Cardiac Rehab Survey

1. Cardiac Rehab Survey Cliona McCormack 12th October 2013, Hilton - Kilmainham

2. Presentation Introduction to survey Findings • Cardiac rehab patients • Waiting times • Phase 3 rehab • Follow-on care • Staffing • Challenges for cardiac rehab

3. Survey Sample • Cardiac rehab co-ordinators (or equivalent) in 37 services. Responses from 36 services. • Details of service in March 2013. Aims • Current level of service provided by cardiac rehab teams. • Differences in resources available to individual services. • Demonstrate any recent cutbacks in staff and service provision. Overview of patient numbers, staffing, waiting lists, equipment and follow-on care for patients. Details of services and perceptions of co-ordinators.

4. Cardiac rehab patients

5. 500 patient increase in 2012

6. Eligible patients • All services (36) MI; CABG; PCI; or valve replacement • Other eligible patients included those with ICD (35); pacemakers (35); stable angina (34); heart failure (31) and following cardiac transplant (30). Referral process • 35 services received referrals from cardiologists; coronary unit nurses; and other hospitals. • 32 services take referrals as a result of patient or family enquiries with all of these requiring a referral letter. • Only 13 services operate a system of automatic referral.

7. Gender breakdown All phases have a majority of male patients. Gender – phases 1 & 3

9. Private Health Insurance • 20 responding hospitals with mix of private and public patients.

10. Waiting times

11. Waiting times • The majority of services (24) contacted patients within 4 weeks of referral. • Significant waiting list nationally. • 1,824 patients on waiting list in March 2013 (36 services). • Largest single waiting list was over 300. • Waiting times for entry to a phase 3 programme varied significantly between services. • Patients in 15 services waited for 1-3 months • Patients in 10 services waited 4-6 months. • A single service had a waiting list of 6 months.

12. Time to first contact following referral

13. Waiting time for phase 3

15. Phase 3 rehab

16. Length of phase 3 programme

17. Patient access to cardiac rehab • Cardiac rehab reduces the risk of cardiac mortality by 26%. • Yet, only 7 services believe that 80-100% of their eligible patients take up phase 3 cardiac rehab.

19. Reasons for non-attendance • Patients choosing not to attend • Patients living too far from the service • Employment issues • Co-morbidities mean patient is unsuitable • Patient not aware of the benefits of rehab • Family / caring commitments

20. Phase 3 completion rates

21. Follow-on care

22. Follow-on care after Ph3 “I would like to get involved in running a support group but due to the huge workload and numbers waiting for service it has not been sorted.”

23. Outreach programme • 6 services provide an outreach programme. 1 service closed its outreach in 2009 due to staff shortages. • 14 services felt that the lack of an outreach service limited the ability of patients to attend their service. “We did a pilot phase 3 programme in a health centre off-site nearer to patients - this went very well. We have been unable to run a further programme.”

24. Staffing

25. Staffing • No cardiac rehab service had all the members of the multidisciplinary team required for the goals of cardiac rehab to be met, as set out in the IACR guidelines. • Medical director • Rehab co-ordinator • Social worker • Psychologist • Occupational therapist • Physiotherapist • Pharmacist • Nursing • Dietician + administrative support

26. Multidisciplinary team members

28. 20 services missing 4 or more team members (incl. secretarial)

29. Variation in hours Relatively good access Poor access Only 9 services have access to a psychologist. 1 FTE 1 x 4 days per wk 3 PT; 1 x 4 hrs per wk 1x 3 hrs per mth 1 x hr per mth 1 x hr per group 8 services have OT (2 goodwill basis) 1 FTE 5 PT 1 x 1 hr every 2 mths • 34 services have rehab co-ordinators • 2 more than one FTE • 30 FTE • 2 PT • 26 services have additional nursing staff • 3 had more than one nurse • 9 WTE • 13 less than FTE

30. Transfer of nursing staff • Coronary care units in (5); general wards (5); ad hoc duties (4). Also A&E; angio day ward; HF services; and surgical wards.

31. Reasons for all staff cutbacks • Not all services had experienced cutbacks since 2008. 27 responses.

32. Have cutbacks impacted quality?

33. Impact of cutbacks

34. Challenges for cardiac rehab • Staff cutbacks • Waiting lists • Non-priority of cardiac rehab by management • Lack of capital funding • Changing needs of patients (younger / fitter) • Non-priority of rehab by other hospital staff

35. Views of co-ordinators • “Promotion and awareness of cardiac rehab has to be a priority. The benefits of the programmes that we run need to be publicised more.” • “All emphasis is on national targets (for example, A&E waiting times, waiting, list etc), headcounts, budgets, inpatient stays and day cases. The patient’s path through healthcare treatments and subsequent management is not seamless. Chronic disease management is not a priority.” • “Patient care has not suffered however clinical governance has such as audit, making timely stats and contributing to national requests for database have been severely curtailed.” • “Most weeks, the staff nurse and co-ordinator will end up working extra hour at least to keep standards and quality of service in place.”

36. Main findings • Despite reductions in resources, cardiac rehab services are providing services to more patients. • Completion rates are very high. • Cardiac rehabilitation services have significantly different staffing levels and resources. • Wide variation in availability of multi-disciplinary team. • Staff cutbacks have been experienced in many locations. • Nationally there are significant numbers waiting to attend cardiac rehab and lengthy waiting times for some individual services. • Social and psychological support is particularly lacking.

38. Thank you cmccormack@irishheart.ie