Cardiology induction booklet was contributed by the following;
written by Dr Benjamin France (FY1)
reviewed by Dr Leventogiannis
updated by Dr Aisal Khan and Dr Sunil Nadar
Select the booklet titles below to expand the table to view more information.
Cardiology Ward Timetable
| Day | Monday | Tuesday | Wednesday | Thursday | Friday |
|---|---|---|---|---|---|
|
AM |
Ward round |
Ward round |
Ward round |
Ward round |
Ward round |
|
PM |
Ward jobs |
12:30 Cardiology Lunchtime meeting CEC (Teaching, mortality review or governance) |
Ward jobs
|
13:00-14:00 Grand Round, CEC. |
Ward jobs |
Cardiology Introduction
RHH offers a full range of cardiac services with the exception of Primary Percutaneous Coronary Intervention (PPCI) and tertiary cardiothoracic services. PPCI is done at New Cross Hospital (NXH) with Dr Banks, Dr Nadar and Dr Martins involved in providing this service.
Echocardiography Department
The echocardiography department is a full BSE accredited Department and offers a full range of echocardiographic services including stress echocardiography and TOE.
Cardiology Services
We have a large Cardiac CT service to assess chest pain patients which is jointly run with radiology and supported by Dr Huggett, Dr Waidyanatha and Dr Shahid. Cardiac Magnetic Resonance (CMR) is led by Dr Huggett and Dr Shahid.
The cardiac electrophysiology service supports a full EP ablation service at NXH. Russells Hall Hospital (RHH) is a recognised centre of excellence for implantation of complex devices (implantable cardiac defibrillators (ICDs) and Cardiac Resynchronisation Therapy (CRT)). This service is offered by Dr Leventogiannis and Dr Barr. Soon the service will be expanded to include the implantation of leadless devices.
NXH offers a full range of coronary interventional work and a 24/7 PPCI service for acute ST Elevation Myocardial Infarctions (STEMIs). Interventional decision-making is supported by a well-developed weekly MDT process and good working relationships between cardiologists and cardiothoracic surgeons.
Cardiac Assessment Unit (CAU)
We have an excellent dedicated specialist Cardiac Assessment Unit (CAU) team (Karen, Liz, Kate, Apollo, Elliot, Heather, Becky,Soba & Andy) who are notified directly when PPCI admissions are expected by the A&E staff. Most of these are directed to NXH by the paramedics themselves. In straight forward cases that self present to RHH, the on-call cath lab team at NXH are activated and the patient is transferred directly to NXH Catheter Laboratory from A&E without delay.
If there is any doubt over suitability for transfer this should be discussed with NXH SpR/interventional consultant.
Needless to say, but unstable non-STEMI and unstable angina patients (on-going rest pain and ECG changes) need transfer to NXH and should be discussed on the established direct communication between the 2 departments.
A STEMI is a medical emergency and there should be no delays in transfer for PPCI caused by medical indecision based on borderline ECGs.
NB: In exceptional cases STEMI referrals to NXH can be turned down – please urgently discuss these cases with the consultants here, who would then perhaps discuss with the team at NXH.
Cardiology Work
The Cardiology work is supervised and led by a consultant cardiologist of the week (CoW; 1 in 8 rota) who is “on take” for the whole week (Monday to Sunday). There is also a designated registrar on-call for the week.
The CoW does a daily morning ward round starting on the Cardiac Care Unit (CCU/PCCU) at 9:00 but occasionally at 8.30am depending on the consultant, progressing to review of new admissions on medical wards as well. Starting on the Cardiac Care Unit (CCU), progressing to post-cardiac care unit (PCCU), then to review of outliers on medical wards and chest pain assessment unit (CAU). Patients accepted under the ACS service are normally transferred into the Cardiology Unit.
CCU Nursing / Ward Standards
Dress code: Bare below the elbow policy. Drs are reminded to remove watches and ties etc.
The CCU sisters and nurses have a wealth of cardiology experience and knowledge which you should gain from. **Please in general do as the CCU sisters ask.**
Angelita is the ward manager and in charge of nursing standards.
Cardiology Ward
Select the titles in red below to find out further information.
