The Trust is located just beyond the M25, North West of Greater London and maintains outpatient Cardiology services at all 3 hospital sites in order to provide local service to local patients, however all acute and inpatient treatment is undertaken at the Watford General Hospital.
Interview
What are the sizes of your Cardiology Department and Hospital?
In March 2009 the phased movement of acute and emergency services from Hemel Hempstead General Hospital and St Albans City Hospital to the Watford General Hospital site was completed and West Hertfordshire Hospitals NHS Trust now boasts the largest Acute Admissions Unit (AAU) in the country. The Trust maintains outpatient Cardiology services at all 3 hospital sites in order to provide local service to local patients, however all acute and inpatient treatment is undertaken at the Watford General Hospital. Watford General Hospital has 2 Cardiac Catheter labs, along with a 12-bed gender-segregated day ward, 15 general Cardiology beds, a 17-bed CCU and 10-bed ICU.
What is the geographical intake area and population served by your hospital?
West Hertfordshire Hospitals NHS Trust serves a local population of approximately 550,000 and treats about 1 million patients per year.
How many staff, and what are their roles?
The Cardiology service has 9 Consultant Cardiologists and 2 Associate Specialists, 12 junior doctors including 4 Specialist Registrars, 23 Clinical Cardiac Physiologists and Cardiographers, 12 Cath Lab Nurses, 3 Cardiac Radiographers, 24 CCU staff and numerous secretarial, administrative and clerical-support staff.
The Clinical Lead of Cardiology, Dr Mike van der Watt, is joined by 8 other Consultant Cardiologists that together offer a broad range of specialties.
Types of Procedures and Tests
Our Cath Labs see a wide range of trans-catheter procedures including coronary angiography (femoral, brachial and radial access), PCI, PPCI, pressure-wire studies, IVUS, IABP insertion, basic and complex device implantation including ILRs, pacemakers, ICDs and CRT-P and CRT-D, as well as cardiac electrophysiology and ablation. We shall be introducing Rotablation procedures in the near future.
The Clinical Cardiac Physiology service offers 12-Lead ECGs, ambulatory BP and ECG application and analysis, physiologist led ETTs, RACPC, CPC, transthoracic echocardiography, TOE, DSE, contrast bubble studies, 3D echocardiography, and ILR, pacemaker, ICD, CRT-P, CRT-D follow up clinics and cardiac device remote viewing clinics.
What have been some of the challenges in setting it up your Primary Angioplasty Service?
We do offer a Primary PCI service between 08:30 and 16:30. Out of hours patients are taken directly to the Harefield Hospital or the Hammersmith Hospital. The process of setting up our Trust for this service has been very well managed by our Cath Lab Business Manager, Alison Robinson, and has therefore been very successful. We put great effort into the educational aspects of this service to ensure that the service could be introduced with minimal complication. This has enabled us a smooth delivery of these patients to the cath labs with minimal door to balloon time, and we have been able to ensure that protocols were in place for the use of new equipment on CCU and ICU – such as the IABP.
What new procedures/techniques have you implemented into the department recently?
In July 2009 West Herts Hospital started an EP service. The process of setting up the service was managed by Sophie Blackman, and Dr Anthony Nathan. We perform electrophysiology studies and RF and Cryo ablations for all arrhythmias currently with the exception of AF and VT.
West Herts has only 3 device specialist cardiac physiologists, but even so it is because of this small, yet incredibly efficient, robust and high-quality pacing service that it has been relatively easy to expand to include complex devices. West Hertfordshire NHS Trust was the leading pacemaker implant centre in England and Wales (per million population) in the 2007/08 National Devices Survey under the lead of Dr John Bayliss, and maintained a good position last year despite the process of consolidating services at the Watford General site. With the arrival of Dr Philip Moore we expanded our service to the implantation and management of complex cardiac devices.
At the 2009 HRC conference Dr Nathan was named as the Consultant with the highest rate of ICD implantations in the country, and West Herts was recognised as one of the leaders in the use of the CCAD database which provides data for the National Devices Agency.
Cardiac Device Remote Viewing is another new service offered to all ICD and CRT-D patients receiving their devices at West Herts. We feel this offers closer monitoring and management of the complex cardiac device patient whilst alleviating some of the pressure on the device clinics.
