Telemedical ECGs Put in Practice » Health » 24dash.com

Can you improve patient cardiac care and working practice for GP clinicians whilst reducing the cost of cardiac care to the NHS? GP, Dr Jonathan Lieberman, points out how a telemedical ECG service has done just this at his surgery in Manchester, and outlines the benefits it has brought to patient, doctor & the NHS.

When a patient comes into your surgery complaining of chest pain what do you do? Do you carry out an in-surgery test using a conventional ECG machine and interpret the result yourself? Or do you immediately refer them to hospital for an ECG test?

This is a common scenario faced by doctors in general practice. However, it is likely that many doctors don’t have access to in-surgery ECG machines, and those who do probably don’t have anyone skilled in ECG analysis available to interpret the results. So the chances are that in the majority of cases the patient is sent off to hospital to be diagnosed.

Heart disease is the United Kingdom’s biggest killer. It is therefore unsurprising to learn that the cost of diagnosing, treating and caring for patients with cardiac related problems such as coronary heart disease (CHD) represents the single heaviest financial burden on the NHS every year.

From primary through to acute care an estimated £34b is spent on cardiac care annually, this on average costs the UK taxpayer a staggering £305,000 per patient.

But it is easy to see why this particular area of the NHS is taking the biggest hit. Lifestyle combined with other deciding factors such as family history mean that today only 10% of the UK’s population is free from the most important risk factors, such as high blood pressure and obesity, for coronary heart disease. And individuals with no obvious risk factors are still more likely to die of myocardial infarction than of any other cause.

The issue needs to be addressed. Delivering effective yet efficient cardiac care is something the Department of Health is attempting to focus on and their National Service Framework for Coronary Heart Disease initiative includes standards for improved prevention, diagnosis and treatment of CHD. However finding a single solution that helps reduce the operational and financial burden of cardiac care on the NHS and delivers distinct benefits to both patients and their doctors would be the ideal.

Diagnosing the problem
Early detection should mean early action; moving diagnoses and treatment away from the acute hospitals into primary care settings would appear to be the best approach. Developing a more proactive and preventative model of care in a primary care setting would ease some of the financial and operational pressures placed upon acute care providers. Diagnosing and addressing any problems at an earlier stage means patients receive more timely and preventative support, this may reduce the need for hospitalisation. This not only benefits patients from a clinical point of view but also frees up resources in secondary care allowing NHS resources to be reallocated to other key areas.

The most common method of diagnosing cardiac conditions is the electrocardiograph [ECG], whilst most GP surgeries have access to ECG machines, the skills required for accurate and detailed 12 lead ECG analyses can be difficult to maintain outside of cardiology or emergency medicine specialities.

The majority of nurses and GPs based in primary care, by their very nature deliver more general care over a much wider medical spectrum and may not all have been able to maintain skills in ECG interpretation. If there is no facility for reliable ECG interpretation at the local point of testing ECGs can be sent away, however this is more time consuming as hospital ECGs take longer to process.

Finding a way to bring expert ECG interpretation directly into the primary care environment could mean patients getting a quicker diagnosis of heart conditions – making a huge difference to their overall well-being and even potentially saving lives, on the other end of the scale those with chest pain symptoms which are diagnosed as not being cardiac related are reassured.

Telemedical ECGs import the same kind of cardiac expertise found in hospitals into a GP’s surgery, and coupled with a cardiac monitoring service to expertly interpret the results, it provides patients with a facility, which not only gives them a full on-the-spot ECG test and assessment, but also cuts out the often lengthy waiting times that go hand-in-hand with waiting for hospital ECG test results.

The telemedical monitoring service is not intended to replace traditional ECGs in hospitals, but to compliment services already in place by giving patients quick and easy access to effective expert cardiac diagnosis within their local doctor’s surgery, in turn helping to remove some of the burden on our hospitals and cardiac staff.

Telemedicine in primary care – ECGs explained
The St Gabriel’s Medical Centre in Prestwich, Greater Manchester, provides care for 8,500 patients. Since 2006 the surgery has been using a telemedical ECG service from Manchester based telemedicine specialist Broomwell Healthwatch.

Broomwell’s NHS accredited cardiology reporting service provides quick expert diagnosis of chest-pain symptoms from trained cardiologists and has proven to be very popular with both patients and staff at the surgery.

The reporting service is incredibly easy to use, 12 lead ECGs are either faxed or transmitted as a sound signal by landline in just seconds to the monitoring centre. Based on a high quality ECG trace the cardiology clinician provides an immediate verbal interpretation by telephone and also a formal written analysis returned by fax for inclusion in the patient’s clinical notes.

Patients who receive a more critical diagnosis receive prompt assessment and intervention and rapid transfer to the appropriate acute facility, such as the hospital emergency department.

Prior to the telemedical ECG sending patients with chest-pain symptoms straight to the hospital for a traditional ECG analysis was the standard procedure for the surgery - this was often stressful for the patient as it meant they had to wait a longer period before being diagnosed.

