Arrhythmia screening: who is in charge?

Your GP, or 'Primary care Physician', is your first point of call.

Whether you have palpitation or have picked up an erratic pulse and are concerned that you may have a heart condition, the GP should be your first point of call. This is because in most cases your GP can diagnose the problem and arrange investigations and treatment where necessary, without the need for specialist referral.  

Although many patients think that their palpitation always requires referral to a hospital specialist, in our experience this is seldom necessary. Your GP has the necessary medical training to spot any 'red flags' or warning signs indicating that you may have a more serious medical problem requiring referral to a specialist for further investigation and expert opinion.  

Your GP may however ask for an expert opinion or more sophisticated testing under certain circumstances such as:

  1. A persistent racing heart where the rate exceeds 150 beats per minute- usually via A&E referral for immediate assessment and treatment.
  2. Short (less than 10 minutes) episodes of terrifically fast heart rate occurring at rest without provocation- especially if associated with breathlessness, chest pains or dimming or actual loss of consciousness.
  3. Where the symptoms are associated with abnormalities on your 12 lead ECG.
  4. Where other red flags are present such as other medical conditions or a significant family history.
  5. Where symptoms remain troublesome after trying our various remedies (including medication such as beta blockers).
The first of these presentations would normally require immediate hospital assessment but the other categories are usually managed with a referral to the local hospital Cardiologist for consideration of outpatient assessment and investigation. 
 

How is referral to the Hospital Cardiologist triaged?

Every GP referral received at the local Hospital is assessed by the cardiologist and 'triaged' for clinical urgency.  Unfortunately there is insufficient capacity in our NHS Cardiology outpatients for all referrals marked 'urgent' to be actually seen 'urgently' so that Cardiologist will usually only offer urgent appointment where there are clinical concerns about safety. All remaining referrals are deemed to be 'less urgent' and therefore will have a longer waiting time (upto 12 weeks) for outpatient assessment.  In many cases however the Cardiologist will request that some investigations are conducted while waiting for the appointment, based on the details given in the GP referral letter. If such investigations show up important abnormalities (such as very fast or slow heart rates) these can be relayed to the GP and patient and appropriate action taken before the actual Consultation.

It is important to realise that until the patient has seen the Cardiologist, responsibility for overall clinical care remains with the GP, so that if the symptoms get worse or change, it is therefore reasonable to contact your GP in the first instance. If this occurs at night or over the weekend, this responsibility is passed to the out of hours GP service - normally contacted through the same telephone number as your GP.

In the event of severe symptoms- for example a racing erratic pulse which develops for > 15 minutes you should consider calling the emergency medical service on '111' (or '999' in event of collapse or associated severe symptoms such as chest pain).

A new and erratic heart rhythm lasting>24 hours may be caused by atrial fibrillation and is in itself a condition that requires emergency assessment because if not treated with anticoagulants a clot can develop that can cause a stroke.

Acute General Consultant Physicians and Clinical Cardiologists conduct emergency ward rounds at our local NHS Hospitals 365 days of the year, which gives excellent and timely access to specialist care in the event of serious escalation of symptoms.

HASTE Network in Guildford and Surrey (HASTENinGS) screening service.

A new ambulatory ECG service has been set up in 2013 with the assistance of a local charity (HASTE) to help GPs obtain more accurate diagnosis of patients in a difficult 'grey area' - where the GP considers that the symptoms are not of sufficient concern to refer for a specialist Cardiology opinion, but where the diagnosis is uncertain or perhaps lies between a common benign medical condition called 'benign ectopic beats' and other conditions that require specialist input such as 'paroxysmal atrial fibrillation'. Many GPs are reluctant to increase the burden of referrals on our already over booked NHS Cardiology clinics without cause for concern and thus would be unlikely to make a formal referral unless there are bothersome symptoms or tangible evidence of a genuine heart condition. The referral criteria for our service have now been changed to include anyone over 40 years of age who has suspected paroxysmal atrial fibrillation or cardiac arrhythmia.

Typically, patients may complain of short periods (seconds or minutes) or rapid or irregular heart beating, or may have no symptoms at all- but have noticed their pulse is erratic- either at the wrist (see pulse check campaign) or on a heart rate or blood pressure monitor.  These lesser symptoms may be the only outward sign of an important medical condition that can eventually lead to a stroke, it is important not to miss the diagnosis.  Because symptoms are usually mild, they fall below the level that would normally be referred to the local hospital for a specialist opinion, yet ideally should be investigated by a 7 day ambulatory ECG recorder, which is a test that has not traditionally been available to GPs directly until now.

Following the establishment of the Haste Academy in 2013 we launched  a new 7 day ambulatory ECG recorder screening service to help identify high risk patients. The service has been set up and is operated by the HASTE Arrhythmia team who are part of the Cardiology department and are employed by the Royal Surrey County Hospital.

The team are funded for two years (2013-2015) and have an office base in the HASTE Academy office in the Guildford Research Park and the service is overseen/ supervised by Consultant Cardiologist (Dr Leatham) and other local Cardiologists. 

