Anxious patients with chest pain who used to wait up to 100 days for review at Counties Manukau District Health Board are now being seen in less than 20 days.Nearly half of heart attack patients who used to wait up to six months for a cardiologist review are now seeing a nurse practitioner or CNS instead. FIONA CASSIE talks to cardiac nurse practitioner Andy McLachlan about the difference nurse-led clinics are making.
The heart is the source of many clichés. But it’s clear from talking with cardiac nurse practitioner Andy McLachlan that specialising in this “muscular organ” requires more than just clinical expertise.
Expert clinician you have to be, but also educator, motivator, and even marriage guidance counselor. These are all things that good nurses excel at, so when McLachlan started on his nurse practitioner pathway last decade he saw real opportunities for nursing to become much more involved in managing people after heart attacks.
That was back around 2004 when Middlemore had only one cardiology clinical nurse specialist working in cardiac outpatient services, and two cardiac nurse specialists (Andy and fellow future NP June Poole) working in primary health.
Middlemore also had “embarrassingly long” waiting times for a cardiologist review after a heart attack – with the understandably frightened and concerned people waiting up to six months to talk to an expert about their heart health.
“That’s long enough for you to develop new bad habits – like I’m not going to exercise because I’m frightened I’m going to have another heart attack,” says McLachlan. “Or I’m not sure about these pills, so I’m just going to stop (taking) them all.”
The waiting lists were a driver in 2007 for the cardiology team to propose stepping up a notch beyond nurses offering cardiac rehab education clinics to support (initially) its two new NPs, and then (latterly) suitably qualified and credentialed nurse specialists, to offer comprehensive outpatient assessment clinics.
Now Middlemore’s cardiac outpatient service has two cardiology NPs, two clinical nurse specialists, two specialty nurses and four other RNs working with the team, providing cutting-edge clinics in acute coronary syndrome follow-up and chest pain; plus specialist NP clinics in heart failure (Poole) and post-valve replacement care (McLachlan).
The impact on waiting lists has been marked (see sidebar) and this confirms McLachlan’s belief in what nursing could provide..
Originally from Glasgow, McLachlan says as a male nurse in Scotland in the 1980s your only options starting out were male urology or general surgery, but he always had a hankering for coronary care.
He also had a craving for warmer climes, so in 1990 he went to America “chasing the sun” while nursing in a variety of coronary care wards in Florida, California and Texas. “I basically had a six-year summer,” he says.
Along the way, he inevitably met some Kiwis and curiosity brought him to New Zealand in 2000. Now married with three children aged one to five, he isn’t looking to move again.
Clinic idea first gells
McLachlan started out in Middlemore in 2000 as a senior staff nurse in coronary care and later a clinical nurse educator.
In 2004 he started working as a nurse specialist in the DHB’s chronic care management programme, which saw him helping set up cardiovascular risk assessment and management clinics in South Auckland for mainly MÄori and Pacific providers.
The work gave him a feel for the challenges that communities and health providers were facing and introduced him to the electronic cardiovascular risk-support tool PREDICT (see sidebar).
Lachlan was still working part time in cardiac rehabilitation at Middlemore, where the head of cardiology was Andrew Kerr (who helped to design PREDICT). “We thought it would be a good idea if we could use the same kind of tool in the acute setting, which was a bit of a revolutionary idea.”
Revolutionary, as secondary specialists didn’t see the need for such a tool. They felt they were already doing all the right things. But McLachlan and Kerr could see how useful the data gathered by PREDICT would be to audit care standards like how good a cardiac service was at helping people with poor diabetes control or “terrible lipids”.
“You can audit these things really quickly with just basically the click of a button”.
So PREDICT was adapted for the acute system, providing a richness of easily accessible data for auditing, plus a strong framework for nurse-led cardiology clinics.
McLachlan at that stage was already envisaging a niche role for nursing, working alongside a cardiologist clinic, to help patients manage their condition.
He says a time-pressed cardiologist’s focus is on things like: Are you going to die after your heart attack? Do you have any significant complications? If not, then it’s ‘You are doing fine, so here’s your medication and see you later’. “So it’s a very quick in and out visit,” says McLachlan.
McLachlan saw a lot of scope for working on how people were coping after their heart attack, what they understood about what had happened, what lifestyle changes they were considering, and what support the DHB could provide to support these changes.
