Article Text

The changing interface between district hospital cardiology and the major cardiac centres
  1. A working group of the British Cardiac Society, with the Royal College of Physicians of London, the Royal College of Physicians of Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow
  1. Dr Brooks, Consultant Cardiologist, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK.

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1. Summary

1.1 The national priority for reducing mortality and morbidity from cardiovascular disease, the resulting expansion in the number of consultant cardiologists, and the reforms of the National Health Service have produced significant changes in delivery of care for cardiac patients and in the relations between district general hospitals (DGH) and the old regional cardiac centres.

1.2 The British Cardiac Society, the Medical Royal Colleges of Physicians of London and Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow established a working group to make recommendations on the most appropriate evolution of these changes to secure high quality care in a cost-effective and professionally rewarding environment. The principal conclusions of the working group were:

i) 
The establishment of new cardiac catheterisation laboratories in DGHs remote from a major cardiac centre should be encouraged provided the workload is adequate to ensure efficient use of the facility.
ii) 
Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre.
iii) 
Close liaison of the district cardiologist with a cardiac surgeon and interventionist is vitally important.
iv) 
The centres will be required to provide tertiary care for emergency and urgent cases from their traditional catchment area, specialised expertise for the management of rare and difficult cases, and angioplasty. Some centres will also offer complex electrophysiology, and ablation techniques.
v) 
The centres must also provide routine cardiology services for their local district, facilities for cardiac catheterisation for DGH cardiologists, and training for doctors, nurses, technicians, and radiographers.
vi) 
Some centres will be linked with paediatric cardiology and paediatric cardiac surgical units.
vii) 
District cardiac centres will be required to provide a full non-invasive diagnostic service and emergency care for patients referred by general practitioners and hospital colleagues as well as facilities for preventative and rehabilitation cardiology. Arrangements for invasive investigation and treatment of their patients will vary according mainly to the distance from the major centre.
viii) 
Both the major centres and the district cardiac units should participate in training and research.

2. Introduction

2.1 The provision of cardiac and cardiac surgical services continues to fall short of the targets set in 19941 2with long waiting lists for elective and urgent cases, and difficulties in transfer of patients for emergency treatment existing in many parts of the country.3 The aging population with coronary heart disease and increasing expectations of and opportunities for treatment are important considerations when assessing needs. 2.2 Specialised cardiac services, closely linked to the provision of surgery have traditionally been provided by the regional or major centres. Staffed by between three and eight consultant cardiologists with a variable complement of clinical and academic training posts, they have aimed to provide comprehensive facilities for invasive and interventional cardiology in addition to non-invasive assessment and diagnosis for between 1 and 2 million people. Not all have offered paediatric cardiology, specialised management of adult patients with congenital heart disease, complex electrophysiology, valvuloplasty or transplantation, and (with the exception of transplantation, which is supra-regionally funded, and paediatric cardiology) these services have developed largely according to the specific interests of the existing consultants. Many centre based cardiologists undertake outpatient clinics in their surrounding districts and some have inpatient responsibilities in nearby hospitals. 2.3 The recent expansion in the number of DGH cardiologists and the separation of purchasers and providers have resulted in changes in the relation of the regional centres with their surrounding districts. Increasingly, DGH physicians are catheterising their own patients either within their nearest centre or in catheterisation laboratories in their own hospitals, which are sometimes shared with adjacent districts. Patients are then referred for surgical treatment, often without the involvement of the cardiologist in the centre. The development of DGH cardiac catheterisation laboratories has been driven by the shortfall in existing facilities, the convenience for patients of not having to travel long distances for their investigation, the training of cardiologists based in the centres, which places strong emphasis on invasive investigation, the demonstrated safety of routine cardiac catheterisation remote from surgery, and by the potential for trusts to generate income. 2.4 These developments in DGHs and the current NHS emphasis on market forces have made strategic planning difficult, and this working group was set up to suggest a framework for the future relation between DGHs and major cardiac centres to ensure the continuation of optimal care, training, research and development, and the maintenance of competence of doctors and institutions.

3. Requirements of the service

The working group agreed that proposals for future developments should be based on their potential to safeguard the essential requirement to promote high quality care in a good professional environment.

3.1 CLINICAL

The service must provide timely access for patients with cardiological problems to the whole range of appropriate diagnostic and treatment facilities. Particular areas addressed by the working group were the provision of surgery, cardiac catheterisation, interventional cardiology, and electrophysiology as it is for these common procedures that waiting lists are currently the longest. The nature of modern cardiology is such that at least two and sometimes three or more specialists—the district cardiologist, tertiary interventionist, and cardiac surgeon—working at different hospitals may be involved in the care of a single patient, and successful management of complex cases requires a close working relationship between cardiologist and cardiac surgeon. Patient safety may also be put at risk if certain invasive diagnostic procedures are undertaken where rapid transfer to a cardiac operating theatre is unavailable.

