Improving Access to Cardiology Services (Echo) Technician Led Clinics Evolution of the Echo...

Improving Access to Improving Access to Cardiology ServicesCardiology Services

(Echo) Technician Led Clinics(Echo) Technician Led Clinics

Evolution of the Echo Evolution of the Echo PractitionerPractitioner

Why (Echo) Technician Led Clinics?Why (Echo) Technician Led Clinics?

Limited resourcesLimited resources

Very long wait lists for cardiology clinicsVery long wait lists for cardiology clinics

Inefficient utilization of cardiology clinic timesInefficient utilization of cardiology clinic times

Limited fundingLimited funding

More appropriate follow-up times (valve clinic)More appropriate follow-up times (valve clinic)

More timely access to echoMore timely access to echo

More control over echo sessionsMore control over echo sessions

Access to fundingAccess to funding

Cardiology Audit July 2010Cardiology Audit July 2010

Echo Stats by Year

0

500

1000

1500

2000

2500

3000

3500

'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10

Year

Pat

ien

t N

um

ber

s


Tech Led PFO echo clinicTech Led PFO echo clinic

Tech Led Contrast (bubble) echo clinicTech Led Contrast (bubble) echo clinic

Tech Led Aortic Stenosis clinicTech Led Aortic Stenosis clinic

Tech Led Exercise Stress EchoesTech Led Exercise Stress Echoes

Tech Led TOE serviceTech Led TOE service

Tech Led GP access to echoTech Led GP access to echo

Tech Led Valve Follow-Up clinicTech Led Valve Follow-Up clinic

Tech Led paediatric echo serviceTech Led paediatric echo service

(Echo) Technician Led Clinics(Echo) Technician Led ClinicsNelson HospitalNelson Hospital







Tech Led Valve Follow-Up clinicTech Led Valve Follow-Up clinicTech Led paediatric echo serviceTech Led paediatric echo service





Tech Led Exercise Stress EchoesTech Led Exercise Stress EchoesTech Led TOE serviceTech Led TOE service




Tech Led Exercise Stress Tech Led Exercise Stress EchoesEchoes

140 Exercise Stress Echoes annually140 Exercise Stress Echoes annually

One (afternoon) session per weekOne (afternoon) session per week

One EchocardiographerOne Echocardiographer

One Physiology TechnologistOne Physiology Technologist

Cardiologist or Physician on the floorCardiologist or Physician on the floor

Tech Led Exercise Stress Tech Led Exercise Stress EchoesEchoes

Echo review sessionEcho review session

Exercise Stress Echo and ETT reported by Exercise Stress Echo and ETT reported by Cardiologist and Echocardiographer*Cardiologist and Echocardiographer*

Echo findings verifiedEcho findings verified

Letter dictatedLetter dictated






Tech Led TOE serviceTech Led TOE serviceTech Led GP access to echoTech Led GP access to echo




Central Region’s Technical Advisory Service Scholarship 2009Central Region’s Technical Advisory Service Scholarship 2009


Who should perform TOE studies?Who should perform TOE studies?

Consultant cardiologists/anaesthetists/intensivistsConsultant cardiologists/anaesthetists/intensivists

Specialist registrars in trainingSpecialist registrars in training

Cardiac TechniciansCardiac Technicians

Dr N Bunce – St George’s Hospital, LondonDr N Bunce – St George’s Hospital, London


Nelson HospitalNelson Hospital No senior cardiology registrarNo senior cardiology registrar Single TOE trained CardiologistSingle TOE trained Cardiologist Senior Echocardiographer assisted in TOEs Senior Echocardiographer assisted in TOEs last 16yrslast 16yrs Sign-off from Gastroenterologist, CardiologistsSign-off from Gastroenterologist, Cardiologists Approx 60-70 per annumApprox 60-70 per annum


Nelson HospitalNelson Hospital Non-sedated TOEs. Safe Non-sedated TOEs. Safe (85% TOEs St Georges non-sedated)(85% TOEs St Georges non-sedated)

Performed in Echo roomPerformed in Echo room RMO presentRMO present Cardiologist on floorCardiologist on floor Sedated TOEs performed in CCUSedated TOEs performed in CCU







Tech Led GP access to echoTech Led GP access to echoTech Led Valve Follow-Up clinicTech Led Valve Follow-Up clinic