Once referred a patient by a GP, the HASTENinGS team will get in touch with the patient within a few days in order to perform a more accurate triage by telephone. If appropriate an appointment will then be made at a local GP Surgery for a 7 day ambulatory ECG recorder to be fitted. The device will be removed after a week and analysed by the arrhythmia team - comprising specialist nurses and Consultant  Cardiologist who will then send a report and the recording to the GP.  Where Where definite abnormalities requiring Cardiology input are found, the results are also forwarded to the NHS Cardiology department at the Royal Surrey County Hospital so that an appointment can be made for NHS outpatient specialist Consultation. This process, as mentioned above, can take 12 weeks in non urgent cases

If symptoms deteriorate the GP should be contacted who can then decide whether medication  or escalation in priority of appointment are required.

The Haste team's role is to fit and analyse the 7 Day ECG and our arrhythmia team are thus not in a position to provide diagnosis or treatment to patients seen in the HASTENinGS screening project. 

Associated Research Project

As well as providing a screening service, the Haste team are conducting clinical research into improved methods for detecting intermittent arrhythmia. This research project is sponsored by the University of Surrey/Cardiology department of the Royal Surrey County Hospital, and funded by local charities HASTE and HASTE ACADEMY.

Selected patients referred to the HASTENinGS screening service will be approached to take part and, if recruited and consent obtained, will be equipped with a personal heart rhythm recorder for up to three months. The research aims to compare the results with the gold standard which is currently a 7 day ECG recorder. See our research pages for more information.

Responsibilities and complaints procedure

As with all clinical services, despite our best efforts, things can go wrong or expectations not met.

The Haste team have a clearly set out responsibilities as follows:

  1. Receive and acknowledge GP referrals within 2 working days.
  2. Make telephone contact with patient referred for a 7 day ECG within 5 working days.
  3. Fit and analyse a 7 day ambulatory ECG within 6 weeks of referral (in most cases within 3 weeks).
  4. Send a written Cardiologist report to the referring GP within 14 days of the test being completed.
  5. Notify patient and GP if the test shows abnormalities requiring onward referring to Cardiologist
  6. Notify patient and GP if the test shows abnormalities requiring urgent treatment via the GP while awaiting a Cardiology appointment.
  7. Send a copy of the 7 day recorder result to the patient if requested (by email or post).

If any of these duties are not met or fall below standard or you wish to complain please let us know by contacting us at:

Haste Academy Administration
Email Admin@hasteacademy.org

We appreciate both negative and positive feedback about our screening service.

Please note that the Haste team cannot take direct clinical responsibilty for patients or offer clinical advice or treatment- since this role lies with the referring GP or Cardiology department (in cases referred on to the hospital).

Although the Haste team are all employed by the Royal Surrey County Hospital, the screening service known as HASTENinGS is operated by HASTE MEDICAL/ACADEMY and so all comments and enquiries about the screening service should be directed to HASTE ACADEMY rather than  Royal Surrey County Hospital.

 


 

Research Study

If you are participating in the research study and  have any questions or concerns about the research please contact the research Nurse or Physician on 

Email Admin@hasteacademy.org
 
If you have a concern about any aspect of the research study you should ask to speak to the researchers who will do their best to resolve any problems (please contact Dr Philippa Howlett: phowlet@hasteacademy.org or 0203 239 8985). If, despite this, you wish to complain formally, you can do this through the NHS Complaints Procedure.

The contact details are for the Royal Surrey County Hospital are as follows:  rsc-tr.Complaints@nhs.net.

Royal Surrey County Hospital referrals

Where patients have undergone screening and certain abnormalities are found that are considered to be good reasons for specialist referral, providing the GP has agreed a referral can be made directly to the Cardiology department at the Royal Surrey County Hospital.   In our experience so far this constitutes about 30% of all patients screened.

The referral will be examined by the Cardiologist and triaged according to risk and appointment offered. Where the referral is considered to be low priority an appointment may take 3 months- in contrast when deemed clinically urgent it may be the same week. This is the only practical way of the NHS Cardiology department coping with a fixed capacity in the face of rising demand. 

In cases where a patient is not satisfied with the waiting time and is concerned about worsening symptoms the GP should be contacted - since neither the PALS department at Hospital nor the HASTE team have the power to arrange earlier appointments at the Royal Surrey County Hospital.

The GP remains in clinical charge of the patient until seen by the Cardiologist. If the GP thinks that the appointment should be expedited then he/she can contact the Cardiologist to request advice - which under some circumstances will lead to an earlier appointment or treatment being offered before outpatient clinical assessment.

Clinical Service Complaints

Until a patient has been seen by the Cardiologist or a test has been done at the Royal Surrey County Hospital, any complaints about the referral or medical care should be directed to the GP Surgery (usually via Practice Manager or GP).

However once seen at RSCH, if there are Hospital service issues causing disatisfaction then the Cardiology Secretaries at the Hospital should be contacted.

If this does not produce results then the issue can be escalated via the Hospital PALS or ultimately by writing the CEO of the Royal Surrey County Hospital. The Hospitals compaints and compliments page displays the contact information and how to go about this.

The contact email for the Royal Surrey County Hospital complaints department is rsc-tr.Complaints@nhs.net

Related Stories and Downloads

This article as a PDF for printing
HASTENinGS in Surrey

 




Written by

user_avatar
Edward Leatham is a Consultant Cardiologist in Surrey and a Trustee of Haste and Haste Academy.

Responses

You must be logged in to leave a reply. Login »