The Liverpool Heart and Chest Hospital NHS Trust would like to thank the OLVG Hospital in Amsterdam for their inspiration and assistance in developing this concept, and helping to implement the idea into the UK.

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Dr Rod Stables, Consultant Interventional Cardiologist, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK

What is the Amsterdam Project?

The Amsterdam project is our attempt to run a pilot study to see if we can employ their ideas for cardiac day care in our environment.  They have for some time now managed day care patients in a completely different ward type environment which they model on the business class lounge employed by airlines in the major airports, where patients rather than being constrained to a particular bed or geographical area can move freely in their own clothes around a variety of settings, which would include for example quiet areas for reading, television channel areas, internet stations to check email or browse the internet, and also an area for free association around a dining table with food and drink.

So we took over what used to be the day room of our day ward, had it redecorated, bought some new furniture, based closely on what we observed when we visited the OLVG Hospital in Amsterdam, and we have run it on a limited scale for five patients a day since then.

When did you first hear about the Amsterdam Project?

I heard about it in a presentation by one of their consultants which was given at a UK meeting focussing on radial access, because of course the radial approach to coronary work is pretty much essential for the successful nature of this project, so the patients can remain ambulant and in their own clothes throughout.  I was very impressed by the presentation, and we arranged a visit, they were very kind, they showed us the basics for the idea, and we were able to move from there.

What do you see are the advantages for the patients, cardiologists, and department in general?

From a patients point of view there is a greater sense of comfort and freedom, in that they are not tied to one particular location, or forced to rest either in a bed or in a chair by the side of that bed.  They can move freely, they can eat and drink when they wish, they can remain in their own clothes, they hopefully would be able to enjoy the facilities, be it food and drink, be it television, be it internet, and have a much more comfortable stay. 

Experience from Amsterdam suggest the patients managed in this way remain for more relaxed, and they have noticed a reduction in anxiety, tension, and sometimes things in the cath lab like vagal reactions can be reduced because of an improved general environment.

What are the restrictions on patient’s clothing?

It is still a subject of debate, and we do need to continue to refine. At the moment we ask patients to wear a single layer of clothing on the upper body.  We ask it to be short sleeved.  We ask for it not to be a particularly high value or highly prized item incase it ever becomes contaminated by cleaning fluid or blood, or in an extremely rare event need to be cut or ripped. Obviously for female patients there is the question about use of bras.  And underwire bras, or bras with prominent metal hooks are also potentially not a good idea as they will show on the x-ray imaging, so that creates a slightly additional limitation. 

What have been some of the challenges faced getting it working?

For many it seems like a radical idea, though we are very fortunate in the experience at OLVG was so positive and they have collected very well kept data on large numbers of patients showing the broad safety and acceptability of the procedure.

It seems a bit of a culture shock for a patient to arrive in the cath lab areas in their normal clothes and to hop on the cath lab table.  Dealing with that radical change, and how it is perceived by some. Obviously many people, myself included have often held thoughts that perhaps it is better to have immediate availability to the chest for defibrillation or maybe the groin for temporary wires or balloon pumps, but then the Amsterdam experience suggests that you may need to experience that need about once every 3500 patients. And this means of course that 3499 will benefit from the experience, for every one that might be marginally inconvenienced.  And in times of true need access can always be obtained with only momentarily additional delay. 

Has Infection Control been an issue?

The Amsterdam experience would suggest it is not an issue. Obviously time will tell whether we experience a surge or a change in infection rates, but in truth in a day case, cardiac coronary, and intervention environment, infection is not really a major problem.

Has it improved patient throughput in the labs?

We have always been a big volume radial center, with overwhelming majority of procedures performed radially.  We are also well embedded in the day case concept, with more than 80% elective coronary interventions being day case, so perhaps in truth I don’t think it has had a massive effect on our turnover, but patients do remain ambulant, they tend to walk to the lab, and their will be some marginal gains there.

Are there any other departments in the UK looking at this?

I am sure there are many. We are actually going to host a visit from Belfast next week who are going to inspect the facilities. The new cardiology lead at Kings College (London), who has moved there from the OLVG in London I believe, will have the idea in mind.  I am sure it will become increasingly commonplace over the next 3-5 years.

Would you say it has been a success?

