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National Service Framework

National Service Framework. NSF sets out 12 standards covering the following areas Reducing heart disease in the population Preventing CHD in high-risk patients Acute coronary syndromes Stable angina Revascularisation Heart failure Cardic rehabilitation. National Service Framework.

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National Service Framework

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  1. National Service Framework • NSF sets out 12 standards covering the following areas • Reducing heart disease in the population • Preventing CHD in high-risk patients • Acute coronary syndromes • Stable angina • Revascularisation • Heart failure • Cardic rehabilitation

  2. National Service Framework • Standard 1 • NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease • Standard 2 • NHS and partner agencies should contribute to a reduction in smoking in the local population

  3. National Service Framework • Health Improvement Programme (HiMP) • Reduce smoking, promote healthy eating, increase physical activity, reduce overweight • Co-ordinated by HA • Clear lines of action and accountability • Structure, process and outcome measures by which local delivery judged to be specified

  4. National Service Framework • Standard 3 • GPs and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks • Standard 4 • GPs and primary care teams should and primary care teams should identify all people at significant risk of cardiovascular disease but have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks

  5. National Service Framework • If established vascular disease • Smoking advice including nicotine replacement • Other risk factor advice (exercise, diet, alcohol, weight) • BP below 145/85 • Aspirin 75mg • Statins to get chol<5 or 30% reduction • ACEI if LV dysfunction • Beta-blockers if previous MI • Warfarin or aspirin if A fib and over 60 • Tight glucose and BP control in diabetics

  6. National Service Framework • Without vascular disease but CHD risk greater than 30% over 10 years • Smoking advice including nicotine replacement • Other risk factor advice (exercise, diet, alcohol, weight) • BP below 145/85 • Statins to get chol<5 or 30% reduction • Tight glucose and BP control in diabetics

  7. National Service Framework • By April 2002 80-90% of heart attack patients should be on proven effective medicines (aspirin, beta-blockers, statins)

  8. National Service Framework • Standard 5 • People with symptoms of possible MI should receive help from appropriately trained person with a defibrillator within 8 minutes • Standard 6 • Possible MI patients should be assessed professionally and, if indicated, receive aspirin and thrombolysis within 60 minutes of the call for help • Standard 7 • NHS Trusts should have protocols so MI patients receive proven cost-effective treatments

  9. National Service Framework • Aspirin 300mg followed by 75mg od • Beta-blockers for at least 1 year • ACEI reviewed after 4-6 weeks • Keep BP < 140/85 • Statins to get chol<5 or 30% reduction • Tight glucose and BP control in diabetics • Risk factor advice • Arrange rehabilitation • Assess potential benefit from revascularisation

  10. National Service Framework • For UNSA • Aspirin, heparin • Beta-blockers, nitrates, calcium antagonists • Interventions as for MI

  11. National Service Framework By April 2001 • Ambulance response time of under 8 minutes for at least 75% of category A calls • At least 75% of A+E departments able to provide thrombolysis

  12. National Service Framework By April 2002 • Door to needle time of under 30 minutes in 75% of eligible cases By April 2003 • Door to needle time of under 20 minutes in 75% of eligible cases

  13. National Service Framework • Standard 8 • People with syndromes of angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events

  14. National Service Framework • Investigations • Hb, glucose, cholesterol • Assess myocardial ischaemia • Treatment • S/L nitrates, Beta-blockers, Oral nitrates, Ca antagonists, Aspirin • Risk factor advice and treatment • Education • What to do about possible MI • Assess benefits of revascularisation

  15. National Service Framework • By April 2001 • 50 rapid-access chest pain clinics nationally • Agreed hospital protocol for investigation and management of suspected angina • By April 2002 • 100 rapid-access chest pain clinics nationally

  16. National Service Framework • Standard 9 • People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently • Standard 10 • NHS Trusts should have a care system so patients with confirmed CAD receive timely and appropriate investigation and treatment to relieve symptoms and improve prognosis

