Percutaneous Coronary Intervention in Merseyside Region - Essay Example

? PCI in Merseyside region PCI in Merseyside region Introduction The United Kingdom reports about 275,000 cases of a heart attack annually and between a third and two thirds of deaths occur outside the hospital. Many of these deaths occur within the first few minutes after the first symptoms are reported. The NSF was developed to modernize CHD services by introducing twelve standards for prevention, diagnosis, treatment, and rehabilitation (Allin and Turnock, 2007c). The NSF has specific standards that are applicable for ambulance services and describes models of pre-hospital CHD management. In 2007, the North West Ambulance Service introduced these standards for the management of pre-hospital cardiac chest pain. The policy outlined three approaches for managing acute cardiac chest pain, which are thrombolysis, and percutaneous coronary intervention (PCI). This is the widening of the coronary artery using a catheter to dilate the artery and fixing a metallic stent to keep it open. Most paramedic services offer PCI as the first choice treatment, and it is gaining preference over thrombolysis. However, the non-uniformity in the provision of PCI forces clinicians to use several options for treating patients with cardiac chest pain (Department of Health, 2008). A feasibility study conducted by the department of health and national societies concluded that the introduction of Primary PCI was desirable, feasible, and cost effective. More than 70 percent of STEMI cases are treated by PPCI, and the service targets 100 percent of the eligible cases. This has been achieved through the collaborative work of NHS and other multidisciplinary teams. The increasing utilization of PCI has led to the decline on thrombolysis since PCI is considered to be more efficient and safer. Pre-hospital thrombolysis requires a joint 60 minute call to needle target, which is a challenge to ambulance services (Barnes, Carpenter and Dickinson, 2006). The North West ambulance service has introduced a care bundle for patients with cardiac chest pains aimed at improving care delivery against an established benchmark. Hospitals and PCI centers in England have the capacity to provide PPCI services for 24 hours, 7 days a week (Deacon et al, 2009; Crowley, 2011). PCI is usually performed on stable patients with AMI who have not received thrombolysis. Several studies have indicated a reduction of mortality in patients with AMI who have received PCI. These patients also have less chances of developing stroke or non-fatal reinfarction than those treated with thrombolytic therapy. Patients with STEMI have a superior and long term benefits of transfer for primary angioplasty after receiving PCI and these benefits are experienced for up to three years (Lin, Dudlev and Redberg, 2008). Patients who receive PCI at a door-to-balloon time of less than 90 minutes have a 90 percent chance of survival or improvement. PCI provides the fastest means possible for effective reperfusion for patients suffering from STEMI. The number of cases requiring traditional emergency revascularization methods such as CABG has reduced due to better and safer PCI procedures. PCI is performed within a shorter time than CABG, which makes it more efficient (Department of Health 2008). PCI is compatible with other revascularization methods such as thrombolysis and CABG. This can occur at the same time or as part of the revascularization strategy. In women, patients suffering from acute MI have a better response to PCI than fibrinolysis. In a PAMI trial, women who received PCI had a 4 percent mortality rate compared to 14 percent in those who received fibrinolysis. Moreover, women receiving fibrinolysis have increased rates of major bleeding and intracranial hemorrhage (Devlin, Appleby and Buxton, 2007; Counsell et al, 2007). However, women who receive PCI have a one-year mortality rate making it more beneficial. Women experiencing recurrent ACS and have abnormal biomarkers have lower mortality after receiving PCI. Patients with recurrent ACS or MI receiving invasive therapy have a tripled mortality risk than those receiving PCI. This intervention has also proven to decrease morbidity, symptoms, and has less procedural risks. Recent studies have indicated a little variance between cardiac deaths of patients who have received PCI of 0.5 percent in women and 1.7 percent in women (Regional Drug & Therapeutics Centre, 2009)). However, PCI has some disadvantages due to location of administration centers, gender differenced and post therapy complications. Women who receive cardiac catheterization have a 1.6 percent risk of