“Observing the patient journey and listening to the patient’s voice drove me to create a business case for a Community Chest Pain Clinic as an alternative to the Emergency Department (ED) for non-acute chest pain patients,” according to Shirley Ingram, an Advanced Nurse Practitioner (ANP) in Tallaght University Hospital (TUH). Shirley’s specialty is the assessment and diagnosis of chest pain. She set up Tallaght University Hospital’s first ANP-led Hospital Chest Pain Service in 2011, believing that if patients could be identified and treated earlier, many would not need to be admitted to the hospital.

Within a year of the establishment of the ED ANP-led service, admissions to the wards had decreased by 60%. As well as improving the experience for patients, the initiative led to a reduction on the pressure on beds, and further allowed for significant cost savings. The decision to appoint a second ANP in 2017 supported the growth of the service, and the nurse-led clinic is now embedded within the emergency care services in TUH.

Before Shirley set up the hospital-based service, chest pain was a principal presenting symptom of coronary heart disease. It represented a significant caseload for the ED, with over 5,000 presentations annually. In 2009, 48% of all individuals presenting to the ED were admitted.

Shirley explains that in her role as ANP in ED, she had noted that “a lot of patients were sent to ED after a GP visit."

"I was driven to find an ED avoidance pathway for these patients, as they often waited hours to be seen. I carried out an audit which showed that approximately one-third of all patients who present to ED with non-acute chest pain, did so after seeing their GP. As 78% of these GP referrals were low risk, this led to prolonged patient-experience time, including some patients who did not wait to be seen. Less than 1% of GP chest pain referrals were having a heart attack. The ED was not the appropriate place for the majority of these patients.”

Slaintecare funding enabled the commencement of the Integrated Community Chest PAIN Clinic in September 2020, during the pandemic. This clinic has reduced ED referrals by GPs of patients with chest pain by 8%.

Reflecting on the innovation involved in establishing both ANP-led chest pain services,  Shirley notes how, in her experience, “the key to successful innovation is to look at the problem, then spend time reflecting on what will improve it - taking time to think and plan is vital.”

Shirley is currently auditing the results of her ANP-led telephone clinic which provides ANP-referred CT Coronary Angiogram tests for patients, reducing outpatient attendances. She adds that “in the community setting I would like to expand the ANP service to accept a group of patients usually referred by GPs for stress-testing. This has the potential to avoid unnecessary use of diagnostics and reduce waiting lists in the acute setting.” She further adds that “ANPs can offer clinical expertise and strategic planning to shape new pathways to improve the care we deliver to our patients.”