A nurse-led heart murmur clinic was introduced at Sheffield Children’s Hospital in 2023 to reduce waiting times, support the clinical nurse specialist (CNS) role development, and improve cost-efficiency. By triaging appropriate referrals to a CNS-led pathway with pre-arranged echocardiography and telephone follow-up, the clinic reduced wait times from 16 to 5–6 weeks and saved over £3,000 in its first year. The model demonstrates that nurse-led services can safely and effectively manage selected paediatric referrals, improve access to care, and deliver measurable service efficiencies.
Introduction
In 2023, a nurse-led heart murmur clinic was established at Sheffield Children’s Hospital. The initiative was introduced with three key objectives: to reduce the paediatric consultant outpatient waiting list, to expand the scope of practice for clinical nurse specialists (CNS), and to deliver cost savings to the National Health Service (NHS) trust. This case study evaluates the impact of the clinic on waiting times and explores its cost-effectiveness over the first year of implementation.
Background
In paediatrics, heart murmurs are frequently detected incidentally by general practitioners (GPs) during examinations for unrelated illnesses. This is partly because murmurs become more audible during febrile illnesses, when elevated heart rate and increased cardiac output lead to greater turbulence of blood flow.1 At Sheffield Children’s Hospital, current policy advises that, if no other cardiac concerns are present, GPs should re-examine the child approximately six weeks later, once they are well, prior to initiating a referral. Exceptions to this policy include murmurs identified at the routine eight-week baby check, or if there are concerns regarding clinical symptoms, such as breathlessness, poor weight gain, or cyanosis.
If an echocardiogram reveals a structurally normal heart, the murmur is classified as ‘innocent’ or ‘benign’. A study by Gandhi et al.2 reported that, at Sandwell and West Birmingham Hospitals NHS Trust, out of 190 children referred with heart murmurs, 140 (approximately 74%) were diagnosed with innocent murmurs.
Case presentation
Prior to the introduction of the nurse-led clinic, children referred for assessment of heart murmurs were typically seen by a general paediatric consultant in an outpatient clinic, with an average waiting time of 16 weeks. The consultant would take a detailed clinical history, perform a cardiovascular examination, and determine whether the murmur was still audible. If so, an echocardiogram would be arranged for a later date. If the echocardiogram confirmed a structurally normal heart, the family would be informed in writing. If any abnormalities were detected, a referral to the paediatric cardiology team would be initiated.
The introduction of a nurse-led telephone clinic, managed by a clinical nurse specialist (CNS) with training in paediatric cardiology, presented an opportunity to streamline this process. The clinic was first held on 15 June 2023 and began with five patients. Referrals are initially triaged by paediatricians with a special interest in cardiology (PECs), who determine the suitability of each case for nurse-led management. For appropriate patients, the CNS arranges echocardiography with relevant clinical information provided.
Following completion of the echocardiogram, patients are scheduled into a fortnightly nurse-led telephone clinic, accommodating up to eight patients per session. The CNS reviews each echocardiogram in advance to confirm that the findings are consistent with an innocent murmur. During the consultation, the CNS explains the results to the family, reassures them regarding the benign nature of the murmur, and discharges the patient from follow-up. In cases where structural abnormalities are identified, the patient is referred to a PEC for further management.
This consultation is not only helpful for families, but is also essential to the running of the clinic. Due to the structure of the appointment system, sonographers are unable to inform families of normal results, dictate letters, or discharge patients. Without the nurse-led follow-up, results would remain uncommunicated, and patients could not be formally discharged from the service.
Outcomes
The implementation of the nurse-led clinic has yielded significant efficiency and cost savings. A paediatric consultant typically sees two new patients per hour, with an associated cost of £75.50 per hour in staffing – equating to £37.75 per patient. In contrast, the CNS sees three new patients per hour at a cost of £25.16 per hour, or approximately £8.39 per patient. Based on 108 patients seen in the first year, the total cost saving is estimated at £3,182.04. Additional savings are achieved through the use of telephone consultations, which eliminate the need for a physical clinic room.
Patient waiting times have also improved. Previously, the average wait from referral to face-to-face clinic appointment was approximately 16 weeks, followed by additional delays if echocardiography was required. Under the new model, the average time from referral to completion of the nurse-led telephone clinic with echocardiogram results is approximately five to six weeks.
Discussion
The development of a nurse-led murmur clinic has demonstrated clear benefits in terms of reduced costs and improved access to care. Moreover, the clinic provides a valuable opportunity for CNS to expand their practice in paediatric cardiology. It enables CNS to take a more active role in interpreting echocardiographic findings and managing patient care, thereby, enhancing clinical knowledge, decision-making autonomy, and professional fulfilment.
Key messages
- Clinical nurse specialists (CNS) can safely and effectively manage certain paediatric referrals
- Utilising these services can lead to improved access to care and savings for the NHS
- It also allows for development of the CNS role, enhancing clinical knowledge
Conflicts of interest
None declared.
Funding
None.
References
1. Children’s Hospital of Richmond at VCU. Heart murmurs. Available at: https://www.chrichmond.org/services/childrens-hospital-foundation-heart-center/conditions-we-treat/heart-murmurs/ [accessed 19 September 2025].
2. Gandhi D, Gali P, Sivakumar S. 617 Outcome of murmurs beyond infancy. Pediatr Res 2010;68(suppl 1):316. https://doi.org/10.1203/00006450-201011001-00617