vascular complications compared to men (Xyrichis and Lowton, 2008). Older women who receive PCI have a higher chance of developing hypertension, unstable angina, congestive heart failure, and diabetes mellitus. Anticoagulants used alongside PCI have negative effects on patients especially women. The effectiveness of PCI depends on the time taken from the onset of chest pains and the administration of PCI. The average successful door-to-balloon time is ninety minutes, for which most patients respond positively. The mortality rate of PCI is dependent on the time required to achieve reperfusion. A shorter time to administer reperfusion is more advantageous than a long time period. Cases which have a door-to-balloon time exceeding than ninety minutes have higher chances of mortality than those having a shorter time (World Health Organization, 2007). A primary PCI service requires a 24/7 availability of a catheter lab, which is not available in several areas and in many district hospitals. Administration of PCI is conducted in special PCI centers or hospitals offering PCI services. In the counties of Cumbria and Lancashire, PCI centers are limited, and patients in these regions have to be transferred to other centers. The scantiness of PCI centers has led to the retention of thrombolysis as an alternative intervention (Grech, 2010). Patients from these areas have long call-to-balloon times due to the long distances between the rural area and the nearest PCI center. About 25-35 percent of patients who receive thrombolysis fail during reperfusion when PCI is administered. The combination of PCI with other drugs causes secondary narrowing of blood vessels due to internal tissue growth, which may cause future cardiac complications (Patwala et al, 2009; Chew-Graham et al, 2007). Patients from hospitals within Lancashire and Cumbria are referred to LCC in Blackpool for cardiac surgery and PCI. This is due to lack of PCI centers within these two counties, and the increase in the number of cardiac arrest cases reported. In other counties and districts within England, patients suffering from cardiac complications are referred to other hospitals for treatment. This has led to the creation of a cardiac network that aids the referral process. Some of the PCI centers do not support 24/7 patient treatment. Patients experiencing cardiac arrests in these regions outside the working hours have to be referred to other hospitals and PCI centers. Referral pathways help hospitals share the available resources. Patients in hospitals without cardiac surgery or PCI equipments can receive treatment from other hospitals which have the required equipments. These referral systems help reduce the mortality rate by up to 35 percent in patients experiencing STEMI (Busk et al, 2008). The current referral system reduces the average treatment time by up to 45 minutes. The effectiveness of PCI depends on the call-to-balloon time, which should not be more than 120 minutes. Referral networks reduce the average time and minimize the mortality rate due to treatment delay. Local hospitals may lack the necessary manpower and facilities to handle severe cardiac arrest cases. Some local hospitals lack heart surgeons who can attend to such cases. Referral networks help patients in such cases by transferring them to PCI centers or hospitals that have PCI services and cardiac surgery. This reduces the number of death caused by cardiac arrest. Patients received at the emergency department suffering from STEMI have to be transferred to PCI laboratories for specialized care. Other patients who have lower mortality risks and receive thrombolysis may be referred to PCI centers for specialized treatment. A particular referral network can develop its own service models to facilitate the transfer of patients who require PCI intervention (White, 2008). Referral networks have some disadvantages such as most PCI centers attend to one patient at a time especially outside of working hours. Referring two patients at the same time will cause the second patient to wait for long before receiving and treatment. Some hospitals do not provide a 24/7 PCI treatment, and they are not considered within the referral network beyond their working hours. This causes overstretching of PCI centers that provide 24/7 services. The networks have to develop pathways for patient referral (Askari, Messerli and Lincoff, 2007). PCI centers have to be informed before the patient is brought in for treatment in order to prepare the required equipment. Some centers do not have a 24/7 staffing system, which causes delay in preparation for the patient’s arrival beyond the normal working hours. The hospital