Welcome to the Cardiology Department - Mark Dayer



Welcome to the Cardiology Department

Musgrove Park Hospital

Induction for Junior Doctors

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We very much hope you will find your time with us interesting and enjoyable

Welcome to the Cardiology Department

INDEX 2

Services provided and layout of the department 3

Who’s Who 4

What is expected of the junior doctors / how do the wards work 5

Consultant and registrar support 6

Annual leave and study leave arrangements 8

How to order cardiology investigations 8

Consent 9

Indications for complex devices 12

Preparing patients on the wards for procedures and post-procedure care 13

Specialist nurses 16

Cardiac Rehabilitation 16

Chest Pain 17

Arrhythmia 17

Audit 18

Discharge Policy 19

Care pathways / protocols and guidelines 20

NICE, ESC, DVLA 20

ACS (MPH Algorithm) 20

Anticoagulation in patients undergoing cardiology procedures 23

Bridging anticoagulation for patients with mechanical valves 24

Insertion of a TPW 28

Educational opportunities 29

Outpatients policy 30

Induction checklist 34

Appendix 37

Consent forms 39

Aspirin Desensitization protocol 45

Services provided and the layout of the department

The Cardiology Department at Musgrove Park provides a full set of secondary care cardiac investigative and treatment options whilst also providing many services traditionally seen as tertiary in nature, for example we have access to full out-patient facilities with specialist clinics for Rapid-Access Chest Pain, Pacemaker\ICD follow up, Pre-operative assessment, Echo, Angioplasty\DC cardioversion follow up and Adult Congenital Heart Disease.

We provide out-patient investigation with ECG, Exercise Testing, simple and complex Echocardiography, heart rhythm and 24-hour BP monitoring, nuclear perfusion scanning and Tilt testing.

For in-patients we provide a full emergency cardiac service via a 9-bedded CCU, a cardiology ward (Fielding), and daily consultant review of patients on the MAU. We also provide nurse led chest pain, heart failure, arrhythmia and rehabilitation services. We run 2 diagnostic\interventional coronary laboratories providing full angiography and stenting services for routine, urgent and emergency work, including a Primary PCI service for Acute MI.

We also run 1 separate pacemaker\ICD\resynchronisation therapy lab for device implantation. At present we do not provide electrophysiology\ablation, interventional congenital nor cardiac surgical services.

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Who’s Who?

Consultants (SKW, DB, DHM, TJM, MXD, DMZ, MDS) and Associate Specialist (RK):

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Stuart Walker David Beacock David MacIver Tom MacConnell

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Mark Dayer Dan McKenzie Mike Seddon Richard Kilbey

Cardiology Clinical Management Team

This group has day to day responsibility for the smooth running of the department. It is held responsible for the budget by the Medical Division Management team. It has a key role in setting strategic direction for the Cardiology Department.

Clinical Services Lead Dr David Beacock

Matron Julia Hogg

Clinical Investigation Manager Elaine Thompson

Catheter Laboratory User Group (CLUG)

This group is responsible for the day to day running of the catheter laboratory, creating a smooth, high quality and timely patient journey within the strategic and budget parameters. This group is responsible for governance standards in the laboratory and reports to the Cardiology Multidisciplinary Team.

CLUG lead Dr Mike Seddon

Senior Nurse Diana Cooper

Senior Radiographer Gill Stapleton-Smith

Senior Technician Charlie Garland

Pacemaker User Group (PUG)

This group is responsible for the day to day running of the pacemaker/EPS laboratory, creating a smooth, high quality and timely patient journey within the strategic and budget parameters. This group is responsible for governance standards in the laboratory and reports to the Cardiology Multidisciplinary Team.

PUG lead Dr Mark Dayer

Senior Nurse Alison Witcher

Senior Technicians Helen Kavanagh and Jess Osman

Cardiology Multidisciplinary Team

This group is in place to ensure the patients and their optimal care is at the centre of our activity. It is the forum where information is exchanged, strategic direction ratified and governance standards set, acted upon, delivered and responsibility taken for. The MDT is led by the Lead Clinician but to be at its most effective it requires contributions from all members of the Team, secretaries to consultants, senior technicians to HCAs.

