Coordination of Top End RHD Patients Requiring Surgery Liz sweetman Cardiac CNC East Arnhem Region

Top End Cardiac CNCs Established; Through federal funding Indigenous Cardiac Co-ordinator split into 3 Cardiac co-ordinator roles in 2013, temporary positions filled from Jan 2014. Permanent roles established for 3 Top End Cardiac CNCs Feb 2015. What existed prior to Cardiac CNC roles; In-patient, out-patient and surgery/procedure patients cared for by Cath Lab staff, NT Cardiac staff, the Cardiologists and Coronary Care staff.

Cardiac Expansion Unit Consists of; Cardiac Expansion Unit Administration Officer Cardiac CNC East Arnhem Region Cardiac CNC Darwin Cardiac CNC Katherine Heart Failure CNC (Top End)

Cardiac CNCs Patient Statistics Guidance/information Royal Darwin In Patient Care Guidance/information to Clinics Quality Improvement Programs Outreach Coordination Procedure /Surgery Coordination Cardiac Rehabilitation (Phase 2) Role & Service Development Out-patient Co-ordination Research Projects (external)

Cardiac CNCs Royal Darwin In Patient Care Outreach Coordination Procedure /Surgery Coordination Cardiac Rehabilitation (Phase 2)

Top End Cardiology Services Cardiology Outreach currently provides Cardiac Services to three Top End regions of the NT including the East Arnhem, Katherine and Darwin regions (3 regional centres & 44 communities) with a population of 146 230 people.

Top End Cardiac Procedures In July – Dec 2014 the Cardiac CNCs coordinated; 106 Patients for interstate procedures In July – Dec 2015 the Cardiac CNCs coordinated; 109 Patients for interstate procedures

Top End Cardiac Procedures In July – Dec 2014 the Cardiac CNCs coordinated; 106 Patients for interstate procedures In July – Dec 2015 the Cardiac CNCs coordinated; 109 Patients for interstate procedures

Top End Cardiac Procedures Jan – October 2016 36 Valve Patients 12 East Arnhem Region 13 Katherine Region 12 Darwin Region

Top End Surgical Candidates

Top End Valve Procedure Candidates May 2016 Clinic Isch Cardiomyopathy , Dual chamber AICD Aug 15 (Medtronic), rv in 6 mths Isch Cardiomyopathy, AICD (Medtronic, seen May 15, rv + device check 6-12 mths Out in hospital Cardiac arr 13, AICD (Medtronic, seen Oct, 15, rv + device P1 RHD AV + MV rp 2006, Seen in Oct 15, rv next clinic probable COPD, seen in Oct 2015, for resp rv and PFT but did not want to head to Darwin P2 RHD, seen May 15, rv in 12 mths Cardiomyopathy,OSA, LV dys, Seen May 15, rv next clinic Needs new referral, AF, Seen May 15, rv + echo in 12 mths RHD, severe MS in April 2016 Hx of polyarthralgia, referral April 16 P4 RHD, Referral Dec 2015, due for 5 year echo in 14 Needs new referral, P1 RHD, MVR (mechanical), seen May 15 RHD, seen May 15, rv in 12 mths Needs new referral, CABG 2012, seen in Oct 15, rv in 2 years Needs new referral, 3VD, accepted for CABG 2015, did not want surgery P1 RHD MV + AV 1994, Seen May 15, rv in 6-12 mths P1 RHD, seen in Oct 2015 ? Was for EST, severe MS P1 RHD, Atrial flutter, seen Aug 2014, rv in 12 mths P2 RHD, seen Oct 2012 P3 RHD, Seen Nov 2013 P3 RHD, Seen Feb 2013, rv in 18 mths P3 RHD, seen March 2013 during pregnancy, rv in 1 year Joint pains over last 3 years mostly treated as gout IHD, STEMI 2011, seen March 2013, rv in 6 mths IHD, Anterior MI + CABG 2013, angioplasty to vein graft in Aug 2015 in Adelaide Systolic mumur in pregnancy P1 RHD, Paediatric pt severe COPD

Top End Surgical Candidates Cardiologist orders post echo investigations ; TOE, CTCA or Angiogram, PFT, Valve work up including Dental Coordination – clothing, accommodation, education, allied health involvement, patient and carer financial support, counselling services. Patient’s Name / HRN / DOB

/Surgery Coordination Flinders Medical Centre Clinics/Regional Centres Procedure /Surgery Coordination Accepted For Surgery Cardiac CNCs Royal Darwin Hospital NT Cardiac Flinders Medical Centre Primary Health Care Clinics/Regional Centres

FMC FLOWCHART

Pre Operative Work Up

Delays in Patients Going for Surgery Cultural Commitments Family Responsibilities Fear Mistrust Linguistic Barriers Skin conditions and other medical conditions

Top End Valve Procedures - Timeframes Range 13 – 523 Days

Interstate Procedures – CEU Referral to Dental Fitness for Valve Surgery (Jan – July 2015) Dental fitness in Katherine region was reduced from the previous 6 months from 55 days to 42 days. East Arnhem was reduced from 33 days in the previous 6 months to 19 days between Jan – June 2015. Darwin increased from 20 days the previous 6 months to 41 days this period. This increase in the Darwin dental rates can be attributed to two patients who took over 200 days each to become dentally fit.

