Welcome and programme
optimisation Jonathan Earnshaw, Clinical Lead, NHS AAA Screening Programme, Public Health
England
Part of Public Health England
Abdominal Aortic Aneurysm
NHS AAA Screening Programme
Network meeting June 2016
Jonothan J Earnshaw
Clinical Lead
Results
• 1.3 million men invited
• 1,019,480 men screened (uptake 79.5%)
• Almost 13,000 AAA (>3cm) detected
• Prevalence 1.3%
•Almost 12,000 men in surveillance
• Some 1923 men referred for surgery
results available https://www.gov.uk/topic/population-
screening-programmes/abdominal-aortic-aneurysm
Large AAA (>5.4cm) detected
1025 65-year-old men first scan
898 men from surveillance
49% EVAR
51% Open repair (OR)
(3:1 EVAR:OR rate in UK overall)
Intervention rate around 91%
Mortality rate 0.9%
Update on Programme optimisation:
Health Improvement Analytical Team, Department of
Health
• Reducing surveillance
• Reinviting men with subaneurysmal aorta
• Inviting women
Surveillance intervals Option A
2year, 3month
Option B
1year, 6month
Option C
2year, 6month
Option D
3year, 3month
Cost Savings per man invited
(£) 2.57 1.51 3.45 3.78
QALY Gain per man invited (£)⁺ -1.25 -1.41 -2.46 -3.28
Net Benefit per man invited (£) 1.33 0.10 0.99 0.50
Total Cost Saving from fewer
Screens per invited cohort (£)⁰ 680,000 480,000 1,110,000 960,000
Fewer Scans per invited cohort 12,000 8,750 20,000 17,000
⁰ Total savings associated to invited cohort of 300,000, discounted at
3.5% per annum
⁺QALYs monetised at £20,000
Increasing detection of AAA
Subaneurysmal aorta – 25 year data from Gloucestershire
0.2
.4.6
Cu
mula
tive
Incid
ence
0 5 10 15 20 25
Time (years)
Initial Diameter: 2.6-2.9cm Initial Diameter: 3.0-5.4cm
with mortality as a competing outcome
Cumulative Incidence Function for Progression to 5.5cm
0.2
.4.6
Cu
mula
tive
Incid
ence
0 5 10 15 20 25
Time (years)
<3cm+ 5 years after first scan 3cm+ 5 years after first scan
with mortality as a competing interest
Cumulative Incidence Function for Reaching 5.5cm+
Subaneurysmal aorta
>2.9cm % 0f 1156 >5.4cm % 0f 1156
Within 5 years 541 47% 7 0.6%
Within 10
years
659 57% 71 6%
Within 15
years
674 58% 138 12%
Within 20
years
674 58% 151 13%
Latest results from the Gloucestershire and Swindon AAA Screening
Programme (unpublished)
Health Improvement Analytical Team Recommendations:
Surveillance intervals for men with small AAAs should be extended so that
scans are performed biennially, as opposed to annually. This will lead to a more
cost-effective programme and 12,000 fewer rescans per invited cohort.
The NSC is asked to give careful consideration to the existing published
evidence relating to sub-aneurysmal aortic dilation. A rescan at 5 years would
require an additional 6,500 scans per invited cohort.
There is not currently enough evidence to justify the introduction of AAA
screening for women though this issue should be revisited in future years.
Optimising AAA screening
• Evidence review
• NAAASP Strategic and Research Groups
• NAAASP Directors, and other interested parties
• NAAASP Advisory Board
• Costing options DH Health Improvement Analytical Team
• 4 Nations Group (June 2015)
• Advice to obtain more independent evidence
• National Screening Committee (Oct 2016)
• Department of Health and Public Health England
• Implementation (2018/19)
Other programme matters
Equality and diversity policies
4 nations results
Uptake of screening and aneurysms
detected by decile of deprivation
Equality and diversity report
Jo Jacomelli Conclusions:
• Uptake affected by social deprivation
• AAA prevalence affected by social deprivation
• Uptake affected by ethnicity – need to improve recording
• AAA prevalence may be affected by ethnicity (confounder is
relationship between ethnicity and deprivation)
Improving uptake
• Inequalities research
• Local solutions
• NAAASP toolkit (4 nations approval)
National update Lisa Summers, Programme Manager, NHS AAA Screening Programme, Public Health
England
NAAASP National Networking
and Information Day
Lisa Summers
NHS AAA Screening Programme Manager
June 2016
Public Health England leads the NHS Screening Programmes
2016-17 Objectives
Review optimisation of AAA Screening Programme
Specify and re-procure national IT screening system to support existing
programme
Improve the dissemination of data to support local screening programmes,
commissioners and QA linking in programme specific operating model for
QA and inequalities reports for local programmes and commissioners
20 ISF UPDATE
Headline data 2015-2016 (provisional)
21 ISF UPDATE
Reports
• Pathway standards
• Quarterly/annual standards reports
• Quarterly waiting times
• KPIs
• Death proformas
22 ISF UPDATE
IT
• SMaRT:-
• Training for Co-ordinators/Admin
• Training for SQAS staff
• Version 9.4
• User Group
• Northgate Helpdesk
23 ISF UPDATE
New Qualification
• Structure
• Assessment
• Awarding organisations and centres
• Costs
• Re-accreditation
24 ISF UPDATE
Nurse Practitioner Group
• Develop, implement and monitor best practice guidelines
• Best practice guidelines to support AAA Nurse Specialist
• Develop and introduce nursing Standard Operating Procedures
25 ISF UPDATE
Screening Quality Assurance Service
• Visit schedule
• PSOM
• PCAs and PCA training
26 ISF UPDATE
Screening in Prisons
• PHE/NHSE/NOMs
• Interim Solution
• Pathways
• AAA SOPs - Annexe
Communications
GOV.UK:
User Survey – professional-facing screening content
Shared Leaning Policy:
https://www.gov.uk/government/publications/nhs-population-screening-
submitting-a-case-for-shared-learning
Accessible information standard:
Implementation - 31 July 2016
Information resources expert group
28 ISF UPDATE
Sign up to our Blogs!
