1. BHF Arrhythmia Nurses Carolyn Shepherd Clare Parker/Sarah Chalkley Arrhythmia Nurse Service 2008/2011

2. History of Arrhythmia Nurse Role Pressure groups – Arrhythmia Alliance. National Drivers (Chapter 8 NSF & NICE) Equity of care for patients in South West Collaborative business case British Heart Foundation Funding for 3 years Steering group established (includes NBT, AGWS cardiac network, PCT)

3. BHI Arrhythmia Nurses 2008 Cardiology Backgrounds. BHF funding for development Working towards MSc in Advanced Practice 2011 MSc module in Arrhythmia Management Physical Examination and Assessment module. Independent Nurse Prescribing module. Applying for BHF funded MSc genetics modules

4. Targets of Arrhythmia Nurse Role Develop links with primary care to promote awareness of up- to-date diagnosis, management and treatments for arrhythmias Establish telephone advice and guidance helpline for patients/ carers/primary care staff Address long clinic waiting list Reduce length of stay and prevent unnecessary admissions Establish robust pre-operative assessment Develop service for survivors of sudden cardiac death and their families

5. Pre-operative Assessment

6. Pre-assessment – 2008 Pre-operative assessment undertaken by ward staff and junior doctors on day of procedure Consent on day of procedure No central point of case management No written information or point of contact provided No MRSA Screening Patient satisfaction running at 60%

7. Pre-assessment today Three one -stop clinics per week Over 1,000 patients expertly pre-assessed and case managed Gold standard nurse-led consent- (Standard set for whole Trust) Pre-written consent forms - (Adopted & adapted nationally) Processes agreed for infection control and anticoagulation management Overall patient satisfaction rose from 60% in 2009 to 96% in 2011.

8. Patient comments. Satisfaction Survey - 2011 I was very well treated by the young lady. I was given the opportunity to ask any questions – did not feel rushed. Good thorough pre-op assessment. I had serious atrial fibrillation lasting days after the ablation, but a phone call to the arrhythmia nurses allayed fears and the atrial fibrillation was sorted by increasing medication. The arrhythmia nurses took a great deal of trouble and time to explain the procedure. It was extremely helpful and reassuring. 10/10 Thank you.

9. Impact of KEY CHANGES to Pre- assessment Pre and post pre-assessment service cancellation rate. Increased day case procedures. PRE - 17% POST - ↓ 2.5% PRE - 37% POST - ↑ 71%

10. Telephone advice/support Line

11. Telephone Advice and Guidance 2008 Calls dealt with by; Medical secretaries Waiting List Office staff Medical staff Cardiology ward staff CCU staff Catheter lab staff Any available person!

12. Telephone Advice and Guidance 2011 Telephone line open to; Patients Carers Relatives Health care Professionals General Practitioners throughout Bristol

13. Telephone Advice and Guidance 2009 - 2011

14. Category of telephone calls

15. GP/Out-Patient Appointments Avoided 175 appointments avoided in 1 year through: Advice given Reassurance given Medication changes made Post op queries answered Pre-op queries answered

16. GP Telephone Calls No Tariff Expert Advice Medications/pre-post op queries/investigations Consultant input Urgent ECG advice

17. Reduce Clinic Waiting Times

18. Nurse-led follow-up clinics One clinic per week. Six patient slots of 30 mins each. Annual Total – 312 patients seen Cost of Nurse-led appointment £111.01p Saving on Consultant appointment of; £120.71p Total Saving = £37,661p per annum

19. Nurse-led Cardioversion follow-up Nurse-led cardioversion follow-up. Clinical expertise to review and plan patient pathway Reduces need for GP re – referral for review Assess and offer ablation treatment if appropriate Assess and discharge to Primary care with care plan

20. Nurse-led follow-up clinics Reduces waiting time for patient Isn’t this repeating what you’ve already said? Reduces Consultant clinic waiting time

21. Unplanned Admissions Averted

22. Unnecessary Admissions Averted Cost of admission to A&E: Mid tariff; £110 – plus tests. CXR/ECG/Bloods etc Number of potential admissions averted. Last full year = 49 Saving. £5,390 plus

23. Unplanned Admissions avoided

24. Wound Review Service/rescue Example of rescue work to reduce admissions Free service On demand Early treatment if required Rescue before major problem occurs Reassurance

25. Reduction in Length of Stay

26. Reduced Length of Stay Elective Patients Nurse-led discharge Reduction of discharge time from 13.00 to 10.30am Improved patient throughput leading to reduced cancellations Improved patient information pre-discharge reduces readmission

27. Length of Stay Patient pathway pre ANs Patient admitted to A&E or MAU Medical Clerking/basic tests ADMIT to CARDIOLOGY. Await specialist EP review - 1 – 2 nights Review by EP – treat/discharge Wait for OPA, 2 - 3 months Attends OPA/listed for procedure/waits Procedure Pre-operative assessment

28. Reduced length of stay In-patient pathway 2011 Patient admitted to A&E/MAU Medical Clerking/Basic tests Picked up by Specialist Nurse on post-take ward round Referred to Arrhythmia Nurse/Treatment plan recommended Patient information given/Listed for procedure / tests Discharge same day with treatment plan Pre-operative assessment Procedure Tests reviewed by AN

29. Overview 2008 - 2011 5,130 Patient contacts 1,165 Telephone calls 84 Wound Reviews/Rescue 312 Outpatient Appointments

30. The Future - EP expansion Cannot have this as the focus for primary care! Appointment of new EP Consultant. Initial aim to reduce waiting list Generate increased pre-assessment work? Need for further follow-up clinic? Increased number of in-patients to review? Commitment to South Bristol Hospital clinics Arrhythmia clinic/pre-op clinic.

31. Summary Cost of two band 7 nurses with add-on costs £85,318 per annum Savings Clinics £111.01p x 312 = £34,635.12p p/a Unplanned admissions A&E £5,390 Two day admission = ? No charge for telephone advice

32. Retreat is not an option! No service! No pre-assessment–(no capacity in general pre-op) No case management --- phone calls redirected/not taken 312 follow-up clinic slots to find No expert nurse-led discharge from wards (↑cancellations) No reduction in length of stay for unplanned admissions (↑ cost) None/limited provocation studies (↓ income/service) No arrhythmia nurse-led clinics at South Bristol Hospital. (↓ income) Reduced quality (↑complaints) All in context of expanding service.