How has the CEU improved Cardiac Care Reducing Dental Fitness Timeframes and subsequent Valve Surgery Timeframes from Dental Fitness

POST CARDIAC SURGERY FMC DOCUMENTS NT INR TARGET 2.5-3.5

Cardiac CNCs Review all Remote Top End Patients and Aboriginal and Torres Strait Islander Peoples from urban Darwin (Post op Echo, ECG, Cardiology Dr Review) Send all post operative documentation to appropriate health care clinic. Dispatch a clinical item on Clinical Work Stations. Arrange post op reviews and involve other clinical specialities if necessary.

EAST ARNHEM VALVE SURGERY PATIENTS EAST ARNHEM VALVE SURGERY PATIENTS 92% of Valve Patients are RHD Patients 1. 27 Year Old Female RHD Hx previous Mitral Valve Repair 2006, MVR June 2016 (Bioprosthetic Valve) 2. 27 Year Old Female RHD, no previous surgery, MVR May 2016 (Bioprosthetic Valve) 3. 26 year old Female RHD, no previous surgery, MVR (Bioprosthetic Valve) + tricuspid annuloplasty July 2016 4. 24 year old Female RHD, no previous surgery, MVR (Mechanical Valve) July 2016 5. 41 year old Male RHD, no previous surgery, MVR (Mechanical Valve) April 2016 6. 24 year old Female RHD, no previous surgery, MVR (Bioprosthetic Valve) June 2016 – Pericardial effusion 7. 32 year old female RHD, MVR (bioprosthetic valve) 2003 + 2007, MVR (percutaneous Bioprosthetic valve) September 2016 8. 42 year old Female RHD, no previous surgery, MVR (Mechanical Valve) July 2016 9. 37 year old Female RHD, no previous surgery, MVR (Mechanical Valve) + Aortic Valve (Mechanical Valve) + Tricuspid repair Jan 2016 10. 19 year old Male RHD, no previous surgery, Mitral Valve Repair October 2016 11. 44 year old Male RHD, previous MVR (Bioprosthetic Valve, MVR (Mechanical Valve) July 2016

EAST ARNHEM VALVE SURGERY PATIENTS 12. 48 Year old Female RHD, no previous surgery, AVR October 2016 13. 49 Year old Male, no previous surgery, Aortic Root Replacement, AVR + CABG October 2016

EAST ARNHEM VALVE SURGERY PATIENTS 1. 27 Year Old Female RHD Hx previous Mitral Valve Repair 2006, MVR June 2016 (Bioprosthetic Valve) – Complete HB PPM inserted 2. 27 Year Old Female RHD, no previous surgery, MVR May 2016 (Bioprosthetic Valve) – Possible obstruction increased MV gradient cleared on TOE 3. 26 year old Female RHD, no previous surgery, MVR (Bioprosthetic Valve) + tricuspid annuloplasty July 2016 – Nil complications on review at RDH 4. 24 year old Female RHD, no previous surgery, MVR (Mechanical Valve) July 2016 – LRTI and pericardial effusion 5. 41 year old Male RHD, no previous surgery, MVR (Mechanical Valve) April 2016 – Thoracic haematoma post operatively 6. 24 year old Female RHD, no previous surgery, MVR (Bioprosthetic Valve) June 2016 – Pericardial effusion 7. 32 year old female RHD, MVR (bioprosthetic valve) 2003 + 2007, MVR (percutaneous Bioprosthetic valve) September 2016 – (L) pleural effusion and poorly controlled BSLs 8. 42 year old Female RHD, no previous surgery, MVR (Mechanical Valve) July 2016 – Pericardial effusion + (L) lower lobe atelactasis 9. 37 year old Female RHD, no previous surgery, MVR (Mechanical Valve) + Aortic Valve (Mechanical Valve) + Tricuspid repair Jan 2016 – nil complications on review at RDH 10. 19 year old Male RHD, no previous surgery, Mitral Valve Repair October 2016 – Bilateral pleural effusions 11. 44 year old Male RHD, previous MVR (Bioprosthetic Valve, MVR (Mechanical Valve) July 2016 – End stage renal failure

CASE STUDY

CASE STUDY Hx RHD MVR (bioprosthetic valve) 2003 + 2007 Poorly controlled T1DM

CASE STUDY Hx RHD MVR (bioprosthetic valve) 2003 + 2007 Poorly controlled T1DM

CASE STUDY

How has Cardiac Care been improved with Cardiac CNC Roles Patients from remote and regional setting feel more supported during their journey through the hospital system. Health care clinics have a point of contact with acute care (multiple contacts are made between Cardiac CNCs and PHC clinics each day). Reduced loss to follow-up of patients due to Cardiac CNCs reviewing and arranging follow-ups on all procedure/surgery patients for their region and also being involved RDH in-patient follow-ups. Streamlines the passage of patients through the acute and primary health care settings.

Cardiac CNCs : Challenges Time Pressures High Patient Loads (Particularly In-patient Darwin Region) Poor delineation of roles Lack of self management by some clients

Where to from HERE Expansion of Telehealth reviews by Cardiologists in 2016 Fine tuning Cardiology Outreach Clinics in 2016 Seek to improve collaboration between acute and remote health care settings by linking in Chronic Disease Coordinators, Chronic Disease Educators, DMOs, CNMs.

Thank you for your attention and time !