What is expected of the junior doctors in Cardiology?

How do the wards work?

The junior doctors are responsible for the day to day care of the patients on CCU, Fielding ward, and the medical patients on Blake ward (our “buddy” ward). Generally, one junior will cover CCU and Blake, as well as ad hoc cover on the “cardiac day unit”, whilst the others will look after the patients on Fielding. However, it is expected that the juniors will work as a team and share the work during times of uneven workload. Division of labour on Fielding ward may depend on the skill and seniority mix – some groups have split the wards by individually covering bays, other groups have looked after all the patients together. It is up to you how you feel best to cover the work, but we expect the more experienced juniors to support those less experienced.

Patients are admitted to the Cardiology Beds via ED, MAU, other wards, or from Outpatients electively. CCU patients are generally stepped down to Fielding.

All new admissions to the hospital should be clerked in by a member of the team (F1, F2, ST1 or ST2) and a summary with problem list and management plan generated. Internal transfers to the Cardiology beds should have a new problem list and management plan generated.

Please request old notes ASAP, but if these are not immediately available please gather information from:

i) Previous Cardiology letters from the cardiology secretaries (or on the shared S: drive)

ii) Echo reports on TOMCAT (CVIS) (please ask DHM for a password)

iii) PACs for previous relevant radiology results

A typical summary might read/ be presented to the consultant/registrar as follows:

68F

Background: T2DM, HT, moderate AS, ulcerative colitis, mild CKD (baseline creat 156)

Last echo 1 yr ago (Normal LV, AS gradient 45 AVA 1.3cm2, mild AR)

Admitted with SOB…treated as pulmonary oedema

Relevant results… (bloods, troponin, radiology, ECG, echo etc)

Current issues / problems…

Plan…

Ward Rounds

Please ensure that your entries in the notes record date/time/person leading the ward round and that you sign off with your name and bleep number legibly. Include the key thoughts and management plan and record any issues discussed with patients/ relatives. Complete/update a current problem list. Please ensure cumulative results sheets are up to date each day. Review prescription charts, write legibly, review date stops for antibiotics, steroids, nebulisers, oxygen.

Communication

We like to know what is happening with our patients. Do not hesitate to contact us or phone us if you have any concerns or problems or unusual developments. Communication is crucial to good patient care and poor communication is the origin of most complaints.

Ask a senior if you are unsure

Keep your seniors and consultant well-informed of significant changes in your patients’ progress

Communicate well and courteously with GPs

Ring the GP about difficult cases and complex discharges and record this

Relatives

Courtesy at all times and keep them well informed. Do not hesitate to ask for help with relatives when there is bad news to be given or you sense dissatisfaction. Record any discussions you have with them.

Consultant and Registrar support

The care of inpatients across the trust is increasingly consultant-led and delivered. New patients must be seen within 24 hours of their admission by a senior member of medical staff and the management plan ratified. If there are immediate concerns about a patient the Consultant Cardiologist on call (or if the patient is on a Cardiology ward already, one of the consultants covering the wards – see below) should be contacted. We hope that you will find us all very approachable.

Six of the consultants contribute to regular inpatient care (with Dr Walker exempt due to his workload as Clinical Director). Three consultants will cover the wards at any time on a 5 week cycle currently in the groups of 3 below:

Dr Beacock (DB) Dr MacConnell (TJM)

Dr MacIver (DHM) Dr Dayer (MXD)

Dr McKenzie (DMZ) Dr Seddon (MDS)

Each week, one of the ward consultants will be responsible for CCU. They will perform regular CCU ward rounds and will see new patients on Blake ward. Any problems on CCU should be addressed with this consultant.

Between them, the three ward consultants will see new patients on Fielding each day. Ward round times are not cast in stone since they have to be flexible around the consultant on call rota and other commitments. When consultants are away on leave, the other ward consultants will cross-cover ward patients.

Separately, we have a responsibility to see patients on the Post-Take Ward Round (PTWR) list each morning – this list resides on CCU and should consist of patients referred by the senior MAU team for specialist Cardiology review. We operate a 1 in 8 rota for the PTWR (all 7 consultants and Richard Kilbey) – the designated person will either go down to MAU themselves or will take a junior with them. This system is separate from the “red top referral” system which should be used by other teams throughout the hospital for inpatients requiring specialist cardiology input.