Ward Rounds
Ward rounds generally start at 08:30-09:00 on CCU, although this varies depending on the specific consultant. You should aim to arrive 10-15 minutes before this time to prioritise quickly anyone who needs seeing by the consultant straight away and/or in which order. You will tend to be allocated to either CCU or PCCU for the week so you should head to the station you are on when you arrive. If you are on PCCU, it is a good idea to let the CCU juniors know that you are in so that they know that there is a junior on PCCU. However, it is better to meet the consultant first before they start their ward round, so that they are also aware that you are on PCCU. The ward rounds are a teaching opportunity and therefore we would like you to be present during most of the rounds, unless there are urgent jobs to be done on PCCU.
Board Rounds
We tend do a “board round” on CCU and PCCU before we start each ward round. This must include the nurse in charge and paramedical staff. Juniors should ideally see the patients prior to the consultant ward round and make plans to discuss with the consultant. If this is not possible due to a shortage of staff or time, all notes should be prepped including the latest blood results (especially kidney function results), early warning scores as well as weight changes. The latter is especially important for those in heart failure.
Most common referrals in cardiology:
- Respiratory – via DRAS on email
- Gastro – via Sunrise. Urgent GI bleeds – must bleep the registrar or consultant
- Haematology – via Sunrise
Outpatient Clinics
Junior doctors (non-registrar level) should try and attend a few OP clinics during your posting if there are adequate staff on the ward. You should all attend the catheter lab and see pacemaker implants and angiograms during your rotation. There are also opportunities to observe and perform echocardiograms under the supervision of the registrars which you should all try to practice especially if you are interested in a career in Cardiology.
If time permits, you could also attend some of the cardiac CT and MRI reporting sessions or even attend some angioplasty sessions at NXH with Drs Martins, Nadar or Banks. However, this should be done with prior agreement with your peers and ensure ward work is not compromised.
Work Allocation
Please work together. Each week, one of you will be on-call or post-on-call or on leave so the ward work needs dividing between you.
One person needs to cover CCU and in general the other juniors will cover PCCU. Rota for junior doctors is on the desktop in the ward Dr’s office (log in: pathology, password: pathology).
There should be a minimum of three doctors in total on the ward. If there are any issues with the rota this should be discussed with Dr Waidyanatha. Annual leave requests are usually dependent on there being adequate staff on the ward. Any requests should be made directly to Dr Waidyanatha. who will usually accommodate.
Handovers
The daytime on-call SpR and SHOs must handover the patients at 17.00; this normally occurs on the EAU to RMO2 (resident medical officer).
The most unwell patients on CCU and any outstanding jobs must be handed over to the RMO2.
Ward Notes
(There is no need to write SOAP in the notes!)
- Subjective: patient complains of etc..
- Objective: on examination etc. or ECG/CXR shows etc….
- Assessment/Impression: this is most important and should include working diagnosis or problem list
- Plan: also list changes to medication etc and if a drug is stopped why it is stopped.
For most major operations a 6/52 follow-up appointment is given (unless stated), or 8/52 for Mr Garnham at New Cross Hospital
For most limb bypass and EVAR operations an US/CT surveillance scan is needed before or at the first follow-up appointment (usually at 4/52, but check before booking)
- If the follow-up is at Russells Hall then book the scan on sunrise
- If the follow-up is at New Cross or Walsall Manor email the secretaries
Ward Work
- Check results on a daily basis – write these in the notes
- Complete outstanding VTE’s on patients- This is very important and is monitored trust-wide. Patients need VTE assessment on admission and at timely intervals that get highlighted when the patients notes are accessed.
- TTOs will need to be done for day-case and NXH patients
- Ward review record sheets to be completed for patients requiring ward reviews and placed in diary kept by the ward clerk on PCCU
- When patients are medically optimised for discharge, it is important to “TICK the relevant box”, otherwise these patients do not get highlighted to the discharge liaison team.
Death Certificates
Discuss all certification of death with the consultant in charge – again, it needs to be precise
“End-stage heart failure” must be secondary to e.g. Ischaemic heart disease or disease.
Do not use abbreviations for death certificates.
Communicating with Relatives
- Always check with patient first
- Document what was said or agreed, especially about prognosis and DNACPR
- If relatives are complaining or venting dissatisfaction then inform consultant and make them a further appointment
- Where conversations may be difficult or there is uncertainty about the reaction of a patient or relative to a topic of conversation, always consider the need for a chaperone (i.e. nurse/ other doctor) for support
- Seek senior support if you find that the conversation is going beyond what you are able to manage. Inform the patient and the family that you will get someone senior to answer their questions.
STEMIs
If an inpatient develops an ST elevation MI, urgent transfer to NXH must be arranged.
This is performed by ringing the ACS emergency phone line at NXH on: 01902 694339.