Why GP access to Echo?Why GP access to Echo? New A Fib guidelinesNew A Fib guidelines New NICE heart failure guidelinesNew NICE heart failure guidelines Free up cardiology OPD clinicsFree up cardiology OPD clinics Faster access to resultsFaster access to results Empower GPsEmpower GPs Greater control over echo sessionsGreater control over echo sessions Meet a demandMeet a demand Access to appropriate fundsAccess to appropriate funds


Initially thought access limited to 3 areasInitially thought access limited to 3 areas Murmurs (new)Murmurs (new) A FibA Fib ? LV function? LV function


Access limited to 2 areasAccess limited to 2 areas Murmurs (new)Murmurs (new) A FibA Fib **


Audit 2 month period Oct/Nov ’09 likely referralsAudit 2 month period Oct/Nov ’09 likely referrals 14 likely GP referrals/month, estimate doubled to 28 likely 14 likely GP referrals/month, estimate doubled to 28 likely

referrals per monthreferrals per month

Jan-April ’10 trial period with covering letter to Jan-April ’10 trial period with covering letter to GP with echo resultGP with echo result

Up to 10 per month, estimate likely to doubleUp to 10 per month, estimate likely to double

May ’10, GP education day. GPs notifiedMay ’10, GP education day. GPs notified Average 20 GP referrals per monthAverage 20 GP referrals per month

GP access to echoGP access to echo

GP Educ. day

0

5

10

15

20

25

Jan Feb Mar Apr May June July Aug Sept

Year '10

Pat

ien

t n

um

ber

s

GP referrals to Echo '10

GP educ. day


Patient not seen by CardiologistPatient not seen by Cardiologist

Limited toLimited to Murmurs (new)Murmurs (new) A Fib*A Fib*

Echo reviewed at cardiology review Echo reviewed at cardiology review sessionsession

Letter dictated by cardiologist to Letter dictated by cardiologist to accompany echo reportaccompany echo report

ECHOCARDIOGRAPHER TECHNICIAN LED VALVE ECHOCARDIOGRAPHER TECHNICIAN LED VALVE FOLLOW-UP CLINIC FOLLOW-UP CLINIC

(VALVE CLINIC)(VALVE CLINIC)

11stst prize Affiliates section prize Affiliates section

EchoValve Follow Up Patient Cardiologist OPD

•Follow up organised•Results/letter to GP•Results/letter to notes

Tech Led Valve Follow-Up clinic Tech Led Valve Follow-Up clinic

Traditional Patient-flowTraditional Patient-flow

EchoValve Follow Up Patient Cardiologist OPD

•Follow up organised•Results/letter to GP•Results/letter to notes

Valve Follow Up Patient

Valve ClinicEchoQOLB/PECG

•Follow up organised•Results to GP•Results to notes

Echo review

Traditional Patient-flow vs Valve ClinicTraditional Patient-flow vs Valve Clinic

Referral to Valve ClinicReferral to Valve Clinic

Initial enrolment into Valve Clinic made by the CardiologistInitial enrolment into Valve Clinic made by the CardiologistAssymptomatic mild, moderate and moderately-severe valve diseaseAssymptomatic mild, moderate and moderately-severe valve diseaseAortic StenosisAortic StenosisMitral RegurgitationMitral RegurgitationAortic RegurgitationAortic RegurgitationMitral StenosisMitral StenosisTissue valve replacementTissue valve replacement

Valve ClinicValve Clinic

Patient aware that they will Patient aware that they will notnot see the Cardiologist see the Cardiologist

EchocardiogramEchocardiogram

Short QOL questionnaireShort QOL questionnaire

B/PB/P

ECGECG

Short QOL questionnaireShort QOL questionnaire

Change in symptomsChange in symptoms

Presyncope/syncope Presyncope/syncope yes/noyes/no

Increased SOB Increased SOB yes/noyes/no

Chest pain Chest pain yes/noyes/no

PalpitationsPalpitations yes/noyes/no

Echo review sessionEcho review session

Review Echo,ECG, B/P, QOL

Valve Clinic with reviewed follow-up interval

Valve ClinicPatient

symptoms/Echo unchanged

Cardiologist OPDClinic visit+/- Echo

Patient symptoms/Echo

changed

Patient Symptoms unchanged

Echo changed

Valve Clinic Follow Up CriteriaValve Clinic Follow Up Criteria

Aortic Stenosis

Mild Stenosis 3-5 year Valve Clinic followup

Moderate Stenosis 1-2 year Valve Clinic followup

Mod-severe Stenosis Needs cardiology OP review 6 month Echo/Cardiologist followup

