Crucial information lacking in chest pain referrals

Important information that could optimise the diagnosis and management of chest pain patients is often lacking on referral between primary and secondary care, according to an influential multidisciplinary working group of the Angina Forum. In a bid to tackle the situation, the group has developed a template for use by both general practices and rapid access chest pain clinics (RACPCs).

The move follows a meeting of the Forum’s expert working group, which highlighted the major problems that can be caused when referrals of suspected angina patients, both to and from secondary care assessment, are not accompanied by adequate information. According to the group, this can result in delay, confusion, misdiagnosis and inappropriate treatment.

The consensus guidance provides a checklist for the essential information which should accompany suspected angina patients on referral to rapid access chest pain clinics and on their return to primary care. The list is also available as a pro-forma which can be adopted or modified for local variations.

Explaining the rationale behind the document, Angina Forum group member Professor Adam Timmis, consultant cardiologist at the London Chest Hospital, comments: “While there are clearly pockets of best practice, the quality of information following angina patients on their disease management journey is patchy. This consensus document has been developed in an attempt to spread best practice more widely and optimise the increasingly important role of chest pain clinics.”

According to the Department of Health, patients in all acute Trusts now have access to RACPCs,1 which were established as part of the National Service Framework for Coronary Heart Disease in 2000,2 and a majority of Trusts are now achieving the target maximum
waiting time of 14 days from referral to assessment.3 However, no clear guidelines exist on referral procedures.

The problem is often most pronounced when patients are returned to the care of their GP from secondary care, according to specialist GP Dr George Kassianos, also a member of the Forum’s working group. “Following the RACPC appointment, patients often return to the GP with no written information about diagnosis or treatment, and the GP has to rely on the patient’s recall of what they were told by the doctor they saw in the clinic,” he explains. “After the patient has been seen in the RACPC and is waiting for their next appointment, there is no protocol for the GP on what to watch for, how often the patient should be seen, or how to address the patient’s concerns about their condition.”

In developing its guidance, the Angina Forum group explored examples of best practice and arrived at a consensus regarding the information that should pass between primary and secondary care in cases of suspected angina. The template addresses many of the things often overlooked, such as family history and known intolerances to certain anti-anginal drugs. It also serves as a check to ensure that urgent cases, such as severe chest pain that occurs at rest or lasts longer than 20 minutes, are treated as emergencies and not referred to the chest pain clinics.

For patients referred back from the RACPC to the GP, the template will help ensure that a rational management plan is included. It will also identify when anti-anginal drugs have been stopped or new medical therapy initiated.

Copies of the checklist and referral form are available from the Angina Forum Secretariat, e-mail anginaforum@phaseiv.co.uk.