Focus on multidisciplinary teams in cardiac care: panel discussion

Speaking at Hospital Healthcare Europe’s Clinical Excellence in Cardiovascular Care event, our panel of three cardiologists considered the role of multidisciplinary teams (MDTs) in cardiac care. Dr Tim Lockie, Dr Clare Appleby and Dr Shazia Hussain shared their views on how MDTs and their collaborative meetings can be most effectively managed.

The way in which care for cardiac patients is managed has changed dramatically in the last twenty years. Previously under the care of a single cardiologist, patients are now looked after by multiple specialists, including nurse practitioners, physiologists and various cardiac experts from interventionalists to radiologists and beyond.

With advances in cardiac imaging and new technologies, more diagnostic tools are available, and greater expertise is needed to interpret the findings. A range of healthcare professionals work together to determine the patient pathway through treatment and care, making multidisciplinary team (MDT) working a key component of contemporary patient care.

All three Clinical Excellence event panellists are heavily involved in MDT working across different areas, including coronary MDTs, structural MDTs and ward work, as well as applying the principles to NHS boardrooms.

They are Dr Tim Lockie, a consultant cardiologist and clinical service lead for cardiology at the Royal Free London NHS Foundation Trust; Dr Clare Appleby, a senior consultant interventionalist and clinical lead for intervention at Liverpool Heart and Chest Hospital; and Dr Shazia Hussain, a consultant interventional cardiologist at Glenfield Hospital, University Hospitals of Leicester NHS Trust.

Along with panel chair Rebecca Dobson, consultant cardiologist specialising in imaging and cardio-oncology at Liverpool Heart and Chest Hospital and the Clatterbridge Cancer Centre, they discuss how to successfully navigate the shared decision-making processes at the heart of MDT care based on their own experiences in clinical practice. As Dr Lockie said: ‘Multidisciplinary team working is what we all strive for. It’s not easy, and it’s not always well done. It has to be really nurtured and cherished.’

What types of MDTs are key to supporting cardiovascular care?

Dr Appleby: TAVI [transcatheter aortic valve implantation] is quite a big team. Within the hospital setting, there are the operators, but germane to the team are the nurse specialists who really run our service. They’re extremely important in terms of their role liaising with patients and referring hospitals and GPs in terms of investigations and managing patients’ and relatives’ expectations.

We have a TAVI coordinator who is an administrator, and that’s crucial for any large service. We have the cath lab staff where we actually do the procedure so the operating team. Then we do a lot of work with the wider team, so the referring hospitals around the region, GPs with special interest as well are very important in terms of in diagnosing and then investigating these patients. You have the outpatient setting and then the more procedural setting within the hospital, but I think in terms of something like a TAVI service, it’s really absolutely reliant on having an efficient multidisciplinary function.

Dr Hussain: We all do ward work and there are various teams that are involved in ward decisions like the TAVI team and the coronary revascularisation team. But, on a day-to-day basis, we have the ward multidisciplinary teams, which involve discharge coordinators, input from occupational therapists, physiotherapists, nursing staff, sometimes from the social department and funding.

These are often MDTs for patients where there’s a certain issue that is difficult beyond the medical issue and we see that on a daily basis – maybe there are difficulties at home, safeguarding issues, patients that are difficult to discharge – the voice of every member of that team is as important as the medical voice and, of course, we like to get the patients and their relatives involved themselves.

What systems do you have in place to make sure every member of the MDT can contribute?

Dr Appleby: I think it’s probably about the structures that you have. For example, if we take the cath lab, where you’ve got a very high-intensity environment with many different staff groups performing procedures. We have a system, which I think is common to many trusts now, where you try and avoid a hierarchy and you have a more horizontal approach.

We have things like halt processes, your safety checks that you go through. We have a very structured approach so that each member of the team within that environment has an opportunity during those safety procedures to say whether they have all the equipment that they need, whether they have anything they want to raise. We do that in a very structured format before the performance of each procedure.

That’s a very particular example to a procedural environment. And that’s very different if you’re in a medical decision-making meeting, or perhaps on a ward base having a patient’s best interest meeting where you might have a much broader audience. But, if you can, structure it to enable other voices to be heard and have the patient at the centre of everything.