Our complex echo service continues to grow and we have recently gained a GE Vivid 9 echo machine in order to expand the stress echo service and to allow dyssynchrony assessments.
What are the benefits to patients attending your facility?
Whether patients are attending the Clinical Cardiac Physiology department, the Cath Labs, CCU or AAU they can expect to receive an excellent standard of care. West Hertfordshire Hospitals has the largest AAU in the country and the Cardiologists perform 2 ward rounds a day during the week, and one on each day of the weekend. This helps with the rapid diagnostic and therapeutic care of all cardiac patients at West Herts. Additionally West Herts was recently recognised as having the shortest length of stay for patients presenting with acute coronary syndromes compared to all other hospitals in the North West London Cardiac Network.
The cardiac procedures are Consultant delivered, so patients receive excellent treatment, and the training to SpRs and other disciplines is exceptional. All patients for the cath lab are pre-assessed so we have a very low rate of procedural cancellations, and we swab all patients at the pre-assessment for MRSA making the levels of MRSA in our Trust one of the best in the country. West Herts is one of the best performing Trusts in the country in regards to C.Diff and we meet national targets for 18-weeks.
It was in the redesign and restructure of the Cardiology department that we were able to review our entire facility to ensure that we offer patients a more holistic diagnostic and treatment service, and this ethos is certainly being felt by our staff and patients alike.
What kind of training can new employees expect to receive?
Training among the different disciplines varies. As previously mentioned the Cath Lab staff are able to receive a lot of educational training in the labs as all cases are Consultant delivered. We hold daily lunchtime multi-disciplinary team meetings to discuss and plan cases and these are excellent for making sure our service is cohesive and evidence based. A lot of consideration has been put into the training of the Clinical Cardiac Physiologists and Cardiographers. Sophie Blackman, our Head of Clinical Cardiac Physiology is undertaking a project that uses confidence score rating to establish areas where training needs to be given to the individual and this is then specifically tailored, and she aims to implement these training programs this year.
Additionally, great effort is made to ensure Cardiology training is offered to other medical disciplines to help encourage better referral patterns and to streamline services.
What kind of competency checks do staff have to undergo once employed?
We have been able, in the process of the merger, to review the competency of staff, and in the lab we are about to embark on a process of assessing all staff in the set-up, calibration and use of equipment.
In Clinical Cardiac Physiology Sophie’s physiologists are all currently RCCP registered, or awaiting their RCCP number. Cardiographers are undertaking a 12-module ECG application and interpretation in-house training course that will guide them to their SCST Part 1 exams. All staff working in Clinical Cardiac Physiology will be assessed by work-based assessors in the areas within which they work to demonstrate competency and to encourage an ethos of training, development and evidence based practice. As the Head of Clinical Cardiac Physiology is an examiner for the SCST all physiology staff are regularly assessed to ensure that they provide exceptional working standards.
All the physiologist working in echocardiography have BSE accreditation and the device physiologists are IBHRE or HRUK accredited.
What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit?
Dr David Hackett, our lead Consultant for the Cardiac Catheter Labs was one of the first Consultants to question the role of reps within the lab, and in his capacity of Vice President of BC he wrote the BSC guidelines on this.
He insisted that the role of the rep in the lab should be exclusively to contribute a positive technical or clinical input into the patient management. Sales staff cannot be influential in the decisions that are made by clinicians.
Our policy is strict in that reps can come to our lunchtime MDT meetings , provide food, and present a lecture on a product or service they offer, but they are not permitted to be present when the clinical element of the meeting begins. . Additionally reps can only be seen at a scheduled appointment time, as ‘dropping-in’ has been found to be disruptive to the working schedule.
What is the best part of working at your facility?
I think that different staff groups would answer this in a variety of ways; however, the general feel of our department is that we always work to the best interest of the patient. We do not perform unnecessary test or procedures, and our team is very close. As all procedures are Consultant delivered we know that patients receive an excellent standard of care and therefore we try to match this with excellent diagnostics and technical expertise.
We encourage an ethos of multi-disciplinary decision making, and this all-staff inclusion in decision making and care pathways means that the whole team believe in the strategy. This creates compliance and opportunities for staff of all disciplines to have an input and an opinion, as well as promoting a good-natured and enjoyable atmosphere within the department. Essentially we respect each other, and this really does create a cohesive unit where the most excellent patient care can be delivered.