Nursing staff will also be required to contact ambulance services to urgently ‘blue light’ the patient over.
Teleologic Transfer System
Teleologic for Transfer to NXH
- Critical care escalation pathways for Cardiology (e.g STEMI or transfers to ITU) should be as per Trust guide lines and under supervision of on-call consultant/registrar in the department.
- As PCI is only available at NXH, therefore the majority of NSTEMIs admitted will require transfer for “cath ? proceed” shortly after admission and ideally within 72 hours
- This transfer is requested electronically via the ‘Teleologic’ system – log in details and instructions will be provided on your first day by the ward clerk.
- Most are for ACS patients needing cath ? proceed. We also use this system for transfers for CABG and valve repair/replacement work-up. This tends to be requested as “angiogram +/- PCI”.
- Sometimes a consultant may ask you to do a teleologic for a TAVI but it is important to ensure that a consultant to consultant discussion has taken place with a NXH consultant and that the patient is for an inpatient TAVI.
- If patients are having on-going chest pain with dynamic ECG changes, it is always necessary to contact the on-call registrar at New Cross to expedite the transfer as per the STEMI escalation pathway for primary reperfusion.
Access the site by going to the Intranet hub> links> Teleologic Inter-Hospital Transfer System, under the heading ‘Clinical Systems’
Cardiology Useful Information
Discharges
Put yourselves in the GP’s position and think about continuity of care.
- Make sure the diagnosis and management are accurate – use S.O.A.P
- Make sure the drug history is accurate
- Do not ask GPs to follow-up test results or make referrals – these must be chased by ourselves. A list of outstanding jobs to follow up should be maintained in a record by the team covering the ward and regularly handed over/refreshed each day.
- Make sure follow-up is mentioned
- Make sure all OP tests are booked before the patients leaves and followed up as required within the first 30 days of discharge according to the trust policy of safety netting.
- If there is uncertainty regarding a diagnosis (e.g. NSTEMI in patient admitted with decompensated CCF with small trop rise), always clarify exact diagnosis with the consultant before writing it on the TTO. This is imperative for MINAP audit data.
**Please make sure you complete TTO’s for day case patients and patients sent to New Cross**
Ward Reviews
Patients are asked to come back to be seen on the ward/CAU for review. We intend the junior doctors to fill a form out on discharge and place it in the diary for the day they are due to come back, it will then be filed in the ADhoc file for further reference and to serve as part of the audit trail. (Tammy or Elaine (ward clerks) have these forms)
Cardiology Day Ward
Please do brief TTOs: catheter angiograms findings/coronary intervention details(from NXH) or pacemaker reports need to be recorded clearly mentioning the procedure done and list medication started and any complications managed.
Gold Standard Framework (GSF) in Cardiology
The GSF is a structure that helps to facilitate the organization of care, including discharge from hospital, for patients considered for palliative treatment.
- Use the proactive ID guidance to spot patients who are palliative (last 12 months of life) and please discuss each patient on ward round daily
- All patients in the last year of life should be given the chance to have an Advanced care plan (these are in a box on CCU – ask the Sisters)
- If a patient is dying, please use the ‘Priorities for Care of the Dying Patient’ documents for communication
‘GREAT’ discharges for GSF patients
Extra care should be taken when writing discharge summaries for GSF patients. The mnemonic ‘GREAT’ serves as a prompt to help remember the key information to include in such discharge summaries:
- GP end of life register
- Ask GP to put on EOL (end of life) register if <12 months life expectancy
- Let GP know also if you have referred a complex patient to the Community Specialist Palliative Care Team
- Resus status
- Is a DNACPR form in place? Make sure that the form goes home with the patient & family/patient (with capacity) are aware. Ensure any decisions have been appropriately communicated
- End of life meds
- If patient is likely to die within the next 12 weeks patient must be discharged with anticipatory medications – pharmacy generally only supplies 10 ampoules of morphine and midazolam; any further requirement can then be met by the GP. End of life guidelines on the intranet give further advice on what to prescribe
- ACP (Advance care plan)
- ? In place or just discussed or booklet given to patient – either Advanced Statement document or ‘Priorities of Care’ document if patient is dying (both available to print from the Intranet)
- Any decisions about future management need to be documented & communicated to the community team
- Treatment Escalation plan
- Advise community team regarding ceiling of care. Would further hospital admission be beneficial or not? (However, do not just say “Do not readmit” as this will be seen by relatives and often complained about)
How to Request Tests
- Bloods
- Bloods are requested by you and you are responsible for checking the result each day and monitor those that are deranged.