Dr Hussain: What’s really made a huge difference to our coronary MDTs is the presence of a neutral chair who is strong, can direct, is well aware of the different parties within the room and allows everyone to have an opportunity.

Sometimes, MDTs can get quite tense between different parties and, at that point, what you need is a chair. We’ve got Gerry McCann, who is our head of imaging, as our chair so he has a neutral perspective and is able to guide the conversation and take everyone’s viewpoint into account and also then decide when it’s time to move on from a conversation. It’s important that any MDT has an atmosphere of safety where everyone can speak, but it is a difficult area to navigate.

Dr Lockie: At the Royal Free we talk about the triumvirate. That works really at every level, whether you’re doing a ward round, whether you’re making decisions on how you’re going to plan your cath lab lists or how you’re planning all your other services.

We very much believe in this triumvirate structure, which is the medical input, the nursing input and then the operations team. At every level within the hospital, from the smallest units within a ward up to the trust executive team, the leadership structure is very much spread between those three. Everyone has a seat at the table, and everyone has a very important voice. Everyone brings something different to the table as well.

Do you have fixed members in your multidisciplinary team?

Dr Appleby: In the structural MDT, we have the same chair all the way through, whereas on our daily revascularisation MDTs it’s chaired by the surgeon of the week. I think it depends on what environment you are talking about, but for many of the cardiac-specific MDT processes, there are key people involved.

So, for structural, you will have your nurse specialists, your imaging cardiologists, your structural surgeons, your structural cardiologists, so there are key people in the room. But then we will invite, for example, the referring physician to present that patient.

Most of our MDTs are done virtually so that people who are off-site referring patients in can present their patients and advocate for the patients. So, I think it does depend on the specifics of the MDT, but certainly, there will be a key skill mix – our core – who you have to call up for that meeting to run efficiently and to be making safe decisions for patients.

How do you manage the impact of different skills and expertise in the decision-making process? 

Dr Hussain: The point of the MDT is that it’s a whole group of people making decisions. Certainly, in our structural MDTs we won’t just have one imaging person or one cardiac radiologist, there’ll be two or three of them. And from the cardiac perspective of the interventionalist we’ll be looking at those things as well. So, it’s never a decision that’s based on one person’s expertise.

Again, if we talk about good chairing and safety within the team, you would expect that if one person is talking outside their expertise, then they will have the honesty to say, ‘actually, what I’d like is a second opinion on this because I don’t know the answer’, and that’s the whole point of the MDT.

How do you mediate disagreements between cardiologists, cardiac radiologists or other members of the MDT?

Dr Lockie: Like all of these things, you need to put the patient back at the focus of everything. There are disagreements about how to approach a particular problem, and I think all of us need to try to put our prejudices and biases outside the room and just look very objectively at what’s going on.

Increasingly, certainly with angiograms, we have got other things we can use now so we can look at intravascular imaging and we use that frequently now to define things further, and we have non-invasive functional data that we can reference. I think the days of disagreeing over angiograms, thankfully, are gone. I think everyone has now bought into a much more objective assessment of the situation.

But disagreements do happen. It will happen in every single MDT because people don’t conform to small, neat boxes and there is almost an infinite number of variables. You need to disagree agreeably, and as long as you keep the emotions out of the room and keep it focused on a particular patient, then that’s the most important thing.

The other thing to remember is that the output from an MDT is also guidance. You can take the output from an MDT, but you shouldn’t feel necessarily obliged to go down one particular path. In medicine, it’s not a black-and-white world, we’re not talking about objective, clear decisions. As the consultant, if your instincts, or your judgement, and the patient’s are different to the output from the MDT, we mustn’t find ourselves going down a particular route that’s been pushed very heavily from an MDT.

We need to be guided by the MDT. You should have a good reason if you do make a decision that goes counter to it. But also, at the same time, they’re not the ones who are either going to operate on the patient, be speaking to the family or having to pick up the pieces afterwards. And I think we always need to remember that this is guidance, not orders and you can always deviate.

How can we encourage colleagues to be more patient-focused? 

Dr Lockie: I think that most hospital committees have some sort of patient representative on the group and including them in the decision-making is increasingly important and potentially difficult to navigate. Patients have their own understanding of things, and they don’t necessarily see the bigger picture.

