice & independent decision making High level of responsibility Highly respected (& relied upon) by other members of the MDT Significant investment in training compared to other roles (beyond MSc pathway) Opens up a wide range of career opportunities Maintain patient contact - historically lost in more senior nursing roles Supportive peers Not-so positives; High expectation for self-directed study & almost continuous ongoing study “Lone” working Admin! High level of responsibility Significant risk for stress/burnout - shifts can be intense