There is always a consultant crdiologist on call, the rota is available on CCU. Dr Seddon currently

produces this rota. If you have an immediate concern about any consultant’s patient you should

initially try to contact that consultant directly.

Dr Beacock 07731 627055

Dr Dayer 07428 690564

Dr MacConnell 07968 275745

Dr MacIver 07887 743705

Dr McKenzie 07801 562183

Dr Seddon 07765 872874

Dr Walker 07977 508077

If that consultant is unavailable contact one of the other consultants, or out of hours the on call

Consultant Cardiologist.

Registrars:

There are 2 Cardiology registrars. They have a range of commitments and training requirements including general medical on call, outpatient clinics and training lists (echo, pacing, angiography). They are also responsible for seeing the red-top referrals (and discussing with consultants if necessary). They have a commitment to do a formal ward round (Fielding and Blake) each Wednesday morning (when the consultants often have other commitments/ departmental meetings at that time) but are also available for advice and support / supervision of procedures at other times during the week – they can be contacted via bleep. The registrars’ office is to the side of the 3 bed bay in CCU. Their individual timetables are as below.

Nitin Kumar (ST5) – Bleep 2105

Phoebe Sun (ST5) – Bleep 2358

| |NITIN KUMAR |PHOEBE SUN |

|DAY |AM |PM |AM |PM |

|Monday |Angio/ |Ad hoc Lab/ |Admin |Angio |

| |Admin |Referrals | | |

|Tuesday |Pacing |Ad hoc Lab/ |Clinic |Echo |

| | |Referrals | | |

|Wednesday |Wards |Clinic/ |Wards |Clinic/ |

| | |Referrals | |Referrals |

|Thursday |Echo |Clinic/ |Pacing |Angio |

| | |Referrals | | |

|Friday |Admin/ |Angio |Angio/ |Admin/ |

| |Ad hoc lab | |Pacing |Referrals |

Annual Leave and Study Leave Arrangements

Your leave must be ratified by the Lead Clinician (DB). Registrars – only 1 of 2 away at any time; Juniors – 2 cardiology juniors from the Fielding and CCU grouping may be on leave at any one time.

Arranging Cardiology Investigations

In Patients

ECG HCA on ward

Exercise ECG Bleep Chest pain nurse 9am-8pm Mon-Sun (Bleep 2473) or

Clinical investigation by arrangement ext 2953

Echocardiogram Echo request form to reception (Cardiology outpatients) ext 2953

IP to be signed by consultant Cardiologist

Please give as much relevant information as possible on the form

If an inpatient echo needs to be done urgently then discuss with one of the echocardiographers.

Stress Echocardiogram By arrangement with senior echocardiographer

Transoesophageal Echo By arrangement with senior echocardiographer

Myocardial Perfusion Scan Not routinely available. As outpatient only by consultant request.

Coronary angiogram Patients name, ward, consultant, clinical problem with expected

findings and whether or not ? proceed to be put on white board in cathlab. Cath lab will assign slot

See coronary angiogram protocol for bloods etc

See consent

Cardiac MRI Very limited slots – to be arranged via consultants through DB

Cardiac CT Cardiac gated CT – - not yet locally available

Consent for cardiological procedures – general principles

• Consent is a process, not an isolated event. Patients should receive advice and the appropriate leaflet with time to digest the information before being asked to sign the form.

• For consent to be informed, a competent patient needs to understand their medical condition, the proposed treatment of it, the risks, consequences of, and alternatives to that treatment.

• If you or your patient are unhappy about the process you should not complete (sign the form) the process and refer the matter to the consultant in charge of the patients care

• A patient cannot give informed consent if sedated

• Generally, a person capable of performing the procedure should obtain consent. Preferably the person performing the procedure should obtain consent. Foundation year doctors should not obtain consent.