We will judge that more efficiently based on patient satisfaction surveys which are being collated at the moment. We will also be looking at other statistics like how frequently are we able to fill the five available slots. Because not every patient is necessarily ideally suited or desire entry into the lounge environment. How frequently a patient who is initially allocated the lounge subsequently needs to go to a more traditional bed area. But on the basis of general perception, word of mouth report, so far it looks really rather good.

Any major improvements you have worked out?

At the moment because this is a pilot project we have started extremely small, and our geographical space for the area is really pretty limited. And as such we are currently missing one key facet of the provision in Amsterdam, which is an area where patients if they so wish to relax in a recumbent, almost lying position. Now in Amsterdam they have beautifully sculpted, trendy chairs with the potential for electronic massage, but we don’t have anything of that type.  But I know for a fact that one or two patients may feel particularly after their procedure the ability to stretch out, take their weight off their feet might be a big bonus.  But if the project is a success and we move to a bigger open area that would be on our list of developments. 

I noticed that patients can have drinks and biscuits before their procedure. This is generally considered not to be the best. What are your thoughts on that?

Well I agree, but there has been an evolution on this over the years.  But even in this centre we have moved from a strict nil by mouth, to a shortage duration of nil by mouth, to free fluids as long as they are clear, and now eventually we have taken the final step to no restriction. Again based on the experience and philosophy of the Amsterdam model. Clearly it could in theory be a problem for a very small number of patients but we have to weight that against the benefits derived by the vast majority in terms of patient comfort, acceptability, overall experience. But also a patient who is adequately hydrated and not hungry is far more likely to represent a better haemodynamic state in the cath lab.  

Linda Chedotal, Senior Sister - Day Ward, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK

Please explain more about the Amsterdam project from a Day Ward perspective?

We really wanted to move things forward for the patient and for their experience, so when we visited Amsterdam we found they had quite a large lounge area, however we didn’t have the same space here so we had to scale it down quite a bit. It was quite a different experience seeing patients in their clothes going off into the labs combined with eating and drinking which is not our normal procedure.

In Amsterdam they said they had no problems post procedure because the patients come in all relaxed due to the relaxed atmosphere. They said they had only had one cardiac arrest in two years.

They had another area as well where there were massage loungers, which we obviously don’t have. It was quite funny watching patients pick their handbags up and trot off to the cath lab, whereas we generally strip them of everything and put them in a gown.

In regards to the lounge design we also looked at the chairs to ensure they were made from an anti-microbial material. We also looked at different colour schemes and lighting so it would be the most relaxing for the patient.

We have a computer in there that is solely for the patient’s use, which being in the NHS is a challenge to achieve due to restricted access. So the patients can go on the internet, but they can’t go on our hospital intranet and access any patient details. So if they want to use the internet for business or relaxation they can.

We also have newspapers and magazines delivered, and we have put a table and chairs in there which some patients like to use to eat at as well. Because we have a Nightingale type ward, we don’t have a table and chairs available so patients have to eat at their bedside, so again it is another social environment for patients as well.

Clinical Assessment and Nursing Care:

We have two clinical assessment rooms we can take the patients into if there is anything clinical to do, so when we admit them we take them into there so it doesn’t disturb the atmosphere in the lounge, and if we are doing the cardiac rehabilitation chat post procedure we also take them in there.

But it wasn’t just changing the environment for the patient, it also made us challenge how we nurse the patient post procedure. Normally we would do an ECG post procedure, but they have just come off the cath lab table where they have been looking at the ECG. So we challenged if we really need to do this post procedure ECG; so we have stopped doing that. We haven’t got to the point of giving patients food pre procedure, but we hope to move towards that, but it is also about getting consultants used to it because it has always been done the other way.

We also usually do half hour observations, but generally if there is something wrong or the patient is unwell you don’t pick it up from the observations, you generally pick it up visually or the patient is complaining of pain or feeling unwell. So we challenged that, so now we do a set of observations when they come back from the lab, and we do one before they go home, so the patients experience is a lot more relaxed.

Because it is a small area we can only accommodate 5 patients, and we allow them to have one visitor with them, but we try and restrict it because of the area. We would like eventually to have a much larger area and have it on a much bigger scale, particularly with the computers, because in Amsterdam they had several arranged in a circle, so a lot more patients could use it at the same time. But because it is a trial at the moment it is still evolving.