Dr. David Lyon

Clinical Governance Lead

Halton PCT

GP Affiliate NPDT

The art of Medicine is to amuse the patient whilst nature cures the

disease

Voltaire

TOP

BOTTOM

Repeated Use of the Cycle

Theories Testing changes Changes resulting in

improvement

A PS D

A PS D

NSF Recommendations for Those with Established Disease

• Risk factors assessed, documented & advised, especially smoking.

• Medication: aspirin, beta blockers, ACEI

• Blood Pressure below 140/85

• Blood cholesterol lowered to less than 5mmol/l and LDL-C below 3mmol/l or by 30%

Getting the Ball Rolling• Disease Registers from medication & READ

coded entries• Additional Nurse Resource Devolved to Practices• Protocols for Nurse & for Referral to Secondary

Care• Computer Templates• Audit Team Geared up to Provide Rapid

Feedback

Advantages of Templates

• Quicker entry of standard data

• Consistent use of READ codes

• Display previous recordings

• Search for previous interventions

• Automatic calculations, e.g. BMI, risk score

• Clinician can be reminded of interventions

• Easier audit

% Population with IHD Runcorn

0

1

2

3

4

5

6

B C G H M T W ALL

1999200020012002

% Co-morbidity

0 10 20 30 40 50 60

Diabetes

Stroke/TIA

Hypertension

2002200120001999

% of patients with proven CHD on Aspirin First, Second, Third and Fourth Wave practices

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

Jul-00

Aug-00

Sep-00

Oct-00

Nov-00

Dec-00

Jan-01

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

Jan-02

Feb-02

Mar-02

Apr-02

May-02

Jun-02

Jul-02

Aug-02

Month

Per

cent

age

Series1 Series3 Series4 Series5

% of patients 1 year post-MI on Beta-BlockersFirst, Second,Third and Fourth Wave Practices

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Jul-00

Aug-00

Sep-00

Oct-00

Nov-00

Dec-00

Jan-01

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

Jan-02

Feb-02

Mar-02

Apr-02

May-02

Jun-02

Jul-02

Aug-02

Month

Per

cent

age

Series1 Series3 Series4 Series5

% of patients with proven CHD on StatinsFirst, Second,Third and Fourth Wave practices

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Jul-00

Aug-00

Sep-00

Oct-00

Nov-00

Dec-00

Jan-01

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

Jan-02

Feb-02

Mar-02

Apr-02

May-02

Jun-02

Jul-02

Aug-02

Month

Per

cent

age

Series1 Series3 Series4 Series5

% of patients with proven CHD who have blood pressure below 140/85First, Second,Third and Fourth Wave practices

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Jul-00

Aug-00

Sep-00

Oct-00

Nov-00

Dec-00

Jan-01

Feb-01

Mar-01

Apr-01

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

Jan-02

Feb-02

Mar-02

Apr-02

May-02

Jun-02

Jul-02

Aug-02

Month

Perc

enta

ge

Series1 Series3 Series4 Series5

Clinical Governance

• Protected Time for Regular Team Meetings

• Significant EventsPremature DeathsNew Cancer CasesUnpleasantness In The Waiting Room

• Summaries to Clinical Governance Team

• SEA News

What Happened

• Focus on the facts

• No blame

• It’s the system

• What went well

• What was OK

• What could have gone better

• What should we do next time?

Acute Chest Pain Protocol

• Is the patient alert?

• Is the patient’s breathing normal?

• Is the pain severe?

• Is there heart problems or diabetes?

• Is it heavy, crushing, pressure or tight?

• Is there nausea or vomiting?

• Is the patient sweating or clammy?

Acute Chest Pain Protocol

• 51 cases in 12 months

• 10 (19%) MI 1 had VF within 5 minutes

• 7 (14%) crescendo angina

• 24 (47%) admitted to rule out MI

• 8 (16%) had blood test etc. & discharged

• 2 (4%) dysrhythmia

• Call to needle time less than 60 minutes

Cardiac Events Castlefields Health Centre

0

10

20

30

40

50

60

92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 00/01 '01/02

IHD Deaths Non-fatal Mis

Cardiac Events per Thousand

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Non-fatal MI Acute CHD Death

1999200020012002

DEATHS

• Practice records

• ONS (Office of National Statistics)

• Public Health

• 3 Character Postcodes

• Trend over Time

• Twelve Month Periods

Percentage Improvement In CHD Deaths All Ages For First Twelve Months Of Waves 1 And 2

-30

-25

-20

-15

-10

-5

0

5

10

15

20

25

%

Percentage Improvement In CHD Deaths All AgesOver Twelve Months

0

1

2

3

4

5

6

7

8

9

England Wave 1 Wave 2

%

At Risk

• Other Athersclerotic Disease

• Diabetes

• Hypertension

• Heart Failure

• Middle-aged men

• Strong Family History

• Smoking, Post-menopausal women

Essential Ingredients

• Clear evidence and Clear focus• Examples From The Field• Time to consider solutions• Reality of working at ‘street level’• Systematic recording of information• Rapid feedback• Appropriate resources• Skilled management