staff has to make an agreement about patient stay in the PCI center. Patients may be booked in at a non-PCI hospital and transferred to a PCI hospital during emergency. The management of both centers has to make an agreement on where the patient is supposed to continue with treatment. Different hospitals within the network have different solutions to this issue. A referral network requires additional resources to cater for patient transfer. This includes nursing staff to travel with patients and make the necessary arrangements for patient transfer (Danchin et al, 2008). PCI treatment requires a 24/7 availability of services for the sustainability of this intervention. This leads to a shift towards out-of-hours working program for nurses and physicians. The ambulance services must also be available for the transportation of patients to PCI centers. Several nurses find it hard to manage changes, which require them to work at night and over the weekends. The referral system also requires nurses who prepare to receive patients from other centers. This calls for an alteration of the normal working program of the hospital. In most cases, working in shifts is considered to be the most effective method for managing these changes. Several nurses are reluctant to engage in the program, but it is a routine to be followed by all workers within the cardiac care department. Nurses who work over the weekend and past the normal working hours are paid on an overtime basis. This motivates the worker to work beyond the normal hours so as to provide a 24/7 PCI service (Abbate, 2008). The introduction of PCI services in a hospital requires special training of the current staff or the employment of other staff who can handle the equipment involved. This treatment requires a specially trained nurses, physiology and radiography staff, and catheter lab staff. The initial training requires participation in an NWAS commissioned program. Newly registered paramedics undergo suitable training and education for the management of STEMI via PCI or thrombolysis. These training sessions are conducted by advanced paramedics or members of the clinical education teams. PCI involves the insertion of coronary catheters and removal of subcutaneous layer from the arteries. This process requires the intervention of specially trained physicians. Stents are inserted into the arteries in order to keep them open to allow blood flow. The implantation process of stents requires trained physicians to avoid future complications due to the meshes. The NHS has included the management of cardiac related chest pain into the mandatory clinical training program. This training is reviewed annually, and physicians have to be certified before they engage in PCI procedures (Stone, 2008). PCI helps open the blocked arteries allowing the blood to flow normally within the heart. In most cases, patients suffering from coronary artery disease have lower mortality rates after the implantation of stents. Patients who have received PCI have a 4.3 percent mortality rate compared to 9.1 percent in patients who have undergone ordinary treatment. The effects of PCI are long lasting, and the patients have an up to one year mortality rate. About 75 percent of patients who receive PCI treatment stay for more than three years without developing additional cardiac problems. Drug eluting stents help prolong the success rates of the procedure. Most patients who undergo PCI are discharged the next day though some can be treated and discharged within the same day. PCI treatment is safer than other forms of treatment due to a minimum number of secondary complications. Patients treated with thrombolysis may develop stroke as a side effect, which is not experienced in PCI (Erne et al, 2007; Kern, 2007). PCI procedures help clinicians deal with few cases of mortality rates compared to other forms of treatment. The administration of PCI is less complex than performing cardiac surgery of fibrinolysis procedure. The procedure for inserting stents in the artery usually takes less time than performing CABG, which makes clinicians spend less time in the laboratory. NHS records few cardiac related deaths since the introduction of PCI. This has improved the overall image of NHS medical interventions, and its support for staff training has resulted to more efficient procedures. The establishment of PCI centers is costly, which has increased the budgetary allocations for NHS. The cost of referral has been estimated to be 45 million pounds per year. Patients who are discharged immediately after receiving save approximately 1,826 pounds (Stewart, 2005; Devlin, 2007). NHS spends approximately 120 million