We also have access to a conventional 12 lead ECG machine to assess patients who present acute clinical symptoms, the machine takes a recording and produces a paper tracing for the GP or nurse to interpret, however the practice staff were not 100% confidant in interpreting the result. This is where the reporting service and telemedical ECG has been of great benefit. An additional benefit of the device is its portability. Traditional ECG machines are large, bulky and difficult to move. The new machines however, are much smaller hand-held devices, which allow clinicians to use them in several different rooms within the practice. It also has the potential to be used by GPs for home visits.

Reaping the benefits
The telemedicine service has had strong support amongst the practice clinicians. Giving them access to fast expert advice on sometimes complex cardiac issues has been extremely beneficial. Often patients present unclear symptoms, this is where the service has proven to be an invaluable diagnostic aid, and diagnosing and addressing problems at an earlier stage means patients receive more timely and preventative support.

The service’s ease of use means staff training is quick. Cardiologists from the monitoring centre demonstrate the procedure, ensuring practice clinicians are 100% comfortable with the method before they carry it out themselves. At the time of taking the ECG monitoring centre staff are in constant communication with the clinician carrying out the procedure, this ensures their awareness of the clinical situation and enables them to provide an accurate interpretation.

Furthermore, the speed with which the monitoring centre interprets the result and reports back to the surgery means the surgery has been able to easily fit in routine ECG readings.

The response from patients has also been overwhelmingly positive. Being able to stay within the familiar surroundings of their doctor’s surgery with faces they recognise and trust means they are more at ease. Having an ECG done at their local surgery also means they do not spend time travelling back and forth to hospital, this means less hassle and reduced stress.

Proof is in the pilot
The burden of ‘frequent flyer’ patients on hospitals is considerable. Cutting unnecessary emergency admissions and referrals to outpatient clinics would free up hospital resources and accrue savings, which could be reallocated to other key areas.

St Gabriel’s Medical Centre was part of an initial 12-month initiative undertaken by four Primary Care Trusts (PCTs) across Greater Manchester to implement the telemedical service within surgeries and walk-in centres across the Trusts. The trial supervised by The Greater Manchester and Cardiac Network, covered 48 surgeries and tested 2788 patients. From the testing group 1268 audit forms were returned by GPs, who said that without the ECG test 57% of the1268 patients tested would have been immediately referred to either A&E or Outpatients.

Since deploying the telemedical ECG service approximately 90% of patients who have come into the medical centre for a test avoided going to hospital and were reassured at the surgery. Without the service these patients would have been sent directly to hospital, unnecessarily consuming NHS time and resources.

The successful outcomes of the initiative means that healthcare bodies are beginning to realise the potential of telemedicine and today the monitoring service is in use across 10 PCTs within nearly 148 surgeries in Greater Manchester.

Telemedicine services have also proven to be hugely successful across many surgeries and walk-in clinics in other parts of the UK. A twelve-month pilot of the services in Cumbria and Lancashire involving 15 GP practices and two walk-in Centres demonstrated the potential cost and resource savings of implementing a telemedicine service within the NHS.

Data from the pilot predicted that 90,000 emergency department, 45,000 hospital admissions and hundreds of lives would be saved each year in England.

Following ECGs at GP surgeries 82% of patients did not need to go to hospital [either emergency department or outpatient], by simply cutting the level of referrals to emergency departments the pilot data estimates that the minimum savings to the NHS will be £46 million per year.

The prognosis for telemedicine
The NHS North West pilot, the deployment across Greater Manchester and the research data all point to the overriding benefits of the telemedicine service to both patient and doctor, and to the NHS, and my own experiences of using a telemedical service is a further testament to that.

Although practice staff are generally very positive about telemedical ECGs and agree they are a good diagnostic aid which bring tremendous benefits to patients and secondary care, at a primary level, time and cost can be areas of concern. Performing ECG tests in-surgery can take up additional staff time. To fully realise the benefits, PCTs should consider allocating additional (or be it small) sums to cover the extra nursing time required.

Cardiac telemedicine is an excellent way to ensure that expert advice is available in a matter of minutes, I have full confidence in the monitoring service and having access to this sort of instant diagnostic expertise helps us better perform our role as a doctor. Instant results means the appropriate action can be taken quickly, helping us deliver an optimal level of care to our patients.

I believe that deploying a telemedicine service for other medical conditions would also be extremely beneficial to patients and the NHS. The surgery has also deployed an arrhythmia watch-monitoring device to aid us in our diagnosis of patient arrhythmia.

Looking at the vast benefits to be gained from telemedicine I would definitely consider looking into the use of telemedicine to help diagnose other chronic conditions within a primary care setting.

Prevention, they say, is better than cure, and this service prevents unnecessary hospital visits by patients who don’t have a life-threatening cardiac condition and it helps to prevent a patient’s condition, which is serious, from worsening by ensuring they receive timely care. This proactive and preventative model of care has brought the expertise of cardiologists straight into the heart of primary care, helping to ensure NHS resources are optimised and used as effectively as possible whilst giving us the tools to be able to provide the highest standard of care for our patients.

http://www.broomwellhealthwatch.com