Just as “It takes a village to raise a child,” the team at Markham Stouffville Hospital believes it takes a community to ensure good long-term cardiac health, including an evolving and growing role for local community hospitals.
“The way cardiac care is delivered in our community is changing,” says Julia Scott, Vice President, Clinical Programs and Chief Nursing Executive, Markham Stouffville Hospital. “With a focus on early intervention for Acute Coronary Syndromes (ACS), patients with ST-elevation myocardial infarctions are transferred by ambulance directly to a regional cardiac centre.”
This has left non-interventional community hospitals pondering their role in cardiac care and, at Markham Stouffville Hospital, this has meant opportunities to change and improve local cardiac programs.
Markham Stouffville Hospital is a 220 bed community teaching hospital located north east of Toronto that services a growing multicultural population of 330,000 residents. Patients who come to the hospital with ACS are transferred 40 kilometres north to the regional cardiac centre for invasive cardiac diagnostics, emergent and urgent catheter-based coronary intervention, as well as cardiac surgery. Once these services are completed, patients return to Markham Stouffville Hospital for ongoing care, continuing education and lifestyle modification guidance, and most importantly for ongoing cardiac management over time.
Markham Stouffville Hospital opened one of the first 24-7 Enhanced Cardiac Care Units in Canada in April of this year. It is a three-bed unit with defined admission criteria and a one-to-three nurse to patient ratio where cardiac patients receive enhanced, non-critical level cardiac care while waiting for early intervention or recovering from their advanced cardiac procedures.
“This unit provides a great service to our community and reaffirms that there is a strong need for cardiac programs in community hospitals,” says Dr. Joseph Minkowitz, Lead Cardiologist, Markham Stouffville Hospital. “We are able to work in partnership with the regional cardiac centre to ensure our patients receive the care they need, in the right place at the right time.”
For cardiac patients, the new unit means that they can receive the majority of care from their community hospital.
“The unit focuses on patient preparation, medical optimization, and patient education with an interprofessional approach. Patients are seen and treated by in-house cardiologists in collaboration with a cardiac nurse practitioner,” explains Sevi Cesta, Clinical Manager, Medicine and Telemetry.
The nurse practitioner manages inpatient care and also links patients and their families with appropriate services as they prepare for discharge.The patients are cared for by registered nurses who have received more than 20 hours of additional advanced cardiac education and are supported by a professional practice leader and an advanced practice nurse specializing in cardiac care and teaching.
“The team in our Enhanced Cardiac Care Unit brings together a tremendous amount of knowledge,” says Dr. Minkowitz. “By having physicians, nurse practitioners, registered nurses and other interprofessional team members working together, we are able to provide patients with excellent cardiac care and support for transitioning home.”
A new first of its kind cardiac clinic also supports the outpatient cardiac care provided at Markham Stouffville Hospital. It offers cardiac care to two broad groups. The first group encompasses low to moderate risk chest pain patients and offers an outpatient option for semi-urgent cardiac investigation.
Traditionally, patients who were seen in the emergency department with chest pain were kept for six to eight hours to rule out ACS. Then, they were either discharged home to wait several weeks for an in-office cardiology consultation, or they were admitted to hospital to have a more urgent and resource intensive cardiac assessment. Now at Markham Stouffville Hospital, once ACS is ruled out they are discharged home and are offered an outpatient clinic appointment within 72 hours. All patient referrals are triaged by the nurse practitioner, with more urgent patients seen within one to two days.
Patients referred to this clinic are comprehensively assessed by the nurse practitioner, appropriate diagnostics are done and interpreted, and then patients are reviewed and seen by the cardiologist or cardiac specialist. Some of the patients are low risk patients and can leave the clinic reassured that a cardiac cause for their chest pain has been ruled out. Others are moderate risk patients who are assessed and have no current evidence of significant coronary artery disease but have significant risk factors for developing the disease such as, for example, diabetes and/or active smoking. They are coached with respect to their risk factors and are given information about lifestyle modification and/or links with community services such as the diabetes education centre or stroke prevention clinic, both located at the hospital. Another 20 to 25 per cent of patients referred to the clinic have higher risk features or positive initial diagnostic results. These patients are then scheduled to have a more invasive diagnostic angiogram and may require semi-urgent percutaneous coronary intervention (PCI) or bypass surgery.
Another category of patients seen in the cardiac clinic are those who live in the Markham Stouffville Hospital catchment area, but who are originally treated at a regional cardiac centre. Those patients are discharged back into their community because there are able to be seen in the Markham Stouffville Hospital cardiac clinic within 48 to 72 hours of being discharged.
“In the past, those patients may have been transferred back to our hospital and put into an inpatient bed,” says Dr. Minkowitz. “We know that they don’t need that level of care or monitoring and that their needs can be met by our cardiac clinic.” The patients are connected with the hospital’s cardiology group and are assessed, educated and treated by the nurse practitioner and cardiologist/cardiac specialist.
“The ‘hub’ for cardiac care is no longer found in one specific building in an inpatient setting. Rather, the patient is the central hub with appropriate services and programs collaboratively delivering care to them,” explains Scott. “There is indeed a role for community hospitals in the provision of cardiac care to ACS patients. We screen, admit, stabilize, transfer, accept repatriated patients, and we coordinate services close to home to ensure that all patients are connected with appropriate professionals, technologies and follow-up to ensure ongoing positive patient outcomes.”