3.2 COMPETENCE

The development and maintenance of expertise of medical and supporting staff requires experience with a large number and variety of cases, and the potential for interaction with colleagues. Cardiologists and centres undertaking procedures must carry a sufficient caseload to maintain individual and institutional competence.4 5 It may not be possible for a cardiologist working in isolation to sustain adequate experience of certain types of procedure; consequently not every district hospital and not every cardiologist can undertake cardiac catheterisation, and certain highly specialist procedures should be limited to a small number of centres.

3.3 TRAINING

The new training programme for the Specialist Registrar Grade has been published.6 The programme provides for the trainee to gain experience in both district hospital and major centres. Any reduction in the number of patients managed in the centres could have serious implications for training, as many district hospitals are unlikely to provide sufficient numbers or diversity of diagnosis to be able to assume this role. Physicians of high calibre who do not wish to undertake invasive procedures on their patients must not be excluded from the specialty.

3.4 ACADEMIC CARDIOLOGY, FURTHER EDUCATION, AND RESEARCH

Facilities are required for academic training, continuing education and research for the following:

i) 
for those undertaking a predominantly NHS career path
ii) 
for those undertaking a predominantly academic career path
iii) 
for those appointed to consultant and staff grade positions in district hospitals and regional cardiac centres.

3.5 Research may be conducted at major centres, district hospitals or a combination of the two. However, it is inevitable that research requiring specialist facilities or access to basic science laboratories needs to be based in major centres. The ability to provide a research environment should be seen by trusts as a desirable marker of clinical quality.

3.6 For trainees, overall responsibility for the research conducted during specialist training will lie with the designated trainer who will usually be based in the centre. Attendance at regular research meetings should be part of the consultant contract.

3.7 Within each complex of major centre and district cardiology hospitals opportunities should be provided for regular clinical and academic meetings, and symposia for continuing medical education, for audit, and for the fostering of collaborative projects.

4 Cardiac catheterisation

4.1 Establishment of new cardiac catheterisation laboratories in DGHs should be encouraged in districts remote from a major centre. To maintain institutional and individual competence and an uninterrupted service the working group suggests that a minimum of 500 cases per year should be carried out and that there should be a minimum of two operators. A cardiac catheterisation laboratory dedicated to cardiac work should achieve a throughput of 1500 to 2000 diagnostic cases per year (at least four cases per session). A close liaison must exist between the cardiologist, surgeon, and interventionist; this should be formalised but a spectrum of arrangements is acceptable. Cardiologists working in districts close to the regional centres should be encouraged to investigate their patients at the centre and consideration should be given to joint appointments. It is vitally important that visiting cardiologists are given full access to waiting lists and facilities similar to their cardiac centre colleagues. 4.2 Low volume complex work (such as adult congenital heart disease, difficult valves) should be done in the centres. 4.3 Many acute cardiac conditions are most appropriately investigated non-invasively but cardiac catheterisation, when required, should be carried out in the centres for suspected aortic dissection, mechanical complications of myocardial infarction, endocarditis, and valve disease with persistent heart failure. Patients with continuing recurrent ischaemia from unstable angina should be investigated in the centres as this allows follow on angioplasty in suitable cases and rapid liaison with the surgical team for those who are unsuitable for angioplasty. Local investigation can be appropriate for patients who have stabilised after an episode of unstable angina, particularly for those distant from the main centres. 4.4 Purchasing authorities must accept that regional centres cannot cope with emergency and urgent referrals and maintain 100% bed occupancy and utilisation of catheterisation facilities. The centres must be able to provide immediate and urgent (within 24 hours) access for critically ill patients without compromising the routine elective workload. 4.5 DGH cardiologists carrying out a major proportion of their own investigational work should be involved in training.