Coming up….
• Four Nations
• PHE Annual Conference
• Programme optimisation
• Programme Directors meeting – November 2016
• National Research Meeting – Spring 2017
30 ISF UPDATE
Research update Jonathan Earnshaw, Clinical Lead, NHS AAA Screening Programme, Public Health
England
NAAASP research
• External to the Programme (Research Lead: Tim Lees)
• Programme research/evaluation
- Self referred men
- Prevalence monitoring
- Safety in surveillance
- National mortality rates
Approvals
Prehabilitation
Diet & AAA
Understanding non-attendance
Cardiovascular risk reduction –
feasability study
Drug study – reducing growth
Aardvark
Pre-operative exercise
Data to inform treatment risk algorithm
UKAGS
Metabonomic analysis serum & urine
Multimodal assessment of AAA
pathogenesis
Programme evaluation – growth rates
& surveillance data
Self referral
Reducing prevalence
Screening year Tested Aneurysm % aneurysm
2009/10 17,133 249 1.45
2010/11 30,549 490 1.60
2011/12 98,529 1,378 1.40
2012/13 183,034 2,463 1.35
2013/14 235,409 2,941 1.25
2014/15 224,517 2,674 1.19
Reducing prevalence of AAA
BJS, 2015
AAA screening of 65
year old men remains
cost effective to a
prevalence of 0.35%
Safety in surveillance
Total 12,804 men in surveillance
Follow-up 24,127 person years
Risk of rupture:
3-4.4cm (7 ruptures) – 0.03 (c.i. 0.02-0.07) per 100 person
years
4.5-5.4cm (8 ruptures) – 0.42 (c.i. 0.21-0.85) per 100
person years
NAAASP Research day
January/February 2017
Reducing AAA-related mortality
Anjum et al. BJS 2012
Deaths with mention of AAA in men and women in
England from ONS statistics
Deaths from ruptured AAA in men and women per
100,000 population from ONS data
Deaths from ruptured AAA in men in England from ONS
statistics according to age
Hospital admission with code for ruptured AAA in men
and women in England according to age
Conclusion
NHS AAA Screening Programme is feasible and cost
effective.
Referral threshold safe
Still room for optimisation
On target to reduce deaths by up to 50%
Data information Jo Jacomelli, Data and Information Manager, Screening, Public Health England
Data and Reporting
AAA networking day, 28 June 2016
Programme specific operating model
47 Data and reporting
Aim – To describe the activities of the Screening Quality Assurance Service
Data chapter
• Outlines the indicators used by SQAS for visits and ongoing
activities
• Cover key points in the screening pathway
• Information on sources, data sharing, reporting and data requests
https://www.tumblr.com/search/cute%20possums
PSOM indicators
National / retired standards
• Ineligible men
• Incorrect contact details
• Eligible men excluded
• Men with an aorta ≥ 3.0cm on initial screen
• Referrals deemed fit for intervention at first assessment post referral
• Operative procedures on AAA <5.5cm at last ultrasound
• 30 day mortality following elective surgery
• One year any cause mortality following elective surgery
• One year AAA cause mortality following elective surgery
48 Data and reporting
PSOM indicators
Invitation and attendance standards
• Men declining screening
• Men who DNA their first appointment
• Men who attend after not attending first appointment
• Men with an aorta 3.0 – 4.4cm on initial screen
• Men with an aorta 4.5 – 5.4cm on initial screen
• Men with an aorta ≥5.5cm on initial screen
Internal QA
• Percentage of scans sent for IQR
• Percentage of men recalled following internal QA
• Delay between scan and QA review
Surveillance men
• Percentage of men lost from surveillance by reason
49 Data and reporting
Process for PSOM data
• Collected from routine SMaRT data
• Produced quarterly on a programme level
• Draft report will be signed off by QA steering group
• Will be piloted with the SQAS (regions) to ensure it is fit for purpose and
obtain a baseline
• No thresholds initially
• Will be made available to programmes through SMaRT
50 Data and reporting
Inequalities report
• Available through SMaRT quarterly
• Tables of
• Eligible, offered, screened and declined by
• GP
• LSOA
• LA
• Ethnicity of men tested by
• Programme
• LA
• Ethnicity of men with aorta ≥3.0cm
• Line list of men referred for surgery by LSOA and ethnicity
51 Data and reporting
Report table examples
52 Data and reporting
How can this information be used?
How do I know if I have a particular ethnic group not attending screening?
Sources of ethnicity data
• Office for national statistics
• NOMIS :
https://www.nomisweb.co.uk/query/construct/summary.asp?mode=constru
ct&version=0&dataset=651
• NOMIS uses 2011 census data – most up to date
You can create a table and chart comparing the breakdown of men you have
tested by ethnicity and the percentage of men in that ethnic group in the
population
53 Data and reporting
Table
54 Data and reporting
Area tested perc tested testedtot population pop total perc_pop
1 0 0.00 608 6 5821 0.10
2 0 0.00 1087 3 9094 0.03
3 0 0.00 1470 5 10323 0.05
4 0 0.00 1768 14 17150 0.08
5 0 0.00 1147 8 9148 0.09
6 0 0.00 1186 13 8906 0.15
7 4 0.25 1611 87 11681 0.74
8 0 0.00 1057 3 8588 0.03
9 15 1.54 973 160 8454 1.89
10 3 0.12 2426 224 20420 1.10
11 0 0.00 2303 17 17811 0.10
12 0 0.00 1231 57 12036 0.47
13 1 0.07 1521 43 11027 0.39
14 1 0.08 1303 16 9547 0.17
15 3 0.18 1711 73 14051 0.52
16 4 0.29 1401 220 11135 1.98
17 9 0.50 1814 91 16213 0.56
18 121 1.85 6540 3398 60611 5.61
19 1 0.10 978 30 7633 0.39
20 1 0.10 1052 8 8533 0.09
Scatter chart – national black or black
British: Caribbean
55 Data and reporting
Scatter chart – national black or black
British: Caribbean
56 Data and reporting
Deprivation
How do I know if men in particular areas aren’t attending?
