Phyllis MurphieLead Respiratory Nurse NHS D&G31st March 2010

Service Improvement –Evolution of Sleep Medicine Service in

NHS D&H

•Service Outline

•Background

•Referral handling

•Booking processes

•Reporting

•Managing DNAs

Service Outline• 430 patients on CPAP therapy• 25 on home NIV therapy. • Predicted annual demand estimated at 80 -100 new patients

commencing CPAP therapy and 12 new patients receiving NIV therapy

• Ear Nose and Throat department used for in-patient based sleep investigations

• Most limited channel studies done as outpatient based service.• > 300 new referrals per year requesting limited channel sleep studies.

Obstructive Sleep Apnoea Hypopnoea Syndrome- OSAHS• OSAHS

– common sleep disorder caused by repetitive upper airway obstruction during sleep

– characterized by pauses in breathing during sleep often accompanied by oxygen desaturation

Signs/Symptoms of OSAHS• Loud snoring• Excessive daytime sleepiness• Lack of concentration• risk factors for developing OSAHS

include increasing age, obesity and being male.

• Prevalence - 4% of middle-aged men and 2% of middle-aged women in the UK.

Clinical Consequences of OSAHS

• 7-14 times more likely to have RTA in OSAHS

Service Consequences for OSAHS diagnosis and treatment

•Sleep studies•One of diagnostic tests that has referral to treatment standard of 18 weeks•To be achieved by 2011

What have we done in NHS D&G

Service Redesign• Clinical teams/18 week teams

working together• Innovative ideas to increase the

number of outpatient based diagnostic sleep studies.

• PDSA - Service redesign projects

Referral handling• Respiratory nurse triage of referrals requests

• All internal/external requests for sleep study on TOPAZ

• Routine/soon (vocational drivers)

• Local referral guidelines developed with ENT/Max fax department

• Electronic SCI referral being developed (now part of National Scottish Sleep Forum ongoing work plan

Booking Processes• Acknowledgment letter regarding referral sent to patient• Requesting they contact secretary to book appointment for sleep

study• No response 2 weeks• 2nd letter • No response 2 weeks • Refer back to GP• Remove from W/L

Diagnostic service redesign• V 1- 45 minute outpatient appointment on the day of sleep investigation, clinical history,

examination, routine bloods – Nurse Led

• V 2- 45min - 1hour return appointment day to download and score sleep study and discuss

further treatment options /interventions – negative studies discharged back to referrer – Medical

Input as requested by RNS

• V 2- Positive diagnostic tests for symptomatic OSAHS offered a 1-2 week trial of Auto CPAP

• V 3- CPAP proven to be acceptable /effective next review, then supplied with fixed pressure

CPAP unit and delivery system

• V4 - Reviewed in the Sleep clinic in 3 - 6 months,

1 year, 2 years,

Could consider open access review in compliant patients

Diagnostic service redesign• Where diagnostic uncertainty, patients reviewed 3-6 months in

sleep medicine clinic for further assessment of symptoms

• Consideration of repeat limited sleep diagnostic testing may be an

option

• Referral for full PSG to the Royal Infirmary Edinburgh Sleep

Medicine Unit.

2007-2008 Service delivery

25

180

5040

220

1528

208

15

0

50

100

150

200

250

2007 2008 2009

Hotel Sleep study

Home Sleep study

IP sleep study

Reporting of sleep studies

• Service limitation – no physiologist input

• Development bid 2009- unsuccessful

• RNS – manually scores sleep studies where indicated

• Result verified by Physician where indicated

• More medical input to the service required- development bid unsuccessful

Managing DNA’s• FA x 1 is given for DNA’s

• Letter sent to patient and copy to GP re DNA in case of postal issue

• DNA rate usually low as patient focused booking with Respiratory secretary.

• DNA’s in Sleep medicine clinics – same as above.

Patient Satisfaction with service

• Questionnaire of patient’s views of service delivery

• Demonstrated overall satisfaction with service provision and a preference for home based testing where possible

• Number of failed/repeat tests are minimal

Current service limitations• People from West of region have to travel to Dumfries for IP/Hotel

based sleep study – 150 mile round trip• No respiratory physiology staff input into scoring of sleep studies• Follow-up needs of the increasing numbers on CPAP is now limiting our

ability to carry out new assessments.• Demand for service now greater that Medical/Nursing staff capacity• New service not sustainable long term with increased demand and new

reduced targets

Benefits of Redesign of Service• 2007- 205 outpatient based sleep studies• 2008- 260 outpatient based sleep studies• 2009 – 251 out patient sleep studies• 881 bed days saved over three year period

amounting to net saving of £263,00 for NHS D&G• Outpatient based sleep studies are an

appropriate/acceptable model of service delivery for majority of referrals

• Current waiting time <12 weeks

Lean Principles Already Applied to Service

• Multi-diagnostic sleep sessions- Increased capacity and workflow• Reduce annual CPAP recall to 2 years –consider open access review• Diagnosis to treatment established reduced from 5 visits to 3• Screening referral protocol introduction to improve quality of referral and

referral to correct service pathway/reduce inappropriate referrals• Auto CPAP trial reduced from 2 weeks to one week in most cases• Home auto titration in all patients – increased capacity and workflow• Home diagnostic/hotel diagnostic and auto titration services in almost all

referrals• Consideration of sleep screening/diagnostic services closer to patients

homes – discussions taking place re feasibility

More Service Redesign Ideas

• Development of recommended local/national referral, diagnosis, treatment and review standards

• Better quality referral to ensure patient on correct pathway

• Development of National Dataset with ISD to measure demand/access/equity of services

• National SCI electronic referral system • Increased specialist nurse/physiology staffing• Investment in more diagnostic equipment• New ways of delivering diagnostic services closer to

home – primary care – remote clinics • Open access review on request of non complex

/complaint patients on CPAP to free up RNS time

Questions?