From around 2005 to 2008, the nurse-led outpatient clinics focused on education and preventative roles. By this time, McLachlan had completed his clinical masters degree, was well into his prescribing nurse practitioner pathway, and had at the back of his mind wanting to run acute coronary syndrome follow-up clinics.
NP assessment clinics grow out of frustration
Working alongside the cardiologists, McLachlan had built up his assessment and pharmacological skills and was becoming increasingly frustrated that, despite believing he had the knowledge and experience to safely titrate patient’s medications, he was hampered by his scope.
But the strong driver of the “embarrassing waiting times” saw Middlemore in 2007 take a brave step in New Zealand cardiology and promote NPs to carry out the assessments for post-heart attack complications that cardiologists would usually undertake. The service now has four well-established NP and CNS clinics.
A post-heart attack patient turning up at Middlemore for an acute coronary syndrome follow-up clinic might find themselves being assessed by their cardiologist, or the NP or CNS working alongside the cardiologist. About 45 per cent of post-heart attack review patients are assessed in a NP or CNS clinic.
“There’s no delineation between complex heart patients and non-complex heart patients. We’re just as likely as a cardiologist to see someone who’s had a major heart attack.” The major difference is that the cardiologist clinic appointment is 10 minutes and the NP or CNS clinic appointment is 30 minutes.
The nurse will carry out the same full physical assessment, looking for signs of complications and deteriorations since the patient’s hospital discharge, as the consultant. If there is an issue, they can call in the consultant for a further assessment, which happens about 20 per cent of the time. The highly-structured nurse clinic process also includes extra time for self-management support and education for the patient.
“I often say we need a course in marriage guidance because (a heart attack) really does bring up a lot of issues people have been avoiding for many years.” Facing their own mortality results in some people questioning whether they want to be in their relationship any more. People also face fear, anxiety and depression.
McLachlan’s own novel NP clinic is operating in the niche area of providing case management for patients who have had valve-replacement surgery (see sidebar). Also, for the past three years, the NPs and clinical nurse specialists have been providing clinics for patients referred from general practice for pains in the chest that are not bad enough to send them directly to hospital, but which are worrying enough to want further review.
The highly-structured clinic includes an appropriate exercise assessment. If the tests are negative the patient is given reassurance about the likely source of the pain; and if the test is positive the service organises angiograms and puts the patient on appropriate medication.
“At the moment the volumes (on the waiting list) are so huge that we’re only seeing about 30 to 40 per cent of all referrals. But we’re hoping to add an extra clinic, which will get us up to about 50 per cent, and next year adding a further nurse and another couple of clinics will cover 75 to 80 per cent of all chest-pain referrals.”
Through hard work and the support of a “workhorse” of a retired cardiologist doing a full day’s chest pain clinic, the service has shifted the waiting-list time from almost 100 days to under 20 days. “But it’s not sustainable.”
Meanwhile, the service is growing the workforce with competency to carry out the work. There is a “rigid credentialing process”, because assessments need to be “100 per cent” as the service doesn’t want to be reassuring and sending away people with latent coronary artery disease or similar conditions.
It’s a busy life for McLachlan and the other nurse clinic leaders. In the past two years, the two cardiology NPs between them have assessed more than 2000 patients each year. And patient surveys report high levels of satisfaction with the NP clinics, including increased time to discuss issues and the “friendly and supportive visits”.
McLachlan is a keen researcher (he has been lead author of numerous research publications), but has only one morning of downtime for admin and research in his four-day working week that is otherwise packed with patient clinics.
Even if the Kiwi summer hasn’t been that hot this year, he remains a staunch advocate of the difference that nurse-led cardiology clinics can make.
Impact of NP/CNS clinics at Middlemore Hospital
• NP/CNS clinics cut waiting time for chest pain referrals from 94 days to less than 20 days.
• More than 2000 cardiac patients a year assessed by Middlemore’s two cardiac NPs free up cardiologist outpatient time and “significantly improve” waiting times for first cardiologist appointment.
• More than 300 patients requiring long-term follow-up after heart valve replacement now being case managed by NP Andy McLachlan.
• About 45 per cent of patients after a heart attack are now reviewed in a NP or CNS clinic (supported by a named cardiologist).
• Randomised audit of NP clinic documentation shows NPs “significantly better” aligned to meeting guidelines for titrating medication, smoking cessation, and healthy lifestyle advice than the cardiology medical team.