Ethical guidance on consent can be obtained from the trust intranet site as well as







SEE APPENDIX FOR PROCEDURE-SPECIFIC CONSENT FORMS

Consent - Pacemaker Implantation

Reasons for implantation

To prevent/ treat symptomatic bradycardia / syncope / high grade AV block

To control arrhythmias

To improvement symptoms of heart failure

The Risks – see consent form in Appendix

Consequences

Long term follow up in technician-led pacing clinic

Generator will need replacement after 5-10 years depending on how much it is used/needed.

Complications of the procedure.

The Alternatives

For a patient with cardiac syncope/ pre-syncope due to conduction tissue disease there is no

alternative treatment. For patients with AF and heart failure, pacemakers are one of many

treatment modalities.

See guidance/pacing/

Consent - Coronary Angiography

Procedure involving injection of radiographic contrast into coronary arteries having passed a tube from the artery in the groin (femoral puncture) or arm (radial puncture).

Reasons for procedure

To gain diagnostic information about coronary anatomy and or heart valves.

The Risks – see consent form in Appendix

Consequences

The information gained from the test will inform the consultant’s advice about whether the patient’s

condition should be treated medically, with percutaneous coronary intervention (PCI) or with

bypass surgery

The Alternatives

Non invasive testing (Exercise testing, stress echo, myocardial perfusion scanning, stress MRI) are physiological tests looking at regional perfusion and ischaemia rather than anatomy. Cardiac gated multislice CT can be used in subsets of patients to demonstrate coronary and cardiac anatomy non-invasively but this service is not yet available locally and image/data quality is not yet comparable to the gold standard, invasive angiography.

Consent – Percutaneous Coronary Intervention

Reasons for procedureEmergency procedureSTEMINSTE-ACS patients with on going pain and ECG changes/ haemodynamic instabilityUrgent procedure - Most NSTE-ACS patients - reduces the likelihood of a further major adverse cardiac event (heart attack/ death) when performed within 72 hours.

Elective procedure - reduces anginal symptoms effectively, improves quality of life

The Risks – see consent form in Appendix

Consequences

Small annual risk ~1% of stent thrombosis (particularly if patient stops antiplatelet agents prematurely)

Small risk of late renarrowing (restenosis): 5-10% risk with a bare metal stent

2-3% risk with a drug eluting stent

The Alternatives

Symptoms can be treated with tablets (but may not be as effective in controlling symptoms)

Bypass surgery could be considered but potentially greater immediate risks for no prognostic

advantage. In some patients there may be a lower risk of recurrence of symptoms of angina (eg

diabetics with complex lesions)

Consent - Cardioversion

Reasons For Procedure

Restoration of normal heart rhythm

May result in improved exercise capacity

Possible reduction in the need for long term anticoagulation

The Risks – see consent form in Appendix

Consequences

Improved exercise capacity (in 60-70% of people)

Reduced need for anticoagulation if sinus rhythm maintained

May require long term antiarrhythmic drugs to maintain sinus rhythm

The Alternatives

Control rate of atrial fibrillation with drugs

Invasive ablation procedures

Treat risk of embolic event with aspirin or warfarin

Consent – (Automated) Implantable Cardioverter-Defibrillator (A) ICD

Reasons For Procedure

Protective therapy for recurrent VT/VF in patients who have already had VT/VF in the past

Protective therapy for VT/VF in patients who have not had VT/VF but are at high risk (see below)

The Risks – see consent form in Appendix

Consequences

Reduces the risk of sudden cardiac death (SCD) in appropriately selected patients (see NICE guidance below)

Can cardiovert sustained VT

The Alternatives

Antiarrhythmics – beta blockers or amiodarone, but mortality improved with ICDs in appropriately selected patients

Consent – Cardiac Resynchronisation Therapy (CRT) or Biventricular Pacing without defibrillator (CRT-P)

Reasons For Procedure

Symptom improvement in a well-defined subset of patients with heart failure (see below)

Prognostic benefit in the same group

The Risks – see consent form in Appendix

Consequences

May improve symptoms in appropriately selected patients (see NICE guidance)

Reduces mortality in randomised controlled studies of appropriately selected patients

The Alternatives

Optimal medical management (diuretics, ACE, beta-blockers +/- an aldosterone antagonist, ivabridine and digoxin)

