Download - Dr. David Lyon
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Dr. David Lyon
Clinical Governance Lead
Halton PCT
GP Affiliate NPDT
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The art of Medicine is to amuse the patient whilst nature cures the
disease
Voltaire
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TOP
BOTTOM
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Repeated Use of the Cycle
Theories Testing changes Changes resulting in
improvement
A PS D
A PS D
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NSF Recommendations for Those with Established Disease
• Risk factors assessed, documented & advised, especially smoking.
• Medication: aspirin, beta blockers, ACEI
• Blood Pressure below 140/85
• Blood cholesterol lowered to less than 5mmol/l and LDL-C below 3mmol/l or by 30%
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Getting the Ball Rolling• Disease Registers from medication & READ
coded entries• Additional Nurse Resource Devolved to Practices• Protocols for Nurse & for Referral to Secondary
Care• Computer Templates• Audit Team Geared up to Provide Rapid
Feedback
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Advantages of Templates
• Quicker entry of standard data
• Consistent use of READ codes
• Display previous recordings
• Search for previous interventions
• Automatic calculations, e.g. BMI, risk score
• Clinician can be reminded of interventions
• Easier audit
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% Population with IHD Runcorn
0
1
2
3
4
5
6
B C G H M T W ALL
1999200020012002
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% Co-morbidity
0 10 20 30 40 50 60
Diabetes
Stroke/TIA
Hypertension
2002200120001999
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% of patients with proven CHD on Aspirin First, Second, Third and Fourth Wave practices
50.0
55.0
60.0
65.0
70.0
75.0
80.0
85.0
90.0
95.0
100.0
Jul-00
Aug-00
Sep-00
Oct-00
Nov-00
Dec-00
Jan-01
Feb-01
Mar-01
Apr-01
May-01
Jun-01
Jul-01
Aug-01
Sep-01
Oct-01
Nov-01
Dec-01
Jan-02
Feb-02
Mar-02
Apr-02
May-02
Jun-02
Jul-02
Aug-02
Month
Per
cent
age
Series1 Series3 Series4 Series5
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% of patients 1 year post-MI on Beta-BlockersFirst, Second,Third and Fourth Wave Practices
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Jul-00
Aug-00
Sep-00
Oct-00
Nov-00
Dec-00
Jan-01
Feb-01
Mar-01
Apr-01
May-01
Jun-01
Jul-01
Aug-01
Sep-01
Oct-01
Nov-01
Dec-01
Jan-02
Feb-02
Mar-02
Apr-02
May-02
Jun-02
Jul-02
Aug-02
Month
Per
cent
age
Series1 Series3 Series4 Series5
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% of patients with proven CHD on StatinsFirst, Second,Third and Fourth Wave practices
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Jul-00
Aug-00
Sep-00
Oct-00
Nov-00
Dec-00
Jan-01
Feb-01
Mar-01
Apr-01
May-01
Jun-01
Jul-01
Aug-01
Sep-01
Oct-01
Nov-01
Dec-01
Jan-02
Feb-02
Mar-02
Apr-02
May-02
Jun-02
Jul-02
Aug-02
Month
Per
cent
age
Series1 Series3 Series4 Series5
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% of patients with proven CHD who have blood pressure below 140/85First, Second,Third and Fourth Wave practices
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Jul-00
Aug-00
Sep-00
Oct-00
Nov-00
Dec-00
Jan-01
Feb-01
Mar-01
Apr-01
May-01
Jun-01
Jul-01
Aug-01
Sep-01
Oct-01
Nov-01
Dec-01
Jan-02
Feb-02
Mar-02
Apr-02
May-02
Jun-02
Jul-02
Aug-02
Month
Perc
enta
ge
Series1 Series3 Series4 Series5
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Clinical Governance
• Protected Time for Regular Team Meetings
• Significant EventsPremature DeathsNew Cancer CasesUnpleasantness In The Waiting Room
• Summaries to Clinical Governance Team
• SEA News
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What Happened
• Focus on the facts
• No blame
• It’s the system
• What went well
• What was OK
• What could have gone better
• What should we do next time?
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Acute Chest Pain Protocol
• Is the patient alert?
• Is the patient’s breathing normal?
• Is the pain severe?
• Is there heart problems or diabetes?
• Is it heavy, crushing, pressure or tight?
• Is there nausea or vomiting?
• Is the patient sweating or clammy?
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Acute Chest Pain Protocol
• 51 cases in 12 months
• 10 (19%) MI 1 had VF within 5 minutes
• 7 (14%) crescendo angina
• 24 (47%) admitted to rule out MI
• 8 (16%) had blood test etc. & discharged
• 2 (4%) dysrhythmia
• Call to needle time less than 60 minutes
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Cardiac Events Castlefields Health Centre
0
10
20
30
40
50
60
92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 00/01 '01/02
IHD Deaths Non-fatal Mis
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Cardiac Events per Thousand
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Non-fatal MI Acute CHD Death
1999200020012002
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DEATHS
• Practice records
• ONS (Office of National Statistics)
• Public Health
• 3 Character Postcodes
• Trend over Time
• Twelve Month Periods
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Percentage Improvement In CHD Deaths All Ages For First Twelve Months Of Waves 1 And 2
-30
-25
-20
-15
-10
-5
0
5
10
15
20
25
%
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Percentage Improvement In CHD Deaths All AgesOver Twelve Months
0
1
2
3
4
5
6
7
8
9
England Wave 1 Wave 2
%
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At Risk
• Other Athersclerotic Disease
• Diabetes
• Hypertension
• Heart Failure
• Middle-aged men
• Strong Family History
• Smoking, Post-menopausal women
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Essential Ingredients
• Clear evidence and Clear focus• Examples From The Field• Time to consider solutions• Reality of working at ‘street level’• Systematic recording of information• Rapid feedback• Appropriate resources• Skilled management
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