Sources of information:
Office for national statistics:
http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/
populationestimates/datalist
Link to IMD2015 by LSOA
https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015
Look at areas of low uptake and see if they are in areas of deprivation
57 Data and reporting
Can anyone help me with this?
Yes!
We will produce a template to help with the ethnicity comparison and
deprivation
Your commissioners can help with interpretation
Look at issues in your area in order to decide which interventions are the most
suitable
58 Data and reporting
8 week waiting time – 2014/15 Breakdown of men referred to and not declining surgery by outcome for the 8
week to treatment standard, by programme
59 Data and reporting
8 week waiting time – Q1 to Q3 2015/16 Breakdown of men referred to and not declining surgery by outcome for the 8
week to treatment standard, by programme
60 Data and reporting
Improvements
2014/15 Q1-Q3 2015/16
England % men
operated on in 8 weeks 56.9% 75.5%
England % breach -
patient comorbidity 24.8% 12.8%
England % breach -
hospital factors 18.3% 11.7%
Number of programmes
reaching acceptable 16 14
Number of programmes
reaching achievable 5 19
61 Data and reporting
Learning from serious
incidents Jane Woodland, Regional Head of Quality Assurance, Midlands and East, Public Health
England
Julie Till-Wylie, Quality Assurance, Midlands and East, Public Health England
Managing and learning from
incidents in the AAA screening
programme
Jane Woodland: Regional Head of Quality Assurance, Midlands and East
28 June 2016
Public Health England leads the NHS Screening Programmes
• Why this is important
• What we like you to know and do
• Examples for discussion
Why this is important
• Ethical duty
• Statutory requirement
Mid Staffs
Duty of candour
• Improve quality and safety of screening programmes –
locally and nationally
65 Managing Safety Incidents in NHS Screening Programmes
Learning from incidents
66 Managing Safety Incidents in NHS Screening Programmes
National learning
• The 2015-16 national service spec was updated to reflect programme
responsibility to track referrals
• All screen positive AAA referrals are tracked using the SMaRT referral
tracking application which was installed as part of release 9 software
upgrade in July 2015
• The national programme checks AAA death proformas and ensures that a
copy is sent to QA if not already done so
• National “blogs” and previous newsletter articles, and enquiries made to
programmes via QA teams
• Refining the process for dealing with queries/incidents involving the national
software
……huge learning and a safer service for patients
What we’d like you to know
The policy framework
The Policy framework Managing Safety Incidents in NHS Screening Programmes
(MSI in NSP)
https://www.gov.uk/government/publications/managing-safety-incidents-in-
nhs-screening-programmes
(October 2015)
NHS England Serious Incident Framework (SIF)
https://www.england.nhs.uk/patientsafety/serious-incident
(March 2015)
68
Managing Safety Incidents in NHS Screening Programmes
Screening safety incident Screening safety incidents include:
• any unintended or unexpected incident(s), acts of commission or acts of
omission that occur in the delivery of an NHS screening programme that
could have or did lead to harm to one or more persons participating in the
screening programme, or to staff working in the screening programme
• harm or a risk of harm because one or more persons eligible for screening
are not offered screening.
Refer to: Section 1.5 ‘Definition of a screening safety incident’ Managing
Safety Incidents in NHS Screening Programmes
69
Managing Safety Incidents in NHS Screening Programmes
70 Managing Safety Incidents in NHS Screening Programmes
• Serious incidents in
screening programmes
have consequences that
are so significant that
they require a heightened
response
• Avoidable severe harm or
death if situation
continues
• Case by case judgement
and expert advice needed
Serious incidents in NHS screening
programmes
Serious incidents in screening programmes Organisation unable to deliver acceptable quality of healthcare services
Examples include
Serious data loss/information governance related incident
Where the potential for harm may extend to a large population
Systematic failure to provide an acceptable standard of safe care
Major loss of confidence in the service including prolonged adverse media
coverage or public concern about the quality of healthcare or the
organisation
0eRefer to: Section 1.6 ‘Definition of a serious incident ’ Managing Safety Incidents in NHS
Screening Programmes
71 Managing Safety Incidents in NHS Screening Programmes
72 Managing Safety Incidents in NHS Screening Programmes
Providers
SIT / responsible
commissioner PHE QA
Accountability, roles &
responsibilities
What we’d like you to do
Reporting, management and investigation
Screening incident assessment form
The screening incident assessment form (SIAF) is to be used for suspected
safety incidents and serious incidents in NHS screening programmes.