Consent – Cardiac Resynchronisation Therapy (CRT) or Biventricular Pacing with defibrillator (CRT-D)

CRT-D devices are implanted for patients who fit the NICE criteria for ICD as well as those for CRT-P

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Preparing patients on the ward for procedures:

Once a Consultant has decided / agreed that a patient should have a procedure they must be listed (by you) on the appropriate board in the Cardiac Day Unit (CDU). This can be discussed with the Co-ordinator on the unit in the week. Out of hours you need to put the: patients name, ward, procedure, date listed, ensuring cathlab and ward know

Angiogram ?proceed

Ensure the patient has had recent bloods – highlight anaemia or any drop in haemoglobin, as well as renal dysfunction (patients with creatinine >150 or eGFR 1 mm in limb leads or

ST depression compatible with posterior infarct or

Left bundle branch block:

(New or presumed new & good history)

MIDDLE PATHWAY

ST depression >0.5 mm

or

T wave inversion >2 mm deep

or

Transient ST elevation

or

GRACE risk score 6 month mortality >3.1%

LOW RISK PATHWAY

Pain resolved

and

GRACE risk score [?]*Adeg²µ¶ÛÝ6 month mortality ≤3%

and

ECG normal

OXYGEN, GTN SL, CLOPIDOGREL 600 mg stat (unless pre-loaded). Check Aspirin 300mg has been given. If necessary, give MORPHINE 5-10mg IV & METOCLOPRAMIDE 10mg IV

OXYGEN, GTN SL, CLOPIDOGREL 300 mg stat (unless pre-loaded). Check Aspirin 300mg has been given. If necessary, give MORPHINE 5-10mg IV & METOCLOPRAMIDE 10mg IV

Trial of sublingual GTN

and/or GAVISCON

Exclude alternative diagnoses

Check TNT on arrival

ADMIT if >14 ng/l

Repeat if negative

6 hr Troponin only if early discharge planned, otherwise

repeat TNT at ≥12 hours

Refer to Chest Pain Nurse

Bleep 2473

Urgent call CCU (2066 or 3066) for Primary PCI. CCU to contact switch board (2222) who contact on-call interventional cardiologist and pPCI team. Transfer pt to Cath lab or CCU as directed.

Further therapy with IV β-blocker, GP IIb/IIIa inhibitors, prasugrel, bivalirudin and/or heparin etc. at discretion of the interventional cardiologist

GRACE RISK SCORE

Assess 6 months risk of death:

also on Intranet – Hospital Systems:

GRACE 6/12 death risk 3-6% or abnormal TNT >14 ng/l

(exclude non ACS causes)

go to Intermediate risk pathway

GRACE 6/12 death risk ≥6% or hypotension or heart failure or pulmonary oedema

go to High risk pathway

Refer to Chest Pain Nurse

Bleep 2473

Troponin T

abnormal >14 ng/l

(exclude non ACS causes)

POSITIVE

NEGATIVE

ISOKET 2-10mg/hr IV for pain/HF.

INSULIN infusion if glucose >11 mmol/l (24 hours)

Rpt ECG at 90 minutes post lysis

Rpt ECG at 90 minutes post lysis

DISCHARGE EARLY IF PAIN FREE

MIDDLE PATHWAY

(see over)

ECG: repeat at 90 min post pPCI

If CAD still possible, formal referral to

Chest Pain Nurses (use Red Top referral) within 24 hours.

Rx ASPIRIN 75 mg od, CLOPIDOGREL 75 mg od, BISOPROLOL 2.5 mg od if no contraindications, RAMIPRIL 2.5 mg bd initially (discharge on OD), Atorvastatin 80 mg nocte (unless interactions etc.).GTN s/l PRN

Admit to CCU

ASPIRIN 300mg stat. followed by 75 mg od. CLOPIDOGREL 300 mg stat. followed by 75 mg od. BISOPROLOL 2.5 mg if no C/I. FONDAPARINUX 2.5 mg s/c OD (if eGFR14 ng/l NEGATIVE ≤14 ng/l

If GRACE mortality ≥6% start TIROFIBAN

unless C/I

and early ................
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