5 Coronary angioplasty

5.1 Coronary angioplasty is currently carried out in 42 NHS hospitals, of which 35 have onsite surgery, and 11 private hospitals, all of which provide surgery. 5.2 The British Cardiac Society (BCS) and British Cardiovascular Intervention Society (BCIS) joint working group on interventional cardiology has produced guidelines for training and continuing competence.4 The recommendations are based on the essential requirement of angioplasty centres to provide 24 hour emergency cover seven days per week, to undertake a minimum of 200 procedures per year, and for principal operators to undertake at least 60 PTCA procedures per year to maintain competence. Trainers should undertake a minimum of 125 procedures per year to maintain accreditation. Onsite surgical cover for PTCA procedures remains the strongly preferred option, and while rapid access to surgery is the essential criterion, the development of further angioplasty services in non-surgical centres should be considered only in exceptional circumstances. 5.3 The conclusions of the group are that expansion of existing angioplasty centres should occur before the development of new ones and that little expansion in the number of operators is required to achieve the target of 400 PTCA procedures per million of the UK population by the end of 1996–97, although a progressive increase in this target is anticipated as the UK level of provision is below many comparable European countries. 5.4 Provision of coronary angioplasty as first line treatment for acute myocardial infarction presents a formidable logistic challenge. It has yet to be demonstrated that the excellent results from relatively small studies reported from highly experienced centres can be validated in large scale studies, therefore, it is recommended that provision of primary angioplasty should not be a key priority.

6 Pacemaker implantation

6.1 Implantation of pacemakers is carried out in both major centres and district hospitals, and a large expansion in pacing services has occurred since a BCS report in 19877 endorsed the view that pacing could be carried out safely and effectively in district hospitals. In 1995 a total of 135 centres in the UK were reporting pacing activity. This expansion has undoubtedly been a major factor responsible for increasing the number of implantations in the UK towards the recommended level of 300 new implants/million/year1 (in 1994 the implant rate was 258 per million population per year). 6.2 Some concern exists that new pacing centres have developed on the basis solely of an enthusiastic cardiologist and a willing purchaser without consideration for geographical location, proximity to a major centre or issues of competence. Guidelines for the establishment of new centres and for the training and competence of personnel have been developed by a joint working group of the BCS and the British Pacing and Electrophysiology Group (BPEG),5 and include the recommendations that new centres should be adequately funded to meet the target of 300 new implants/million/year, undertake a minimum of 60 implants/year to maintain competence, provide an appropriate mix of implants, and provide 24 hour cover ideally with at least two cardiologists but if necessary on the basis of a formal collaboration with a nearby centre. Certain complex pacing problems, in particular the extraction of endocardial leads for which emergency surgery is occasionally required, should be carried out in the major centres.

7 Interventional cardiac electrophysiology

7.1 The advent of catheter based ablative techniques has increased dramatically the scope for effective treatment of arrhythmias and has been accompanied by an increase in the number of trainees and the establishment of new centres. Questions of training and competence have become important issues because of the demanding nature of the techniques both for cardiologists and technical staff, and the demonstration that success rates are highest, complications least frequent, and procedure times shortest in high volume centres.5 7.2 The implantable cardiovertor-defibrillator (ICD) has proved to be highly effective in the management of malignant ventricular arrhythmias, and the implantation procedure is, in most cases, technically straightforward. However, the devices are expensive and patient selection, post-implantation programming, and follow up are complex and may require a multidisciplinary approach. 7.3 The recommendations of the BCS/BPEG working group are that ablation and ICD therapy should be practised only in specialised units that can in addition provide full facilities for diagnostic electrophysiology, coronary angiography, and echocardiography, and can maintain a sufficient number of procedures to ensure that individual and institutional competence is sustained. It is likely, therefore, that these procedures will remain largely confined to the major centres for the foreseeable future and that not even every major centre should aspire to provide the service. 7.4 Surgical treatment of arrhythmias is a highly specialised technique, the role of which has diminished in parallel with the development of catheter ablation and ICDs. It has been established that only about 50 such procedures are currently carried out each year and the working group endorses the view that these treatments should be designated as a supra-regional service.5

8 Cardiac centres

8.1 The pressure exerted by market forces, increasing numbers of cardiologists, shorter training periods, increasing demand for services, and increasing requirements for regulation and audit are likely to create significant changes in the role of cardiology centres and the cardiologists working in them over the next 5 to 10 years. The centres will be required to provide:

i) 
Emergency and urgent care for patients from their traditional catchment area, many of whom will require surgical treatment.
ii) 
Specialised expertise for diagnosis and management of rare or “difficult” cases referred to them by the district hospital cardiologists (such as hypertrophic cardiomyopathy, adult congenital heart disease, complex ultrasound).
iii) 
Specialised procedures requiring the maintenance of a high level of expertise and, consequently, a large case load for each consultant. The main procedures in this category are angioplasty, valvuloplasty, ICD implantation, and ablation, but include low volume complex cardiac catheterisations such as those in adult patients with congenital heart disease and some valve cases.
iv) 
Secondary care for the local catchment area that will ensure there is the critical mass of routine work for reasons of training and continuing competence.
v) 
Facilities for cardiac catheterisation for local DGH cardiologists who wish to investigate their patients in the centre.
vi) 
Training for doctors, nurses, technicians, and radiographers.
vii) 
Some centres will be on the same site as and linked with paediatric cardiac units providing neonatal cardiac surgery, and transplant centres.
viii) 
Centres need to provide a research environment and research support for training and academic advancement, and as the basis for innovation and clinical development.