- If specific tests are required e.g. haematinics, vasculitic screens, it is the doctor’s responsibility to make sure these are put out
- ECHO and exercise tests
- Via Sunrise – if they are urgent then discuss with the sonographers in the cardiology department
- Angiograms
- If inpatient, you must add the patient onto the cath lab list (speak to Paula in the cath lab) and discuss it directly with the on-call registrar to arrange
- Outpatient angiograms can be booked through the relevant consultant’s secretary. You can request this on Sunrise and document it in the discharge letter and the ward clerk will forward the needed details to the secretaries
- Stress Imaging (DSE & CMR perfusion)
- Via Sunrise, but discuss with consultant first.
- Imaging requests are frequently rejected due to lack of clinical details. Always ensure to write plenty of risk factors on the request
- For CMR stress perfusion imaging patient must avoid caffeine for 24 hours pre-test
Other advice
Sickness:
You must call both CoW and HR/Workforce and also let them know when you return.
Datix Incident Reporting:
Make sure you know how to do this and take consultant advice if needed before filling in. Do not use it to complain about a member of staff’s attitude or bad behaviour.
Study Leave and Annual Leave:
This is done via Dr Waidyanatha- You must give 6/52 notice and only 2 doctors off at the same time.
Cardiology Learning Opportunities
There are many opportunities to get cardiology-specific practical skills under guidance from seniors, including cardioversion (elective & emergency) & arterial line placement.
With prior discussion and provided there is adequate ward cover, attendance at clinic may also be arranged.
Grand Rounds are weekly on Thursdays between 1300-1400 in the education centre. These are lectures presented by different clinicians in the trust on useful and important topics.
Audits and Quality Improvement Projects
Dr Leventogiannis is audit lead and all proposals should be discussed with him.
Whilst the Trust clearly doesn’t want to suppress original and good ideas for audits, or even stop people completing portfolios, it does want to discourage a culture of “me too”, “tick box” audits and attempts to publish poor quality work. It is better to be involved in the rolling audits and understand the benefit of clinical audit than to never finish a good idea.
From a Trust point of view the bottom line is that audits relating to the national agenda and mandatory audits should be prioritised.
Rules for clinical audit projects in Cardiology are:
- It has to be done properly using explicit NICE or equivalent standards
- It has to be completed
- It then has to be presented and the audit report completed in a timely manner
- Lastly and importantly the monitoring of clinical outcome data, unless part of a change process, is not considered clinical audit. I would ask you to think about this last point in relation to any proposed project
Rules for clinical audit projects in Cardiology are:
- All clinical notes/continuation sheets must use the patient stickers
- You must put the date and time and your name in the margin
- You must sign and date entries legibly (use your GMC stamps)
VTE Audit
Need to check VTE forms first thing, as CoW will be getting emails from Sarah Hughes complaining at you for non-completion.
Research
The cardiology department encourages research and we have an active research portfolio. We have two research nurses supporting us at the moment. Dr Barr is responsible for most of the commercial research activities that are on-going in the department. If however, you wish to take part in any academic research activity and have ideas, please contact Dr Nadar who would be very happy to guide you on this.
Education Supervision
Allocation of clinical and educational supervisors is coordinated through the induction lead and educational supervisors are expected to meet their trainees within 2 weeks to set educational objectives for their placement.
All consultants are qualified educational supervisors and do ward based and OP based teaching daily.
You are welcome to come to any cardiology sessions. It is suggested that, to get the most out of the cardiology job and as a minimum you should:
- Revise ALS protocols: especially cardiac arrest and peri-arrest algorithms (tachy/bradyarrythmias)
- Read ECG made easy again
- Discuss interesting ECGs
- Read the Oxford handbook section on cardiology
- Ask questions on ward rounds.
- Read about interesting cases that you have seen on the ward
- Read about medications that you see being used
- Familiarise yourself with treatment protocols for heart failure and coronary artery disease
Other good books include:
- ECG in practice (9th Ed.), By Roger Hampton.
- Oxford Handbook of Cardiology
Health and Wellbeing
Staff that are happy and thriving in their working environment will inevitably have a more enjoyable experience in the workplace, contributing to the provision of excellent health care for all of our patients. The Dudley Group recognises our commitment to staff wellbeing in a variety of ways.
Select the link below to find out more how the Trust can support you.