The form should be accessed from the DH.gov.uk website at
https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-
screening-programmes
74
Managing Safety Incidents in NHS Screening Programmes
75 Managing Safety Incidents in NHS Screening Programmes
Safety incident suspected
Provider informs QA & SIT
Fact Finding
Classification and handling plan in 5
working days
Serious incident declared
Reported on STEIS within
48hours
Serious incident team
Serious Incident team reports level
of investigation within 72 hrs
SI Report including incident chronology and
RCA & recommendations
QA disseminates lessons identified
Screening incidents – Actions
Incident team
Immediate actions – patient focus
Produce / implement Action plan
RCA – depth varies
Oversee implement
actions
Identify and share lessons learnt
Agree timescales for closure
76
Managing Safety Incidents in NHS Screening Programmes
Managing incidents
77
Managing Safety Incidents in NHS Screening Programmes
Data Gathering
Analysis
Solution
What’s happened? Investigation
Why did it happen? Determine root cause
What should we do to prevent
it happening again? Implement corrective actions
Adapted from CPA Standard H6.2
Safety Incident reports by SIAF classification
Safety incidents for internal investigation – no further QA action –
• Provider decides format in line with its governance process
• Screening and immunisation team may want to review
• Recorded on SQAS and SIT monitoring systems
Safety incidents internal investigation and RCA
• QA advise that a one page report is produced – suggested template
available
• SIAF included as an appendix
Safety incident (multi-organisation/disciplinary, investigation panel and
RCA
• QA advise that NPSA concise report with SIAF included as an appendix
78
Managing Safety Incidents in NHS Screening Programmes
Escalation
79
Managing Safety Incidents in NHS Screening Programmes
Scenarios for discussion
Is this a -
• safety incident
• a serious incident
• not an incident
What immediate actions would you take?
80
Managing Safety Incidents in NHS screening Programmes
Activity
Categories
81 Managing Safety Incidents in NHS Screening Programmes
Not an incident
Screening safety incident
Serious incident
Questions – Slide 1 (10 mins to discuss)
82 Managing Safety Incidents in NHS Screening Programmes
Scenarios around 8 week breaches
1 Patient cancelled surgery date which was offered within 8 weeks (due to
his daughters wedding), and then AAA ruptured before next offered
surgery date.
2 Stent was not available within 12 weeks and patient’s AAA ruptured
3 Surgery cancelled due to ITU bed availability. Surgery re-scheduled for
after 12 weeks. Patient AAA ruptured in the interim but patient recovered
well from emergency surgery.
4 Surgery scheduled outside of 12 weeks due to shortage in interventional
radiologists. Patient died of a AAA rupture before surgery date.
5 AAA repair conducted successfully. Patient died post operative within 30
days.
Questions – Slide 2 (10 mins to discuss)
83 Managing Safety Incidents in NHS Screening Programmes
Scenarios within the screening pathway
1 Images saved to incorrect patient file
2 Images lost during upload to SMaRT
3 Patient appointments cancelled due to staff sickness on day of
clinic
4 Scanner stolen from technician’s front seat of car after a busy
clinic day
5 Last weeks 2nd DNA letters to GP did not generate and SMaRT
shows an error
6 A number of surveillance patients were not being routinely
called to 3 monthly surveillance appointments over an annual
period.
Any Questions?
Breakout session one: • Waiting Times - Jonathan Earnshaw, Clinical Lead, AAA Screening Programme, NAAASP
• Management of self-referrals - Lewis Meecham, Specialist Registrar, Vascular Surgery,
Black Country Vascular Unit
• UKAGS and screening in women - Matthew Bown, Professor of Vascular Surgery,
University of Leicester
• Previous aortic surgery? Exclusions/Non-visualisation - Jonathan Earnshaw, Clinical Lead,
AAA Screening Programme, NAAASP
• 2017 Research meeting - Jonathan Earnshaw, Clinical Lead, AAA Screening Programme,
NAAASP
Self referral to the NHS Abdominal Aortic
Aneurysm Screening Programme
Lewis Meecham, Jo Jacomelli,
Arun D. Pherwani, Jonothan Earnshaw
Introduction & Aims
• NHS abdominal aortic aneurysm screening programme introduced in England 2009
• Fully operational since 2013
• All men are invited for screening in 65th year
• Men aged more than 65 years are allowed to self –refer for screening
• Currently screening approximately 300, 000 men per annum
• The aim was to provide a descriptive analysis of men who self refer to the NAAASP from 2009 to August 2014
Demographics
• 2009 to Aug 2014
• 58,999 self referrals (700,816 invited in same time period)
• Mean age 73 years (range 47-100).
• 82% with smoking history
• Incidence of AAA was 4.13% (n = 2,438), in contrast to 1.4% in the invited cohort (age 65)
• Of these 7.6% (n=186) were 5.5cm or greater.
Small AAA (3-4.5cm)
Large AAA (5.5cm and greater)
P Value
Aspirin 41.7% 43.0% 0.416
Statin 64.9% 61.3% 0.681
Results
Self referrals have increased year on year
Monthly increase in self referrals with noticeable spikes
Results
Type of surgery
N Percentage
Open 39 38.8%
EVAR 84 55.3%
Outcome Percentage
Surgery 81.7% (n=152)
Declined 5.4% (n= 10)
Unfit 4.8% (n = 9)
Died in referral pathway
1% (n=2)
30 day operative mortality – 0% 8 Week referral to surgery target –(n = 88) (57.9%) Mean time from referral to surgery was 69 days (2 – 361 days)
Discussion • NAAASP 65 currently 1.4% 1
• MASS trial incidence 4% (screen age 65-74)2
• US veterans affairs incidence 7% (mean age 72)3
• We found in self referrals an incidence of 4.13% likely due to (age (73 years), smoking (82%), ethnicity (96% white), low compliance with BMT)
• Self referral element is cost effective
• Role of future publicity from local / natinal programme
1. http://aaa.screening.nhs.uk/news.php?monthye=0713 2. Thompson SG, et al. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the
randomised Multicentre Aneurysm Screening Study. BMJ 2009;38:2307 3. Chun KC, et al. Risk factors associated with the diagnosis of abdominal aortic aneurysm in patients screened at a regional
Veterans Affairs health care system. Ann Vasc Surg. 2014 Jan;28(1):87-92.
Conclusion
• Self-referral has yielded higher detection rates than the invited cohort, more than justifying its cost.
• Now that NAAASP is fully operational it is important to continue media campaigns and publicity to target the high risk men over 65 who would otherwise miss the benefits of AAA screening.
