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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
(Echo) Technician Led Clinics(Echo) Technician Led Clinics
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 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 clinicTech Led paediatric echo serviceTech Led paediatric echo service
(Echo) Technician Led Clinics(Echo) Technician Led Clinics
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 EchoesTech 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
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
(Echo) Technician Led Clinics(Echo) Technician Led Clinics
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 serviceTech 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
Tech Led TOE serviceTech Led TOE service
Central Region’s Technical Advisory Service Scholarship 2009Central Region’s Technical Advisory Service Scholarship 2009
Tech Led TOE serviceTech Led TOE service
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
Tech Led TOE serviceTech Led TOE service
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
Tech Led TOE serviceTech Led TOE service
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
(Echo) Technician Led Clinics(Echo) Technician Led Clinics
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 echoTech Led Valve Follow-Up clinicTech Led Valve Follow-Up clinic
Tech Led paediatric echo serviceTech Led paediatric echo service
Tech Led GP access to echoTech Led GP access to echo
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
Tech Led GP access to echoTech Led GP access to echo
Initially thought access limited to 3 areasInitially thought access limited to 3 areas Murmurs (new)Murmurs (new) A FibA Fib ? LV function? LV function
Tech Led GP access to echoTech Led GP access to echo
Access limited to 2 areasAccess limited to 2 areas Murmurs (new)Murmurs (new) A FibA Fib **
Tech Led GP access to echoTech Led GP access to echo
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
Tech Led GP access to echoTech Led GP access to echo
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
(Echo) Technician Led Clinics(Echo) Technician Led Clinics
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 clinicTech Led paediatric echo serviceTech Led paediatric echo service
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
Valve Clinic Follow Up CriteriaValve Clinic Follow Up Criteria
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
Valve Clinic Follow Up CriteriaValve Clinic Follow Up Criteria
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
Valve Clinic ResultsValve Clinic Results
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
Valve Clinic ResultsValve Clinic Results
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
Valve Clinic ResultsValve Clinic Results
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
Valve Clinic ResultsValve Clinic Results
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 Clinic ResultsValve Clinic Results
Nov ’06 to Sept ‘10: 715 pt visitsNov ’06 to Sept ‘10: 715 pt visits
Valve Lesion Distribution
Aortic Stenosis43%
MR25%
AoVR18%
AR6%
MVR6%
MS1.5%
Valve Clinic ResultsValve Clinic Results
Nov ’06 to Sept ‘10: 715 pt visitsNov ’06 to Sept ‘10: 715 pt visits
<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
(Echo) Technician Led Clinics(Echo) Technician Led Clinics
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 clinicTech Led paediatric echo serviceTech Led paediatric echo service