pounds when setting up a PCI center. Patient referral networks spend an average of 35 million pounds annually while consultations are estimated to be 45 million pounds annually. NHS spends about 2 percent of its budget treating cardiac arrest related complications. Seventy percent of these costs are spent during hospitalization of patients including the administration of PCI (Agostoni, 2006). Paramedics respond to emergency calls for patients suffering from cardiac arrests. People with symptoms of a heart attack receive help from paramedics. This requires the use of a defibrillator, which should be used within 8 minutes of calling for help to maximize the benefits of resuscitation. According to NHS standards, people suffering from a cardiac arrest should be assessed and if necessary receive aspirin. Patients experiencing cardiac related chest pains are placed on oxygen and titrated to maintain spo2 >= 94% before being transferred to the ambulance (Cannon, and O’Gara, 2007). In some localities, the nearest PCI center is more than the required door-to-balloon time of 90 minutes. This may force paramedics to administer thrombolysis to stabilize the patients before they get to the nearest PCI center. In the ambulance, the physician together with the paramedics is involved in the stabilization process of the patient. They assess the patient for STEMI and administer buccal GTN if necessary and acquire a 12 lead ECG (Hean and Dickinson, 2007). Paramedics help the physician determine whether patients require PPCI and determine the nearest center. They have PPCI criteria on the assessment checklist, which is used to determine if the patient requires PPCI. During patient referral process, paramedics help the physician examine the patient before being transferred to a PPCI lab. The assessment date is sent via GPS to the lab physicians to confirm whether the patient requires PPCI. Paramedics determine the time elapsed since the call was made, time spent on the scene, and time needed to take the patient to the nearest hospital. These times are summed to determine the call-to-balloon time required for cardiac arrest patients. Paramedics also inform the PCI lab or hospital of the estimated time before patient arrival to prepare the necessary equipment for treatment (Boult et al, 2008). The higher education system has included catheter-based treatment of cardiac diseases in the curriculum. PCI has become the most common treatment procedure and interventional cardiologists have to meet the NHS and NWAS professional standards. This training also covers the knowledge of anticoagulants during PCI and the insertion of drug eluting stents (Ellis and Holmes, 2006). Paramedics also undergo through higher education programs for training on how to handle cardiac patients and determine whether they are eligible for PCI. These paramedics are also involved in the training program of other paramedics and hospital staff. Higher education institutions provide specialized training for cardiologists and physicians working in chest pain evaluation units (Zwar et al, 2008). The inclusion of these programs into the education system has helped produce the necessary workforce required in PCI labs and hospitals with PCI treatment. Heart surgeons undergo PCI administration training before leaving the medical college. CPD modules provide paramedics with a medical model that guides their practice of acquiring comprehensive history of the patient. When paramedics reach the emergency scene, they are supposed to collect the medical history of the patient before engaging in any stabilization process if possible. These modules provide paramedics with the necessary skills required when collecting patient information especially sensitive personal information (Tcheng, 2009). Paramedics provide a wide range of therapeutic interventions and CPD modules provide them with an introduction to some aspects of clinical pharmacology. These include areas of chemistry, basic physics, mathematics and the anatomy of key body organs such as the heart, kidney, and liver. Some patients are difficult to handle when administering pre-hospital care. The management of such patients is usually stressful and challenging for many paramedics. CPD modules help paramedics understand the rationale behind some personality behaviors (Mazzocco et al, 2009). Patient handover between paramedics and hospital staff requires effective communication between the two parties since errors in communication can be detrimental to the patient. CPD modules provide paramedics with the necessary guidelines and skills for effective communication. Ambulance clinicians have to provide pre-hospital treatment for