8.2 These requirements will lead to changes in the pattern of work of cardiologists working in the centres and subspecialisation will be necessary. This is most clearly defined for angioplasty, valvuloplasty, and electrophysiology but the pace of change and increasing technical complexity of echocardiography, nuclear cardiology, computed tomography, and magnetic resonance scanning is such that few cardiologists will be able to acquire and maintain the expertise to provide a tertiary referral service in all disciplines. The shortened training for cardiologists and the consequent need for active training and periodic assessment will result in the requirement for at least one cardiologist in every centre to have a special responsibility for training.

9 District cardiac centres

9.1 ELECTIVE PROCEDURES

The district cardiologist will be required to provide prompt diagnostic services and treatment for patients with cardiac problems referred by general practitioner and hospital colleagues. All districts should provide a full non-invasive diagnostic service, including transoesophageal echocardiography, and many cardiologists will also have sessions in pacing and invasive investigation, either locally or in the nearest tertiary referral centre.

9.2 EMERGENCY CARE

The district cardiologist is becoming increasingly and heavily involved in the emergency care of medical patients with acute cardiological disorders. This commonly involves the investigation and management of acute coronary syndromes, arrhythmias, and heart failure. These changes in the management practice of acute cardiac emergencies at the receiving hospital has close parallel in other medical subspecialties, and is certain to have a major impact on emergency medical care in the future.

9.3 PREVENTATIVE CARDIOLOGY AND REHABILITATION

It is essential that DGH cardiologists are experts in preventative and rehabilitation cardiology.

9.4 TRAINING

Larger district cardiology services should assume a responsibility for training for doctors, nurses, technicians, and radiographers.

9.5 RELATION WITH MAJOR CENTRES

Optimal organisation of the relation between the major centres and their surrounding district cardiology units will be determined mainly by geography and by arrangements already in place. It is suggested that developments of cardiac services in district hospitals should be determined to some extent by their proximity to a major centre; however, the working group recognises that many models could deliver an effective service and it is not intended that the recommendations should be proscriptive. The proposals principally concern the provision of cardiac catheterisation, interventional cardiology, and cardiac surgery.

i) District hospitals close to a major centre

Cardiac catheterisation for patients living within a reasonable travelling time of a major centre would most logically be provided in the centre by the district cardiologist on the basis of a regular sessional commitment. For larger districts, and for those in which the cardiologist does not wish to carry out his own invasive investigation, some or all of the patients could be catheterised by a cardiologist in the centre who might also have a sessional commitment to see outpatients or inpatient referrals in the district hospital.

These arrangements promote an optimal liaison between the district cardiologist and interventional cardiologists and cardiac surgeons. The visiting cardiologist should participate in the regular clinical and audit meetings in the centre.

The arrangements must ensure that all cardiologists, whether from a DGH or the cardiac centre, perform cardiac catheterisation in sufficient numbers to maintain competence.

ii) District hospitals remote from the centre

For such districts arrangements for local cardiac catheterisation must ensure close liaison between the DGH cardiologists and their interventional colleagues in the referral centre. This might be achieved by establishing regular (once or twice monthly) visits by an interventionist and cardiac surgeon from the centre to discuss catheterisation data and angiocardiograms or vice versa, and such visits could be combined with joint clinics. Where this is not possible, rapid transfer of data to the centre must be established. Every effort should be made to maintain regular personal contact between staff of the centre and the district and this could be facilitated by joint meetings and continuing medical education projects.

9.6 RESEARCH

Although facilities for more fundamental research may not be available in the district hospital, there are important opportunities for collaborative clinical research. This may involve a group of hospitals or large scale multicentre studies. In both instances the research would allow cardiologists and trainees to be involved in key clinical developments and innovation.

References

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Footnotes

  • Members of the working party D J Parker (Convenor) R Balcon (Chairman) N H Brooks (Secretary) T R D Shaw (Royal College of Physicians, Edinburgh) S Cobbe (Royal College of Physicians and Surgeons, Glasgow) R H Swanton (Royal College of Physicians, London) K A A Fox R J C Hall M J Joy A A McLeod A J Mourant N Naqvi

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