• Self referrals increased with increased publicity – could this be channeled to target more at risk individuals
• Publicity should be targetted to high risk individuals
UKAGS and Research on Screening Women
Matt Bown
University of Leicester
www.le.ac.uk
UK Aneurysm Growth Study
Background
• Prospective cohort study of men screened for AAA
• Circulation Foundation/British Heart Foundation funded
• Sample size: 10,000 controls, 5000 AAA
• Postal consent
• Various invitation methods
– Invitation card at screening/surveillance clinic
– Mailshot
– Direct contact (media)
– Non-NAAASP surveillance clinics
Recruitment
Sep-1
1
No
v-1
1
Jan-1
2
Ma
r-1
2
Ma
y-1
2
Jul-1
2
Sep-1
2
No
v-1
2
Jan-1
3
Ma
r-1
3
Ma
y-1
3
Jul-1
3
Sep-1
3
No
v-1
3
Jan-1
4
Ma
r-1
4
Ma
y-1
4
Jul-1
4
Sep-1
4
No
v-1
4
Jan-1
5
Ma
r-1
5
Ma
y-1
5
Jul-1
5
Sep-1
5
No
v-1
5
Jan-1
6
Ma
r-1
6
Ma
y-1
6
0
2000
4000
6000
8000
10000
12000
14000
Cumulative AAA
Cumulative Controls
Original recruitment Revision
Recruitment
Sep-1
1
No
v-1
1
Jan-1
2
Ma
r-1
2
Ma
y-1
2
Jul-1
2
Sep-1
2
No
v-1
2
Jan-1
3
Ma
r-1
3
Ma
y-1
3
Jul-1
3
Sep-1
3
No
v-1
3
Jan-1
4
Ma
r-1
4
Ma
y-1
4
Jul-1
4
Sep-1
4
No
v-1
4
Jan-1
5
Ma
r-1
5
Ma
y-1
5
Jul-1
5
Sep-1
5
No
v-1
5
Jan-1
6
Ma
r-1
6
Ma
y-1
6
0
500
1000
1500
2000
2500
3000
3500
Cumulative AAA
Original recruitment Revision
Female AAA Screening
Projects
1. Screening Women for abdominal aortic ANeurysm (SWAN)
2. Female Aneurysm screening STudy (FAST)
SWAN
• NIHR HTA commissioned project
• Project team
– Simon Thompson (PI)
– Mike Sweeting
– Janet Powell
– Edmund Jones
– Pinar Ulug
– Matt Glover
– Jonothan Michaels
– David Sidloff
SWAN: Rationale
SWAN: Methods
• New programmable statistical/economic model
• Wide range of parameters required
• Data sources
– Literature
– Databases (NVR, HES-ONS, Vascunet)
– Male (screening) data
SWAN: Outputs
• New model
• Estimate of clinical effectiveness
• Economic analysis
• Value of information
FAST
• NIHR RfPB (researcher led)
• Pilot of AAA screening for women
• Leicestershire, Rutland and Northamptonshire
FAST: Methods
• GP read codes used to identify cohorts at GP practices
– Smoking (current or ex)
– History of coronary heart disease (MI, PCI, CABG)
– Ethnicity
– Healthy (non-smokers and no CHD)
– First-degree relatives of patients with AAA
• 65 to 74 year-old women
FAST: Methods
• GP read codes used to identify cohorts at GP practices
– Smoking (current or ex)
– History of coronary heart disease (MI, PCI, CABG)
– Ethnicity
– Healthy (non-smokers and no CHD)
– First-degree relatives of patients with AAA
• 65 to 74 year-old women
FAST: Methods
• NAAASP type invitation
• Consent at clinic for screening
• Consent for research at the same time as screening
• Data collection
– Screening outcomes
– Basic demographics/biometry
– QoL
– Linkage (GP, hospital, HES-ONS)
FAST: Sample size
0
500
1000
1500
2000
2500
3000
Sam
ple
siz
e
Prevalence estimate
FAST: Sample size
n
• Smoking: Current smokers 2626
Ex-smokers 2626
• History of coronary heart disease 1700
• Ethnicity 1000
• Healthy (non-smokers and no CHD) 1000
• First-degree relatives of patients with AAA 1003
FAST: Outcome measures
• Primary
– Attendance
– Prevalence of AAA
• Secondary
– Accuracy of primary care read codes for AAA risk
– Long-term outcomes
FAST: Timeline
• Project start: 1st Aug 2016
• Screening start: 1st Nov 2016
• Project end: 31st Dec 2017
FAST: Timeline
• Project start: 1st Aug 2016
• Screening start: 1st Nov 2016
• Project end: 31st Dec 2017
FAST: Timeline (not so FAST)
• Original application: 16th Sept 2014
• Rejection: 23rd March 2015
• Revised application: 18th May 2015
• Acceptance: 26th Nov 2015
• Pre-project bureaucracy: 7 months!
• Project start: 1st Aug 2016
• Screening start: 1st Nov 2016
• Project end: 31st Dec 2017
Breakout session two: • New qualification
• Nursing SOPs
Patrick Rankin, National Education and Training Manager, Public Health England
NAAASP National Networking
and Information Day Patrick Rankin
National education and training manager
Public Health England leads the NHS Screening Programmes
New qualification
• level 3 award on the regulated qualification framework (RQF)
• Level 3 is academic level not AfC
• Diploma for Health Screeners (DES/AAA/NBHS)
• provides clinical screening staff with a nationally recognised
qualification
• ensures clinical staff have the knowledge, skills and understanding
to work in a healthcare environment
• provides screening staff with a framework to develop knowledge
and clinical skills required for their specific screening programme
• opens up numerous career development opportunities for staff
within screening programmes
• can add additional screening programmes if required
Reaccrediation Update June 2016
Who needs to take the qualification….?
