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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. Page 1 of 6 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. Page 2 of 6 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 Page 3 of 6 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. Page 4 of 6 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 Page 5 of 6 Yes Refer to consultant for opinion and echocardiogram (if not done already) Cardiology Consultant Consultant opinion Consider referring again if symptoms cause clinical concern Page 6 of 6