Black Country CHD Collaborative

West Midlands Cardiac Rehabilitation Unit - home page

News 2004

Walsall Trust (now the PCT) was fortunate to be given funding to develop one of the first phases of the CHD Collaborative. Suzanne Ursell, Manager at Heart Care was Project Manger and Mark Walsh, Advanced Nurse Practitioner in CHD at the Manor Hospital was Clinical Lead for the cardiac rehabilitation project within the local Black Country CHD Collaborative.

Our main statement was, and still is, to provide a complete cardiac rehabilitation service that is widely accessed, and that is tailored to meet the individual CHD patient's assessed social, psychological and physical needs. Within this we aim to improve support to patients pre-surgery, those with heart failure and those suffering from stable angina.

The work that has been implemented has been beneficial to those using the service and also to those working within the service, with communication and liaison being paramount between the different agencies. The liaison, particularly, between Heart Care and the Manor Hospital and Community Services has developed considerably, and we feel that we are able to provide a more comprehensive service from Phase 1 rehabilitation, within the Hospital, to Phase IV, either after care at the Heart Care Units at Walsall or Streetly, or in the Community within Leisure Services.

What we have achieved so far

  1. The appointment of a CHD pathway co-ordinator has allowed the team to look at every aspect of the patient journey, to include those patients who have stable angina, who have been referred to tertiary centres for surgical procedures, those who are awaiting surgery, heart failure patients and those patients who do not attend at any stage of the programme. All referral pathways are now in place and are being constantly reviewed.
  2. MI (heart attack) patients are now given one appointment card instead of 4 different letters detailing all their appointments such as outpatients, exercise test, Heart Care.
  3. MI patients are given an appointment for Heart Care prior to discharge from hospital
  4. MI patients are given a pre-introductory sheet prior to their interview at the hospital, outlining the issues to be discussed and encouraging family members also to be present
  5. All MI patients are contacted within 7 days following discharge by the Community Cardiac Nurses
  6. Raised the aware of cardiac rehabilitation for stable angina patients
  7. Direct angina referrals to Heart Care from Consultant Cardiologists as appropriate
  8. Developed better communication with GPs advising of patients assessment on completion of structured rehabilitation course (Heart Care) or advising of problems/failure to complete
  9. Established links with the Leisure and Community Services team to widen the Phase IV rehabilitation services on offer.
  10. Established better links and paperwork with our main Tertiary Centre, Walsgrave who refer direct to Heart Care following surgery, in order that patients can be tracked more easily.
  11. Looking at the best way to give and provide advise and at the 'right' time for the patient and carer. This is an on-going project across all areas of patient care. We have produced a new Hospital booklet and folder.
  12. Established an exit questionnaire at the end of the Heart Care 13 week programme to monitor and action any comments patients have on the service provision
  13. Developed links and referral systems with GPs in order that they refer appropriate patients, particularly stable angina patients to our new after care angina service
  14. Established a rolling educational programme which can be undertaken by all patients even if they are unable to attend the exercise programme at Heart Care - in all aspects carers are encouraged to attend
  15. Provision of a 'fit for surgery' programme. We are providing educational talks to those patients awaiting surgery and if suitable offering them an exercise programme as well.
  16. Provision of a service for heart failure patients within the structured programme
  17. Provision of CPR training to patients and carers

Areas we are still looking to develop

  1. Developing the Community service for those patients unable to attend the structured programme at Heart Care and involving other Community professional groups
  2. To develop links with other Tertiary Centres who could refer direct to Heart Care - this is particularly important if patients are able to be given a choice of where to have their surgery undertaken. We are particularly working closely with staff who are involved in the setting up of the new Heart and Lung Centre in Wolverhampton to ensure that patients receive relevant information and are referred to the appropriate rehabilitation unit.
  3. Need to develop further information at the 'right' time for carers.

Although Phase 1 of the collaborative has been completed, both myself, and Mark Walsh are continuing to review, with the support of our teams, the service given to all cardiac patients, and strive to improve the service making changes as necessary.

We are conscious that there are many other areas we could look at and would appreciate any comments patients or carers may have on the service from Phase 1 in hospital to Phase IV out in the community. We will look at all comments and try and act accordingly to give you the best service we are able to offer.

In my continuing role within the Collaborative I am networking ideas and 'best practices' and working with Dudley and Wolverhampton to enable all patients within the Black Country to receive excellent service whichever cardiac rehabilitation service they are referred into.

Suzanne Ursell
Manager Heart Care/Project Manager Cardiac Rehabilitation

Registered Charity Number 1109021

Walsall Cardiac Rehabilitation Trust - 12 Portland Street
Walsall - West Midlands - WS2 8AB
Telephone - +44 01922 725050 | Fax - 01922 659157
Email - heartcare@walsall.nhs.us