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Rivelin Healthcare Ltd
Tramways Medical Centre
54 Holme Lane
Hillsborough
Sheffield
S6 4JQ
Registered Company no 06970994
SERVICE SPECIFICATION
Primary Care Based 24hr ECG (Holter) Monitoring Service
PROTOCOL
The Service Proposed
This service will enable GPs to directly access 24 hr ECG monitoring within a Community
base. This will allow patients with low risk of significant cardiac pathology who are suffering
from palpitations/suspected clinically significant arrhythmia.
Outline of the Service
Sheffield West will provide a centrally based service initially for the patients within the
consortium.
Patients who meet the referral criteria (as per Management Pathway) for this test will be
referred by the requesting GP and given an appointment for fitting the Holter device and
given instructions on how to look after it and when to return. Patients who require a resting
ECG prior to fitting of the 24hr recorder will be able to access this at the same time.
When the monitor is returned, the data will be transferred to a PC then forwarded by the
Information Highway (NHS.net) to the provider supplying the interpretation. The results are
then reported by the Cardiac Physiologist or Cardiologist in both paper and electronic form.
The results will be forwarded to the referring GP who will then decide how to manage the
patient from there on. In the event that the patient requires urgent referral then the referring
GP/practice will be contacted by phone.
Stage 1 - The Initial Consultation
A patient presents to the practice with episodes of palpitation. The GP takes a history and
performs any necessary examination.
If the GP decides further investigation is necessary, they should assess the patient’s risk of
IHD or sudden cardiac death as well as establishing on examination whether the patient has
valvular heart disease, atrial fibrillation or any other significant dysrhythmia. If the following
questions are answered in the negative they are suitable for further investigation in primary
Care
Exclusion Criteria



Valvular heart Disease and known Atrial Fibrillation
Resting ECG showing WPW, short PR interval and Long QTc
Family History of sudden death <40
These patients should be referred to secondary care.
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Stage 2 – Initial Investigation from the Practice
GP should obtain blood tests to exclude thyrotoxicosis as appropriate. TFT, FBC, Ca U&E
Perform or obtain 12 lead ECG, with interpretation performed by suitably trained personnel.
(A resting ECG can be provided by this service immediately prior to fitting of Holter recorder if
necessary).
Stage 3 – Refer To Community Based Service
Completion of the referral form by the GP. (See Appendix 1) This can be faxed or sent to the
practice who will give the patient an appointment for fitting of the recorder.
The patient attends the service and is given
 A questionnaire to establish more detail about their known symptoms (Appendix 2)
 Detailed explanation of how the monitor works and its purpose
 Information about how to look after the monitor and an agreement to return it in good
condition. Contact details are also provided in case of any problems
Stage 4 – Returning the Monitor
The next day the monitor is returned to the Community Service carrying out the investigation.
It is put in an envelope, clearly labeled with the Name, DOB, date. The technician downloads
the data onto a PC and is then transmitted via the secure super Highway NHS.net to the
provider of the interpretation.
Stage 5 – Results
The trust provides interpretation and posts, faxes or electronically transmits a report back to
the base practice. This is forwarded to the referring practice.
If the reporter has concerns about an abnormal result, a consultant cardiologist opinion will be
sought which may result in referral or a management plan.
Stage 6
The Patient is informed of the results and managed appropriately.
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INFORMATION PATHWAY FOR 24HR ECG RECORDING IN PRIMARY CARE
Patient seen by own GP in Primary Care (refer to management pathway)
Patient referred to West PBC Service for fitting of 24hr Holter monitor.
Full Instructions given
Patient returns Holter to West service after agreed monitoring period.
Community Service downloads recording and sends in PDF format via NHS.net
to Royal Hallamshire Hospital for interpretation.
Interpretation by Cardiac Physiologist.
ABNORMAL
Rapid Atrial or Ventricular Rhythms.
Atrial Fibrillation/Atrial Flutter (<40bpm or >160 bpm)
VT/Broad Complex Tachycardia (>5 Beats)
2nd Degree, Complete Heart Block
Daytime Pauses >3.0 Seconds
A-V Blocks
No abnormality detected
Cardiology Opinion
GP Contacted
Report e-mailed in PDF format
via
NHS.net
to
referring
practice, cc Community Service
(for audit purposes) within
48hrs (Mon – Fri)
Hard Copy posted to referring
practice with 5-7 working days.
Patient
referred to
Cardiology
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Management plan
sent to GP
Palpitations/Suspected Clinically Significant Arrhythmia – Patient Management Pathway
Patient Presentation
‘Palpitations’
A&E
Acute Hospital
Admission
GP
Are there any red flag symptoms:
Loss of Consciousness
• Loss of consciousness
Yes
Cardiology Consultant
Refer for appropriate
investigations within 72 hours
•Palpitations associated with chest pain
•Severe light-headedness, nausea or
breathlessness (consider panic attacks
See Ambulatory
ECG Algorithm
Normal ECG
No
Primary Care
Perform or obtain 12 lead
electrocardiogram (ECG).
Interpretation of ECG should be
performed by suitably trained
personnel. (This can be provided if
necessary)
Blood tests on all patients: TFT, FBC,
Ca, U&E.
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Cardiology Consultant
Refer to be assessed in 72
hrs
Abnormal ECG eg long
QT interval, delta wave
Atrial Fibrillation (AF)
Left bundle branch block (LBBB)
Left ventricular hypertrophy (LVH)
Old Myocardial infarction (MI)
Refer to NICE guidelines
See Ambulatory ECG
Alogrithm
Ambulatory ECG monitoring by Intermediate Specialist Service
Daily symptoms
(>1 episode per day)
Less than daily
symptoms
24 hour ambulatory ECG
Other ambulatory monitoring
Had typical symptoms during
ambulatory recording?
Yes
No
Clinically significant arrhythmia?
No
Send letter to GP recommending
patient reassurance and provide
information leaflet
GP
Reassure patient and provide
information leaflet
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Yes
Refer to consultant for opinion and
echocardiogram (if not done already)
Cardiology Consultant
Consultant opinion
Consider referring again if
symptoms cause clinical
concern
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