cardiac arrest patients. These patients require life support mechanisms such as oxygen support and aspirin. Paramedics may respond to emergency scenes that require legal interventions through the police department. CPD modules focus on key legal issues and procedures relating to paramedic practice (Falk, Shah, and De Feyter, 2010). These modules also provide paramedics with the necessary ethical issues when dealing with patients and hospital staff. Adults and children require different emergency care for accidents, burns, and cardiac arrests. CPD modules provide paramedics with the different approaches of handling adults and children in pre-hospital care. It also provides them with general treatment procedures such as a wound dressing, burn treatment, and accident care (Zwarenstein et al, 2007). Cardiac arrests result to death when patients are not taken to the hospital for treatment within the shortest time possible. Some patients require 24-hour nursing care, which cannot be provided at home and may require surgical operation. When such patients are not taken to hospital, provision of health care becomes difficult, and this may lead to worsening of the patient health. Hospitalization helps reduce the infection rate of diseases for other family members. Patients suffering from contagious diseases require hospitalization to curtail the spreading rate of the disease. Patients with pulmonary and heart diseases require specialized life support mechanisms. Complex life support machines cannot be provided at home. PCI procedures are administered in specialized labs, which require physicians with specialized skills and equipment (O'Cathain, Murphy and Nicholl, 2007). These services require hospitalization of patients to prevent death or stroke. Patients involved in accidents may damage their spinal cord, which may result to disability when they do not receive immediate treatment. Doctors and physicians run several lab tests on patients who seek medical care in hospitals. This helps them determine the root cause of the disease and the effective treatment methods. Patients who do no visit hospital care may receive over-the-counter medication for the wrong disease or weak dosage for the disease. Visiting the hospital helps doctors develop a health record for the patient for future reference. Patients who fail to visit hospitals may receive inconsistent treatment for certain disease or have a disjointed health history. Visiting the hospital helps the patient develop a personal relationship with physicians, who attend to them regularly making patients feel comfortable when seeking medical care (Evans and White, 2009). The implementation of PCI care requires the interaction of several physicians within the hospital. Paramedics, radiologists, surgeons, and nurses interact within the work environment. Interprofessional interaction promotes the exchange of skills between clinicians to improve the quality of care and collaboration. In 2000, NHS introduced the involvement of interprofessional learning and collaboration within healthcare in its plan. This made undergraduate education incorporate interprofessional working in its training to encourage a team approach to patient needs (Tse, Lip and Coats, 2011). NHS also provided a strategy for allied health professionals to guide interaction, education and training for different professionals within the medical field. The NHS plan aims at creating a service that encourages professionals to work together meet patient needs. Professionals working in the hospital have different reactions to change brought by increased working time and the introduction of new treatment procedures. This makes it difficult for these professionals to relate and interact well with each other (Department of Health, 2007). Interprofessional working has led to the establishment of a common learning program in healthcare facilitated by the NHS plan. Professionals benefit from sharing knowledge and experience assistance in handling cases outside one’s own limit. Interprofessional interaction facilitates collaborative education in order to promote collaborative working. Physicians and cardiologists conduct collaborative assessment of patients before the administration of PCI or performing heart surgery. This encourages transfer of ideas and knowledge exchange between the involved professionals (Sauer, 2010). NHS has established guidelines for intermediate care for older populations. This involves little medical input and often rehabilitation after episodes of illness. Rehabilitation involves the interaction of several professionals such as occupational therapists, speech therapists, and physiotherapists. The new