  17. National Service Framework • Angiography • Extensive ischaemia on non-invasive testing • Persisting angina in spite of medical Px • Quantitative assessment of priority • System for stratification (immediate/urgent/soon) • CABG or PTCA • Secondary prevention • and rehabilitation

  18. National Service Framework • Increase number of revascularisations by 3000 by April 2002 • Aim for at least 750 PTCAs per million population and 750 CABGs per million • Maximum waiting times • GP to specialist for new onset CP (2 weeks) • GP to consultant for routine • First stage 13 weeks • Second stage 4 weeks

  19. National Service Framework • Maximum waiting times • Decision to investigate to angiography • First stage 6 months • Second stage 3 months • Decision to operate to PTCA • First stage 12 months • Second stage 3 months • Decision to operate to CABG • First stage (urgent inpatient, high risk 3 months, others 12 months) • Second stage (urgent inpatient, high risk 3 months, others 6 months)

  20. National Service Framework • Standard 11 • Suspected heart failure patients should be offered appropriate investigations (ECG, ECHO) to confirm/refute diagnosis. In confirmed cases treatments most likely to relieve symptoms and reduce mortality should be offered

  21. National Service Framework • ACEI • Diuretics • Beta-blockers (advise specialist initiation) • Nitrates/hydralazine for ACEI intolerant • Digoxin • Lifestyle/risk factor advice • Control BP • Flu vaccine • Tight BP and glucose control in diabetics

  22. National Service Framework • Outreach follow-up by specialist nurses • Multidisciplinary community support including palliative care • Heart failure clinics (nurse practitioners or doctors, primary or secondary care) • Clear protocols • Easy/open access echocardiography

  23. National Service Framework • Standard 12 • NHS Trusts should put in place agreed protocols so patients admitted suffering from CHD are invited into secondary prevention protocols and rehabilitation

  24. St Mary’s response to the NSF • Standard 7 (proven treatments offered) • Secondary prevention nurse • Standards 9 and 10 (revascularisation) • Standards largely in place • Standard 11 (heart failure) • Open access echo in place • Heart failure clinic • Standard 12 (rehabilitation) • Programme in place

  25. St Mary’s response to the NSF • Standard 6 (thrombolysis) • Triage ECG room • Chest pain specialist nurse • Standards 8 (new onset/stable angina) • Rapid assessment unit • Chest pain specialist nurse

  26. Chest Pain Services at St Marys • Refer high risk patients with potential MI or unstable angina to the on-call cardiologist (bleep 1216) for assessment in casualty • Patients potentially at moderate risk • Recent onset chest pain (within 3 months) • Worsening chest pain of possibly ischaemic origin can be referred to the Rapid Assessment Unit (0171 886 2000)

  27. Rapid assessment unit nurse review • Suspected myocardial infarction or unstable angina  • Transfer to casualty resuscitation • ECG immediately in resuscitation • Contact cardiologist immediately • Insert IV cannula • Give soluble aspirin 300mg po or aspirin 300mg po chewed

  28. Investigations arranged by RAU staff • Cardiovascular observations • ECG • Routine bloods • BMstix if known or suspected diabetic • CXR • Exercise treadmill test if possible ischaemic pain • Echo and spirometry if shortness of breath

  29. Cardiologist assessment • After patient already worked up • Admission • Diagnosis of stable angina with appropriate drug treatment and follow up • Reassurance • Communication • Faxed report on the same day of referral

  30. Summary • Patients with probable MI/UNSA to on-call cardiologist • Patients with recent onset/worsening chest pain of possible ischaemic origin to RAU (0171 886 2000) • If in doubt ring the RAU to discuss

  31. Summary • Easy access • Same day assessment with full non-invasive work up • Same day communication of results

  32. Summary • Early risk stratification • Prevent potential disaster of missed diagnosis • Targeting of high risk patients • Reduce morbidity/mortality • Some reduction in pressure on A+E and routine outpatients

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