• from 1st April this is the required qualification for clinical staff in DES,
AAA and NBHS(2017)
• includes new all non-professionally regulated new clinical staff
• screening technicians in NAAASP
• previous qualification will remain valid and existing staff do not have
to undertake the diploma for health screeners
• can apply for recognition of prior learning
Reaccrediation Update June 2016
Structure of the qualification
• similar structure to NVQs
• work based qualification
• based on a number of units and evidencing work based
competency to an assessor
• assessors will need to have a qualification in assessing
• learners provide evidence of competency via local
assessments
• different method of delivery from current course
Reaccrediation Update June 2016
Mandatory units (13)
• provides screening programme staff with the basic understanding
and core knowledge and skills of working in a healthcare setting
• formalisation of learning that should already undertaken in
screening programmes
• should be covered in employee induction
• based on significantly on the care certificate
• provides confidence that all staff have the same induction - learning
the same skills, principles, knowledge and behaviours to provide
compassionate, safe and high quality health care
• resources available online that cover the majority of the learning
outcomes required for the mandatory units
• skills for care and skills for health websites have lots for
resources……..
Reaccrediation Update June 2016
Mandatory units • Engage in personal development in health, social care or children’s and young people’s settings
• Promote communication in health, social care or children’s and young people’s settings
• Promote equality and inclusion in health, social care or children’s and young people’s settings
• Promote and implement health and safety in health and social care
• Principles of safeguarding and protection in health and social care
• Promote person centred approaches in health and social care
• The role of the health and social care worker
• Promote good practice in handling information in health and social care settings
• The principles of Infection Prevention and Control
• Causes and Spread of Infection
• Cleaning, Decontamination and Waste Management
• Principles for implementing duty of care in health, social care or children’s and young people’s
settings
• Health Screening Principles
Reaccrediation Update June 2016
Reaccrediation Update June 2016
Core units
• 3 core units for AAA
• similar content and level to the previous qualification
• updated and combined
• based on feedback and survey from learners who have
undertaken the previous qualification
• allows local programmes to tailor the learning and
assessment for each individual learner
• Undertake role specific units………..
Reaccrediation Update June 2016
Core units AAA
• Principles of AAA screening and treatment
• Principles of ultrasound for AAA screening
• Undertake AAA screening • All staff that undertake screening within NAAASP need to undertake the
qualification
Reaccrediation Update June 2016
Unit structure • each unit has a number of learning outcomes
• these are statements that describe the essential learning that learners need to be
able to clearly demonstrate at the end of the unit
• Syllabus
• the learning outcomes can then be broken down into assessment criteria
• these list in further detail the content that the learner must be able to demonstrate
during assessment of the unit
• should be used to guide the learners in their study and as to what needs to be
covered
• the assessors will then also receive the indicative content
• this details what the learner must cover in their assessment of the unit
• learners must not see the indicative content
learning outcomes assessment criteria indicative content
Reaccrediation Update June 2016
Unit structure
Reaccrediation Update June 2016
Principles of AAA Screening and Treatment
1. Understand the circulatory system
2. Understand the medical terms relevant to Abdominal Aortic Aneurysm
Screening
3. Understand the pathophysiology and formation of arterial disease
4. Understand the treatment options for Abdominal Aortic Aneurysms
• 30 hours minimum
• An elearning package exists for this unit
• Significant supplemental learning will be required
• Use internal resources and supplement learning
• CST/assessor should have oversight of this
Reaccrediation Update June 2016
Principles of ultrasound for Abdominal
Aortic Aneurysm Screening
1. Understand the theory of diagnostic B-mode ultrasound
2. Understand the main functions of ultrasound equipment controls
3. Understand ultrasound safety and the potential biological effects
• Minimum 40 hours total learning hours
• Elearning package to compliment
• Significant supplemental learning required
• Oversight from CST/assessor
Reaccrediation Update June 2016
Undertake AAA Screening 1. Be able to minimise risk of injury within the health screening setting
2. Be able to assess the environment and equipment for an Abdominal Aortic
Aneurysm screening episode
3. Be able to prepare the individual for an Abdominal Aortic Aneurysm
screening episode
4. Be able to use an ultrasound transducer to acquire diagnostic images of the
abdominal aorta
5. Be able to manipulate the ultrasound equipment controls to optimise images
6. Be able to accurately save, record and store results of the screening event
7. Be able to follow agreed protocols following the screening event to
determine the appropriate course of action
Reaccrediation Update June 2016
• Practical unit
• Portfolio of experience on the CDP screening website
• Similar to previous portfolio
• Same competency levels
• Gateway one and two replaced with stage one and stage two
• Internal clinical assessments for each stage by CST
• External clinical assessment replaces the OSCE at Salford
• Internal and external CST complete the assessment
• 4 individuals (2 minimum to be aneurysmal)
• 300 hours of work based learning
Reaccrediation Update June 2016
Reaccrediation Update June 2016
Assessors • OFQUAL and Skills for Health requirement that there must be suitable
trained workplace assessors for this qualification
• level 3 Certificate in assessing vocation achievement (CAVA)
• City and Guilds assessors without the CAVA qualification or equivalent will
need to undertake it
• PHE Screening and NOCN have developed a streamlined process at a
significantly reduced price
• work based distance learning/3 months to undertake
• recognition for prior learning and assessing
• completion of log book outlining previous experience
• final professional discussion with an external assessor
• Will provide assessors with nationally recognised assessor qualification,
role enhancement and CPD
• 1-3 per local programme
Reaccrediation Update June 2016
Assessment methods • feedback from programmes and learners was the assessment requirements
were too rigid
• now local programmes can tailor the assessments they use to the individual
learners
• will be quality assured by the awarding centre to ensure appropriateness of
assessments
• can use existing resources and assessments
Assessment methods
portfolio of evidence logbooks on-line tests
clinical assessments elearning assignments
case studies reflective practice short notes
course attendance one:one discussions recorded discussions
existing in-house resources
Reaccrediation Update June 2016
Technicians as assessors • Existing screening technicians can train to become assessors within their
departments
• Undertake the CAVA qualification locally
• Can assess parts of the qualification
• Must be occupationally competent in the learning outcome
• Funded by local screening programme
• Will need to be putting a new technician through the qualification whilst
undertaking the CAVA
• CAVA must be sourced and undertaken locally
• Liaise with Trust’s Learning and Development departments regarding the
CAVA initially
Reaccrediation Update June 2016
Funding
• Health Education England are funding the qualification
for 2016/17
• PHE Screening are administering it centrally
• only for new clinical staff within local programmes
• cost varies between awarding centres
• £800-1000/learner
Reaccrediation Update June 2016
How to register a new learner……
Reaccrediation Update June 2016
Further information
Reaccrediation Update June 2016
Nurse Specialist Best Practice Guidance
Background
• Role of the nurse has been varied across the country since inception
• The nurse specialist is an important role in the NHS abdominal aortic
aneurysm screening programme
• The role of the nurse practitioner/vascular nurse is to assess men and give
them appropriate advice on lifestyle changes
• They can also refer men on to other specialists and services, such as
smoking cessation.