With all sorts of decisions about services, patients do need to be involved. But as an organisation, and as different members of the triumvirate, we need to understand how to work effectively with patients to get their voice heard, but also to allow services to be planned and difficult decisions to be made.

It’s so important to have people in the room who actually know the patient. We will, unless it’s a real emergency, defer the meeting until the referring doctor, or the person bringing that person forward, whose actually met them, seen them walk across the room, shaken their hand and spoken to the family can be there. Otherwise, you end up making these very, very complex and potentially life-changing decisions based just on an angiogram, or a set of blood results, and we know there’s so much more than that. You’re absolutely right, it has to be patient focused because what might be right for one person will be completely inappropriate for another.

Dr Appleby: I know of another trust when they are presenting on the aortic valve disease pathway, they have a photo of the patient just to try and keep focus because sometimes the revascularisation MDT can become a bit of a bun fight – a robust atmosphere. Sometimes we just need to bring back and focus on the patients.

I don’t think it’s feasible to have video links live with patients, you’re just not going to be able to get through the numbers. But if you have ways of bringing the patient into that environment, I think it can be quite helpful.

How does the culture of an organisation affect MDT working?

Dr Lockie: I think that everyone needs that to feel valued. Mutual respect and kindness – these are things that need to come from all the people in senior leadership positions and really emphasise that on a daily basis. It’s about clear communication, it’s about respect for others, it’s about allowing others to have their voice in the space. I think it’s up to all of us to remember that. We have to set a culture where we want to work and where we want our colleagues to feel valued. The knock-on benefit in terms of staff happiness, retention, the overall atmosphere of the team can be really transformed by the simple things.

As soon as you have an environment where people get intimidated or, when they do speak, they’re made to feel as if their point is either irrelevant or not valuable in any way, then people are much less likely to speak out again. Whether you’re talking about the micro unit down on a ward, discussing an individual patient, discussing patients in a meeting, sitting in a boardroom, or you’re presenting a business case, I think that culture really permeates.

On one level, a negative culture can be terrible in terms of staff morale and retention, and you end up with people getting stressed and burnt out, not coming to work. But on another level, we’ve also had situations where there are genuine patient safety concerns because you get to the stage where certain individuals are so unwilling to actually listen to what other people say that people then stop raising concerns. Then things get missed and that is the sign of a properly dysfunctional team.

We’ve got quite a good system at the Royal Free called ‘what matters to you’ – a sort of formalisation of the speaking up process. It starts off with an opportunity to submit feedback online and then they have sessions where they bring it all together and you then have a constructive output and you repeat the process. It’s been really effective in sorting out some of these team relationships and building the kind of the structure which we all seek to have.

If things aren’t good or the communication isn’t there and you don’t have mutual respect, kindness and opportunity for people to speak out, it’s important to speak to your organisation about doing something to change that.

What are the best ways to introduce change?  

Dr Appleby: We are in the process of moving to a new single point of access pathway in terms of aortic stenosis. As part of that, we’ve had to engage with the different members of the team, particularly our surgeons, and agreeing criteria for where we would, up to the point of referral, triage them direct to surgery versus to the cardiologist.

It’s about really engaging the key members first. So, you can agree criteria for which we will triage them. And then when you’ve worked out a provisional pathway, we then opened it up to the wider team for comments. Now we’ve signed it off, which wasn’t a single event, I’m now in the process of going to the region, through our various partner hospitals and taking it through the clinic cardiology clinical leads.

There’s always going to be people who don’t enjoy the change. You have to explain why it’s very necessary, why it’s going to happen and then try and engage people who are perhaps the biggest opponents in designing that so that they feel they have some ownership of it. Then it’s about engaging the whole team and getting feedback before you roll it out.

And it’s getting across to the team that it’s not going to be a one-stop shop where we introduce it and suddenly everything’s great. It’ll be an evolving process. Things will come out of the woodwork we hadn’t anticipated which we’re going to need to deal with. So, managing expectations is also quite a big part of that.

Dr Hussain: It’s great to be able to engage all the key stakeholders from the beginning, but sometimes you just can’t and then you’ve got to go ahead and do it in the best way you can. We’re not talking about utopia where everyone’s going to agree, but as long as you know that it’s in the best interest, you’ve got the majority of people on board and, of course, management and the data behind it, then ultimately, if it’s for patient benefit, then you just have to go ahead.