The ChallengeThe treatment of patients presenting with ACS has changed considerably in recent years and NHS Trusts throughout the UK are in the process of implementing new treatment and care pathways in accordance with NICE (National Institute for Health and Care Excellence) and ESC (European Society of Cardiology) guidelines.

As part of these developments, the Royal Free London NHS Foundation Trust has collaborated with AstraZeneca to optimise and accelerate the management of ACS patients in the acute setting, to investigate if recruiting an ACS Specialist Nurse to provide risk assessment, medical and invasive management of ACS patients arriving at the Trust would have a positive impact on the Trust’s efforts to exceed the NICE/ESC guidelines.

According to MINAP (Myocardial Ischaemia National Audit Project) data, patients arriving at the Trust’s Barnet/Chase Farm site are less likely than patients at the Trust’s Royal Free Hospital site to receive access to in-patient angiography in a timely manner. This means that some ACS patients are not proceeding along the recommended treatment band care pathway.1

A primary cause of this delay is lack of access to specialist cardiology care, with ACS patients generally going through the traditional referral process via A&E and acute medical teams. A more successful approach can be seen at the Royal Free NHS Trust Hospital, where additional cardiology junior medical staff are available and there is also provision for patients to be seen out of hours and at weekends.

These observations prompted the Trust to work with AstraZeneca to develop a pilot project which ran from Jan 16 to Dec 17, with the aim of improving the adherence of patients presenting with suspected chest pain to the Trust ACS pathway, encouraging early discharge of low-risk ACS patients and identifying high-risk ACS patients early.

The Steps TakenThe Trust anticipates that the creation of a role for a nurse specialising in ACS, which has been jointly supported by AstraZeneca, could significantly improve the treatment and care journey for patients who arrive in A&E with chest pain and suspected ACS.

The specialist nurse's role involved:

• Helping to differentiate between low-risk ACS patients who can be sent home early and high-risk patients who can be fast-tracked onto the correct treatment and care pathway.

• Working closely with consultant cardiologists, who would provide support and training.

• Acting as a point of contact for questions and queries on ACS patients and treatment.

• Providing on-going education and training for Emergency Department staff and medical teams.

OutcomesThe expected outcomes are:

For the patient:

• Early access to specialist cardiology input for risk assessment and triage

• Facilitated early discharge of low-risk ACS patients by increasing discharges from A&E, and avoiding unnecessary admissions of low-risk patients presenting with chest pain

• Reduced in-patient bed days through earlier access to interventions

• A drop in major adverse cardiac events (MACE) in patients presenting with ACS

For the NHS:

• Increased adherence to NICE Quality Standards.• Reduced length of stay (LOS) in line with NICE Guidance

with potential bed saving days of 1000 per year• A reduction in low-risk ACS patient admissions

For AstraZeneca:

• Create more opportunities for the appropriate use of medicines, including AstraZeneca’s medicines in suitable patients in line with NICE Guidelines.

Achieving these outcomes will provide evidence to support a business case for the Trust to permanently fund the ACS nurse role.

Key Facts at a Glance• Aim to reduce acute coronary syndrome (ACS) in-patient

bed days

• Introduction of a specialist ACS nurse to improve patient experience and outcomes

• Increased adherence to National Institute for Health and Care Excellence (NICE) Quality Standards

Royal Free London NHS Trust has collaborated with AstraZeneca to develop a joint working project to address the differentiation in care of acute coronary syndromes (ACS) across the Trust. An ACS Specialist Nurse has been funded to improve patient experience and outcomes and improve service across the Trust.

1. Myocardial Ischaemia National Audit Project. How the NHS cares for patients with heart attack. Annual Public Report April 2013 - March 2014. Available at: https://www.ucl.ac.uk/ nicor/audits/minap/documents/annual_reports/minap-public-report-2014 Last accessed June 2018

Optimising the management of ACS patients in the Royal Free NHS Foundation Trust Hospital

Veeva: GB-9497 | Date of preparation: April 2018

The ChallengeThe treatment of patients presenting with ACS has changed considerably in recent years and NHS Trusts throughout the UK are in the process of implementing new treatment and care pathways in accordance with NICE (National Institute for Health and Care Excellence) and ESC (European Society of Cardiology) guidelines.

As part of these developments, the Royal Free London NHS Foundation Trust has collaborated with AstraZeneca to optimise and accelerate the management of ACS patients in the acute setting, to investigate if recruiting an ACS Specialist Nurse to provide risk assessment, medical and invasive management of ACS patients arriving at the Trust would have a positive impact on the Trust’s efforts to exceed the NICE/ESC guidelines.

According to MINAP (Myocardial Ischaemia National Audit Project) data, patients arriving at the Trust’s Barnet/Chase Farm site are less likely than patients at the Trust’s Royal Free Hospital site to receive access to in-patient angiography in a timely manner. This means that some ACS patients are not proceeding along the recommended treatment band care pathway.1

A primary cause of this delay is lack of access to specialist cardiology care, with ACS patients generally going through the traditional referral process via A&E and acute medical teams. A more successful approach can be seen at the Royal Free NHS Trust Hospital, where additional cardiology junior medical staff are available and there is also provision for patients to be seen out of hours and at weekends.

These observations prompted the Trust to work with AstraZeneca to develop a pilot project which ran from Jan 16 to Dec 17, with the aim of improving the adherence of patients presenting with suspected chest pain to the Trust ACS pathway, encouraging early discharge of low-risk ACS patients and identifying high-risk ACS patients early.

Veeva: GB-9497 | Date of preparation: April 2018

The Steps TakenThe Trust anticipates that the creation of a role for a nurse specialising in ACS, which has been jointly supported by AstraZeneca, could significantly improve the treatment and care journey for patients who arrive in A&E with chest pain and suspected ACS.

The specialist nurse's role involved:

• Helping to differentiate between low-risk ACS patients who can be sent home early and high-risk patients who can be fast-tracked onto the correct treatment and care pathway.

• Working closely with consultant cardiologists, who would provide support and training.

• Acting as a point of contact for questions and queries on ACS patients and treatment.

• Providing on-going education and training for Emergency Department staff and medical teams.

OutcomesThe expected outcomes are:

For the patient:

• Early access to specialist cardiology input for risk assessment and triage

• Facilitated early discharge of low-risk ACS patients by increasing discharges from A&E, and avoiding unnecessary admissions of low-risk patients presenting with chest pain

• Reduced in-patient bed days through earlier access to interventions

• A drop in major adverse cardiac events (MACE) in patients presenting with ACS

For the NHS:

• Increased adherence to NICE Quality Standards.• Reduced length of stay (LOS) in line with NICE Guidance

with potential bed saving days of 1000 per year• A reduction in low-risk ACS patient admissions

For AstraZeneca:

• Create more opportunities for the appropriate use of medicines, including AstraZeneca’s medicines in suitable patients in line with NICE Guidelines.

Achieving these outcomes will provide evidence to support a business case for the Trust to permanently fund the ACS nurse role.