direction for community service implemented by NHS promotes the interaction of health professionals and social care workers. This partnership aims at meeting the needs of patients in the society in service delivery by providing the population with intermediate health care. Placement students require monitoring and assessment by other professionals in the hospital. This interaction promotes learning and educational advancement by these students (Manojlovich and DeCicco, 2007). Interprofessional working faces several challenges due to differences in opinions of workers involved. Communication is the basis for collaborative working in the health center. Many professionals are reluctant to share information or share it discriminatively. An increase in the level of communication is necessary to facilitate learning between different teams involved (Clifton, Dale and Bradshaw, 2006). The hospital management has to develop guidelines that govern the flow of information between different teams involved in a particular task. Interprofessional healthcare experiences role overlap and role protection is a barrier to collaborative work. Nurses are highly protective of their role within the healthcare and believe that it is their sole responsibility to take care of patients. Changes in the working practice may force nurses to view their contribution as less important. This requires an intervention program where all departments and professions are involved in decision making. This allows every member of the team to contribute his or her idea without considering ones’ idea to be perfect or superior (Manser, 2009). This encourages different professionals to engage and benefit from collaborative working conditions. Different healthcare philosophies also act as a hindrance for interprofessional working. Cure-oriented medics have a paternalistic approach while public and social health advocates for health visitor. Practicing professional ethics in the work place helps overcome differences caused by these philosophies. Budgetary allocations, rationalization, and limited resources are barriers to collaborative practice. Localizing budgets and allocating resources for skill acquisition can act as a solution to these barriers. Clinical governance within the NHS provides different powers to different professionals. Clinical agendas should be driven by medical professions to avoid power culture conflicts (NHS Improvement, 2009). Many pre- and post-registration health care professionals engage in learning processes throughout the United Kingdom. Increasing reference for team work and collaborative medical practice facilitates interprofessional learning. The government policy, educational directives, and health regulatory bodies encourage professional learning as a mechanism for improving health provision services. Deficiencies in communication and collaboration between professionals have a negative impact on patient outcomes. Skill mix and flexible working between professionals are promoted by interprofessional interaction among workers. These interactions help students and other clinicians to switch training pathway to expand career progression. Interaction between different professionals develops a new type of workers who have a wide range of knowledge and can handle different health cases. Students interacting with experienced professionals gain several skills and knowledge. These enable them handle clinical challenges effectively and expand their careers (Xyrichis and Lowton, 2008). Conclusion PCI has been proven to be an effective intervention for patients experiencing cardiac arrest. The insertion of stents into the artery helps patients recover within a short period and stay for up to three years without seeking any medical assistance (Nicol et al, 2008). However, hospitals providing PCI care are limited especially in the rural areas. Residents of Cumbria have to be transferred to Lancashire to access PCI services. The implementation of PCI services around England will provide less complicated heart operations such as CABG (Cooper and Spencer-Dawe, 2006). Other interventions such as thrombolysis have side effects such as stroke and hemorrhage, which are not experienced in PCI. Patients who undergo PCI are discharged on the same day or the next day minimizing their hospital expenses. PCI is cost effective, safe, and efficient cardiac procedure that helps reduce the number of cardiac related deaths. This practice introduces several changes in the workplace due to the demand for a 24/7 availability. This forces physicians to work past the normal working hours and over the weekend. The North West Ambulance service has incorporated several