Severe Stenosis Needs cardiology OP review 3-6 month

(assymptomatic) Echo/Cardiologist followup


Mitral Regurgitation (MR)

Mild MR 5 year Valve Clinic followup

Mild-moderate MR 3 year Valve Clinic followup

Moderate MR 2 year Valve Clinic followup

Moderately-severe MR 1 year Valve Clinic followup

Severe MR Needs cardiology OP review 3-6 month

Echo/Cardiologist followup

Tissue Valve Replacements

Baseline post Op Echo, then 3x biannual Valve Clinic follow up, then yearly


Patients remain in active follow-up in the Valve Clinic until the age of 80-85 years

Valve lesion being followed Severity of valve lesion Patients discharged back to their GP

Valve Clinic ResultsValve Clinic Results

Audited: feasibility, safety and efficiencyAudited: feasibility, safety and efficiency


FeasibleFeasible

Absolutely feasibleAbsolutely feasible Echoes are not extra echoesEchoes are not extra echoes Altered patient journeyAltered patient journey ‘‘Extra’ tests: ECG, B/P, QOLExtra’ tests: ECG, B/P, QOL


Safe. No patient was admitted or seen acutely during Safe. No patient was admitted or seen acutely during the period between Valve Clinic visitsthe period between Valve Clinic visits


EfficientEfficient

Makes better use of Echo clinic timesMakes better use of Echo clinic times Makes better use of Cardiologist clinic timesMakes better use of Cardiologist clinic times Fits department ethos on clinical efficienciesFits department ethos on clinical efficiencies


Nov ’06 to Sept ‘10: 715 pt visitsNov ’06 to Sept ‘10: 715 pt visits

7

107

162

225

274

0

50

100

150

200

250

300

Patient Visits

06 07 08 09 10

Year

Valve Clinic Activity



Valve Lesion Distribution

Aortic Stenosis43%

MR25%

AoVR18%

AR6%

MVR6%

MS1.5%



<20% of patient’s disease progressed to warrant formal Cardiologist <20% of patient’s disease progressed to warrant formal Cardiologist outpatient reviewoutpatient review

>80% of patients entered into the valve clinic remain in active follow-up >80% of patients entered into the valve clinic remain in active follow-up in the valve clinicin the valve clinic

Valve ClinicValve Clinic

Hugely reduced impact on Cardiologist clinic Hugely reduced impact on Cardiologist clinic timestimes

Reduced patient waiting timesReduced patient waiting times

More timely follow up of chronic valve conditionsMore timely follow up of chronic valve conditions

More control over echo sessionsMore control over echo sessions

Appropriate access to appropriate fundingAppropriate access to appropriate funding

Proven to be a safe process in which to follow-up Proven to be a safe process in which to follow-up valve lesionsvalve lesions

ConclusionConclusion

Within the framework of tight clinical governance the Within the framework of tight clinical governance the Echocardiographer Technician Led Valve Follow-up Clinic has Echocardiographer Technician Led Valve Follow-up Clinic has improved patient care. improved patient care.

Patient waiting times have reduced allowing tight, timely follow Patient waiting times have reduced allowing tight, timely follow up of chronic conditions. up of chronic conditions.

In addition consultant clinic time has now been targeted towards In addition consultant clinic time has now been targeted towards

the higher risk patients.the higher risk patients.

Valve Clinic Requirements/Tech Valve Clinic Requirements/Tech Led ClinicsLed Clinics

Competent Echocardiographer/sCompetent Echocardiographer/s Technically and clinically*Technically and clinically*

Echo database (‘no notes’ dept)Echo database (‘no notes’ dept)

100% support from Cardiologists100% support from Cardiologists

Understanding of Cardiology Department Understanding of Cardiology Department funding streamsfunding streams

Improving Access to Cardiology Services (Echo) Technician Led Clinics Evolution of the Echo...

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