Quality improvement report

Achieving national service framework standards for cardiac rehabilitation and secondary prevention

Hasnain M Dalal, project leader, ^a Philip H Evans, director. ^b

^a Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3LJ, ^b Somerset and North and East Devon Primary Care Research Network, Peninsula Medical School, Postgraduate Medical Centre, Exeter EX2 5DW

Correspondence to: H M Dalal, Lower Lemon Street Surgery, Truro, Cornwall TR1 2LZ hmdalal{at}doctors.net.uk

Problem: Integrated care for patients who survive a myocardial infarction is lacking. Many patients are not offered cardiac rehabilitation, and secondary prevention is not optimal.
Design: 12 month audit of 106 patients who survived an acute myocardial infarction.
Background and setting: Carrick Primary Care Trust in Cornwall (population 98 500) and one district general hospital.
Key measures for improvement: Proportion of patients who complete a cardiac rehabilitation programme after a myocardial infarction. Proportion of patients with optimal secondary prevention, as measured by smoking status, body mass index, cholesterol <5.0 mmol/l, and blood pressure <140/85 mm Hg.
Strategies for change: We set up a novel, integrated, and seamless system for cardiac rehabilitation. We employed a cardiac liaison nurse to identify and assess in hospital all patients with suspected acute myocardial infarction. The nurse offered patients the choice of home based rehabilitation with the Heart Manual or hospital based rehabilitation. The nurse gave discharge details to the patient's general practice; these were to be included on a practice based register of coronary heart disease.
Effects of change: All 106 eligible patients were offered cardiac rehabilitation and were included in a practice based register of coronary heart disease to facilitate long term follow up in primary care. 47 (44%) patients chose home based rehabilitation with the Heart Manual, and 41 (87%) of these completed the programme; 35 (33%) patients chose hospital based rehabilitation, and 17 (49%) of these completed the programme. The numbers of patients achieving secondary prevention targets improved significantly: those with serum cholesterol <5.0 mmol/l at discharge increased from 28% at baseline to 75% at 12 months. Optimal care (at least 80-90% uptake of an intervention) was seen with antiplatelet and statin treatments and with smoking cessation. Significantly more patients were prescribed statins at follow up than at baseline (77/106 v 80/91, P=0.005).
Lessons learnt: National service framework targets for cardiac rehabilitation and secondary prevention can be achieved in patients who survive a myocardial infarction by integrating rehabilitation services (home and hospital) with secondary prevention clinics in primary care. Nurse led clinics in primary care facilitate long term structured care and optimal secondary prevention.