measures when attending to cardiac arrest patients (Melis, 2008). Paramedics are supposed to evaluate the patient to determine whether they require PCI services or ordinary cardiac procedures. This also depends on the proximity of the PCI lab within the call-to-balloon time frame (Barnes, Carpenter and Dickinson, 2006; Liberat et al, 2009). Some patients may decline to consent for PCI intervention due to lack of knowledge or fear of complications. Gender issues also prevent women to participate in the intervention of cardiac arrest using PCI (Chew-Graham et al, 2007; Clavien and Breitenstein, 2010). NHS and other health care teams are supposed to carry out intensive campaign for heart attack intervention and the importance of PCI. The number of PCI labs in some parts of England is limited, and physicians have to use alternative methods such as thrombolysis. The government together with NHS has to develop more PCI centers to enhance the availability and effectiveness of this intervention. Equipping more hospitals with these facilities will reduce the number of referrals done and the amount of resources spent by referral networks. References Abbate A., Biondi-Zoccai G.G., Appleton D.L., et al. 2008. Survival and cardiac remodeling benefits in patients undergoing late per-cutaneous coronary intervention of the infarct-related artery: evidence from a meta-analysis of randomized controlled trials. Journal of American College of Cardiology, 51(9). 956-64. Agostoni P, Valgimigli M, Biondi-Zoccai GGL, Abbate A, Gar-cia HMG, Anselmi M, Turri M, McFadden EP, Vassanelli C,Serruys PW, Colombo A. 2006. Clinical effectiveness of bare-metal stenting compared with balloon angioplasty in total coronary occlusions: Insights from a systematic overview of randomized trials in light of the drug-eluting stent era. American Heart Journal, 151,682–689. Allin L and Turnock C .2007c. Working with others in the workplace. Making Practice Based Learning Work. Available at: http://www.practicebasedlearning.org/resources/materials/intro.htm.[Accessed 20 July 20, 2012]. Askari, A. T., Messerli, A. W., and Lincoff, A. M. 2007. Management strategies in antithrombotic therapy. Chichester, J. Wiley. Barnes, D, Carpenter ,J., and Dickinson, C. 2006. The outcome of partnerships with mental health service users in interprofessional education: a case study. Health and Social Care in the Community,14(5) 426-435. Barnes, D, Carpenter, J and Dickinson, C.2006. The outcome of partnerships with mental health service users in interprofessional education: a case study. Health and Social Care in the Community,14(5) 426-435. Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, et al. 2008. Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Bioligical Sciences Medicine, 63(3),321–7. Busk M., Maeng M., Rasmussen K., Kelbaek H., Thayssen P., Abildgaard U., Vigholt E., Mortensen L.S., Thuesen L., Kristensen S.D., Nielsen T.T., Andersen H.R., for the DANAMI-Investigators. 2008 The Danish multicentre randomized study of fibrinolytic therapy vs. primary angioplasty in acute myocardial infarction (the DANAMI-2 trial): outcome after 3 years follow-up. European Heart Journal, 29, 1259-66. Cannon, C. P., and O’Gara, P. T. 2007. Critical pathways in cardiovascular medicine. Philadelphia, Pa, Lippincott Williams & Wilkins. Chew-Graham CA, Lovell K, Roberts C, Baldwin R, Morley M, Burns A, et al. 2007. A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people. British Journal General Practice, 57(538):364–70. Clavien, P.-A., and Breitenstein, S. (2010). Malignant liver tumors current and emerging therapies. Oxford, Wiley-Blackwell. Clifton ,M., Dale, C., and Bradshaw, C.2006. The Impact and effectiveness of interprofessional education in primary care: an RCN review. London: RCN. Crowley, L. V. (2011). Essentials of human disease. Sudbury, Mass, Jones and Bartlett Publishers. Cooper, H and Spencer-Dawe E. 2006. Involving service users in interprofessional education narrowing the gap between theory and practice. Journal of Interprofessional Care, 20(6), 603-617. Counsell S.R, Callahan C.M, Clark D.O, Tu W, Buttar AB, Stump TE, et al. 2007. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA, 298(22),2623–33. Danchin N. et al. 2008 Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percu-taneous coronary intervention for st-segment- elevation acute myocardial infarction: Data from the French registry on acute ST- elevation myocardial infarction (FAST-MI). Circulation,118(3) 268-276. Deacon, L., Harrison, R., Timpson, C., Tocque, K., Bellis, M..A. 2009. Health and Lifestyles in the North West. North West Public Health Observatory. Department of Health. 