• Links with other departments within the Trust to support these men
• All men found to have a small (3.0-4.4cm) or medium (4.5-5.4cm) aneurysm
are offered an appointment with their local programme’s nurse specialist
• Requirement for appointment within 12 months/3 months
• Phone appointments!!!
Reaccrediation Update June 2016
New guidance • Developed following consultation with nurse specialists, programme co-
ordinators, directors
• Programmes had been asking for further guidance and support
• 18 months to develop
• a document that encompasses the best practice guidelines for those nurses
undertaking the role of nurse specialist within a local provider of NAAASP
• Endorsed by Society For Vascular Nurses as best practice
• SQAS to use to benchmark Nurse Specialist service within local
programmes
• Not mandated via programme standards or service specification
Reaccrediation Update June 2016
Contents • Background and training of nurse specialists
• Staffing requirements
• Roles and responsibilities within the programme
• Clinic locations
• Timeliness of the nurse assessment
• What the nurse assessment should include
• Importance of face to face assessments
• Role of Screening technicians in nurse assessment
Reaccrediation Update June 2016
Background and Training • Registered general nurse
• 3 years post registration experience
• Appropriate knowledge of the management of vascular disease (AAA)
• Job description for their role including clinical accountability
• Links with other key clinicians within the programme
• Knowledge of the screening programme
• NAAASP don’t provide specific training
• Working towards the SVN ‘Advanced Nurse Competency’s’
Reaccrediation Update June 2016
Staffing requirements • 0.1 WTE as a minimum
• Highly recommend this time is ring-fenced
• Attend appropriate meetings of the screening programme and MDTs
• Provide training and support to screening technicians where appropriate
• Regular contact with the programme co-ordinator and director
Reaccrediation Update June 2016
Roles and responsibilities • Ensure all men have opportunity to attend face to face
• Provide support, advice, secondary prevention and referrals if appropriate
to screen positive men
• Use SMaRT system to record patient contact
• Attend training where appropriate
• Cannot screen unless they have completed the required training
• Cannot sign of screening technicians as competent or perform IQA of scans
unless they possess a post graduate degree in medical ultrasound
Reaccrediation Update June 2016
Operational requirements • Face to face appointment within 12 weeks
• Telephone consultation with those that can’t or won’t
• Reason for decline to be added to patient record
• Once they reach 4.5cm additional appointment to be offered
• Administrator should be utilised to book and contact patients
• Additional appointments can be given if requested
• 30 minute time slot for each appointment
Reaccrediation Update June 2016
Assessment • Measure and record weight and height
• BMI
• Smoking status
• Resting BP
• Review current medication
• Diet, exercise and alcohol consumption if appropriate
Reaccrediation Update June 2016
Assessment advice • Explanation of condition and brief overview of possible treatment options
• Surveillance programme and clinical preference
• Optimisation of BP
• Smoking cessation advice
• Determine and discuss any potential interventions required by GP
• Appropriate lifestyle advise in line with NICE guidelines
• Addressing emotional issues
• Discuss contact with DVLA
• Discuss familial risks with AAA
• SMaRT letter to GP and patient
Reaccrediation Update June 2016
• Following detection of an aneurysm technicians should actively encourage
men to attend
• Technicians should not be undertaking physiological measurements under
the auspices of working as a screening technician within NAAASP
• Not included in their scope of practice
• Appropriate training, QA, competencies would be requires if NAAASP was
to introduce this role enhancement
• Not recommended from NAAASP
Reaccrediation Update June 2016
More details • PHE Screening CPD website
http://cpd.screening.nhs.uk/cms.php?folder=5165
• PHE Screening blog
https://phescreening.blog.gov.uk/
• PHE Screening helpdesk
Reaccrediation Update June 2016
CST training • role of CST is integral to NAAASP
• improving the integration over the last 2 year into the programme
• updated the training of CST’s from May 2016 following discussions with
vascular scientists, CST’s and screening technicians
• training can now all be undertaken locally
• 7 elearning units
• 0.5 days shadowing an existing CST in clinic
• SMaRT/data session with co-ordinator
• assessor qualification (if appropriate)
• sign off from programme director
• must maintain their appropriate registration/accreditation with appropriate
bodies
• Do not have to attend for reaccreditation
Reaccrediation Update June 2016
Screening technician reaccreditation • Reaccreditation process updated April 2016
• More robust framework to help strengthen technician understanding of the
core principles of their roles
• Now consists of two sections
• Knowledge assessment
• Scanning assessment
• Knowledge assessment
• Two elearning modules
• Must be completed before they can register for scanning assessment
• Pass mark of 90%
• Scanning assessment
• Two scans to NAAASP requirements
• Recovery portfolio if unsuccessful
• Reaccreditation every two years
Reaccrediation Update June 2016
Feedback from external QA visits Mark Gannon, Vascular Consultant, AAA Screening, Heart of England NHS Foundation
Trust
Kim Kavanagh, AAA Screening Coordinator, Heart of England NHS Foundation Trust
Philippa Castell, Senior QA Advisor, Public Health England
AAA QA Visits
Process tips and outcomes
Public Health England leads the NHS Screening Programmes
Visit in a nutshell 6 months - date agreed
- documentation sent for completion (contacts list, room
booking requirements and pre-visit questionnaire)
2 ½ months - return completed questionnaire to QA team
Day of visit - relax!