2008. High Quality Care for All. The Stationary Office. London Department of Health. 2008. Putting prevention first -Vascular Checks: risk assessment and management. Crown Copyright, London Department of Health. 2007. Shaping the future progress report 2006. The Coronary Heart Disease National Framework. DH, London, Devlin, P. M. (2007). Brachytherapy applications and techniques. Philadelphia, PA, Lippincott Williams & Wilkins. Devlin, N.J., Appleby ,J., and Buxton, M.2007. Getting the most out of PROMs: putting health outcomes at the heart of NHS decision-making. London, King's Fund. Ellis, S. G., and Holmes, D. R. 2006. Strategic approaches in coronary intervention. Philadelphia, PA, Lippincott Williams & Wilkins. Erne P, Schoenenberger AW, Burckhardt D, Zuber M, KiowskiW, Buser PT, Dubach P, Resink TJ, Pfisterer M.2007. Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: The SWISSI II randomized controlled trial. JAMA, 297,1985–1991. Evans, C. H., and White, R. D. 2009. Exercise Stress Testing for Primary Care and Sports Medicine. New York, NY, Springer New York. Falk, E., Shah, P. K., and De Feyter, P. 2010. Ischaemic Heart Disease. London, Manson Pub. Grech, E. D. 2010. ABC of interventional cardiology. Oxford, Wiley-Blackwell. Hean, S. and Dickinson, C. 2007 The Contact Hypothesis: an exploration of its further potential in interprofessional education. Journal of Interprofessional Care, 19 (5), 480-91. Kern, M. J. (2007). SCAI interventional cardiology board review book. Philadelphia, Lippincott Williams & Wilkins. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. 2009.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Bmj, 339,b2700. Lin, G.A., Dudlev, R. A., and Redberg, R.F. 2008. Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. Journal of General internal medicine, 23(9), 1458-1463. Manser T. 2009. Teamwork and patient safety in dynamicdomains of healthcare: a review of the literature. Acta Anaesthesiol Scand, 53(2):143–51. Manojlovich M, DeCicco B. 2007. Healthy work environments, nurse-physician communication, and patients’ outcomes. American Journal of Critical Care, 16(6), 536–43. Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, et al. 2009. Surgical team behaviors and patient outcomes. American Journal of Surgery, 197(5),678–85. Melis R.J, van Eijken M.I, Teerenstra S, van Achterberg T, Parker S.G, Borm G.F, et al.2008. A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home (Dutch EASYcare Study). J Gerontol A Biol Sci Med Sci, 63(3),283–90. NHS Improvement. 2009 Commissioning for Stroke. Prevention in Primary Care – The role of Atrial Fibrillation. Nicol, E.D., Fittall, B., Roughton, M et al. 2008 NHS heart failure survey: a survey of acute heart failure admissions in England, Wales and Northern Ireland. Heart, 94, 172–7. O'Cathain A, Murphy E, Nicholl J. 2007. Why, and how, mixed methods research is undertaken in health services research in England: a mixed methods study. BMC Health Serv Res, 7,85. Patwala A.Y et al, .2009. Maximising patient benefit from cardiac resynchronisation therapy with the addition of structured exercise training. J Am Coll Cardiol, 53,2332-2339. Regional Drug & Therapeutics Centre. 2009. North West SHA Annual Prescribing Report. Sauer, H. 2010. Studies on cardiovascular disorders. Heidelberg: Humana Press. Stewart, S. 2007. Financial aspects of heart failure programs of care. The European Journal of Heart Failure, 7,423 -428. Stone G.W. 2008. Angioplasty strategies in ST-Segment–elevation myocardial infarction. Circulation, 118, 552-566. Tcheng, J. E. 2009. Primary angioplasty in acute myocardial infarction. Totowa, N.J., Humana. Tse, H.-F., Lip, G. Y. H., and Coats, A. J. S. 2011. Oxford desk reference. Cardiology. Oxford, Oxford University Press. White H.D. 2008. Systems of Care: Need for hub-and-spoke systems for both primary and systematic percutaneous coronary inter-vention after fibrinolysis. Circulation,118(3) 219-222. World Health Organisation. 2007. Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk. WHO Press, Switzerland. Xyrichis A, and Lowton K. 2008.What fosters or prevents interprofessional teamworking in primary and community care? A literature review. International Journal of Nursing Studies, 45(1):140–53. Zwar N, Hermiz O, Hasan I, Comino E, Middleton S, Vagholkar S, et al. 2008 A cluster randomised controlled trial of nurse and GP partnership for care of chronic obstructive pulmonary disease. BMC Pulmonary Med, 8,8. Zwarenstein M, Reeves S, Russell A, Kenaszchuk C, Conn LG, Miller KL, et al. 2007. Structuring communication relationships for interprofessional teamwork (SCRIPT): a cluster randomized controlled trial. Trials, 8,23. Read More