4-6 weeks post visit - factual accuracy comments required
8 weeks post visit – final report issued –start action plan
12 weeks post report published – exec summary published
Every quarter – progress against action plan required
12 months post visit – completed action plan requested
153 AAA QA visits tips and outcomes
Process tips • Use your QA advisors – they are there to help and support you
• Don’t be afraid to ask questions or ask for clarification
• Let your QA advisor know if there is something you are anxious about or
feel should be included as part of your visit
• Answer the questions in the pre-visit questionnaire as fully as possible and
wherever possible provide evidence (or state evidence can be provided if
required)
• Label and reference your evidence logically
• Don’t be worried about recommendations– we aren’t going to ask you to do
something for the sake of doing it
• Use the process to foster engagement with your wider team and to highlight
the good work you are doing or where you need support with you executive
level team and commissioning team
154 AAA QA visits tips and outcomes
Process tips 6 months – date agreed and documentation sent to you so ideal time to think
about…….
Who is going to be the lead for the visit (usually falls to programme co-
ordinator)
Letting everyone know about the visit date – make sure those required for
interview will be available
How you will complete the pre-visit questionnaire – who will do what sections,
who will co-ordinate?
What venue will you use for the day, how many rooms can you book in
advance, can you provide lunch?
Post visit – establish task and finish group for producing action plan
155 AAA QA visits tips and outcomes
Recommendation themes Staffing – organisational diagrams, job descriptions and wte, regular systematic
feedback on screener performance and quality of images, training,
attendance at team meetings
SOPs – document key work areas and appropriate formatting (version control,
review dates and sign off)
Risks – risks on programme register, clear governance and escalation
processes
Incidents – policy in line with national incident guidance, reporting of incidents
Treatment timelines - review of processes, monitoring, tracking and breach
reporting, actions identified and implemented
Non-visualisation – monitoring equipment and staffing against rates, timelines,
tracking and access of appointments
Audits – undertake DNA audits, audit NVR completion, share results and
actions from audits at boards
156 AAA QA visits tips and outcomes
Recommendation themes
157 AAA QA visits tips and outcomes
Programme board – quoracy, membership, participation, standard agenda
items, action logs, inclusion of compliments/complaints, user
representation,
Equipment - checks performed in line with NAAASP recommendations,
processes documented in a SOP, replacement plans, maintaining
competency on models, storage
Cohort information - review including information requests on transgender
males to females / translation / disability / mobility needs/additional support
when asking GPs for relevant information on their eligible cohort prior to
invitation, processes within prisons, home visits, risk assessments, user
surveys, requirement for early/late/weekend clinics
Shared learning themes Technicians – involved in audits, increased understanding of functionalities with
ultrasound machines, attending theatre to observe EVAR procedures and
vascular clinics, training in British Sign Language, dementia training,
opportunity to observe and scan aneurysms being imaged in the main
vascular laboratory to ensure regular exposure, physiotherapy support, left
and right handed scanning techniques, protocol for return to work after
absence, CSTs running educational and interesting case reviews
Service improvement - improving access for men with learning disabilities,
detailed analysis of uptake rates/dna rates and targeted initiatives with
lower uptake GPs, engagement with homeless shelters, summary language
sheet to identify requirement for information in another language, project
with traveller community to promote GP registration, GPs review cohort
lists, electronic warning alert added to hospital Trust systems for all men
detected with an AAA , card provided to surveillance men to carry which
states they have a AAA, men routinely opted in to a smoking cessation
service
158 AAA QA visits tips and outcomes
Shared learning themes Health Promotion - ongoing encouragement strategy and promotion/screening
at various venues – golf clubs, bowling clubs, football/rugby/cricket clubs,
rotary clubs, round table events, DIY stores (on discount days for 50+),
betting shops, supermarkets, libraries, keep fit classes
Policies/Processes - Detailed overarching operational policy for the entire
screening programme, referencing all policies, procedures and governance
arrangements in one document, trackers developed for ensuring robust
failsafe of patients through referral, surveillance, non-visualisation and
incidental findings and production of waiting times, streamlined same day
assessment clinic for pre-operative investigations, decline forms for opting
out of surveillance and non-visualisation appointments
Programme Board - effective working relationships between providers and
commissioners, service user attending and contributing to the programme
board
159 AAA QA visits tips and outcomes
Feedback Feedback through our questionnaire link is currently limited – please complete
the link provided to you after a visit so that we can evaluate and review the
process.
Overall, has been noted as a positive experience, better than expected and
that good support is provided.
To note: review of pre-visit questionnaire is taking place
review of screener technician input into process is taking place
160 AAA QA visits tips and outcomes
Professional Clinical Advisor plea!
Being a PCA is really interesting, you learn a lot, is a great opportunity to
network and make friends, along with visiting a different part of the country
Opportunity for CPD – undertake national training
Plea for CSTs/QA Leads to become reviewers, please contact your QA advisor
if interested in becoming a PCA
161 AAA QA visits tips and outcomes