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

Why (Echo) Technician Led Clinics? Limited resources Very long wait lists for cardiology clinics Inefficient utilization of cardiology clinic times Limited funding More appropriate follow-up times (valve clinic) More timely access to echo More control over echo sessions Access to funding

Cardiology Audit July 2010

(Echo) Technician Led Clinics Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service

(Echo) Technician Led Clinics Nelson Hospital Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service

(Echo) Technician Led Clinics Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service

Tech Led Exercise Stress Echoes 140 Exercise Stress Echoes annually One (afternoon) session per week One Echocardiographer One Physiology Technologist Cardiologist or Physician on the floor

Tech Led Exercise Stress Echoes Echo review session Exercise Stress Echo and ETT reported by Cardiologist and Echocardiographer* Echo findings verified Letter dictated

(Echo) Technician Led Clinics Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service

Tech Led TOE service Central Region’s Technical Advisory Service Scholarship 2009

Tech Led TOE service Who should perform TOE studies? Consultant cardiologists/anaesthetists/intensivists Specialist registrars in training Cardiac Technicians Dr N Bunce – St George’s Hospital, London

Tech Led TOE service Nelson Hospital No senior cardiology registrar Single TOE trained Cardiologist Senior Echocardiographer assisted in TOEs last 16yrs Sign-off from Gastroenterologist, Cardiologists Approx 60-70 per annum

Tech Led TOE service Nelson Hospital Non-sedated TOEs. Safe (85% TOEs St Georges non-sedated) Performed in Echo room RMO present Cardiologist on floor Sedated TOEs performed in CCU

(Echo) Technician Led Clinics Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service

Tech Led GP access to echo Why GP access to Echo? New A Fib guidelines New NICE heart failure guidelines Free up cardiology OPD clinics Faster access to results Empower GPs Greater control over echo sessions Meet a demand Access to appropriate funds

Tech Led GP access to echo Initially thought access limited to 3 areas Murmurs (new) A Fib ? LV function

Tech Led GP access to echo Access limited to 2 areas Murmurs (new) A Fib *

Tech Led GP access to echo Audit 2 month period Oct/Nov ’09 likely referrals 14 likely GP referrals/month, estimate doubled to 28 likely referrals per month Jan-April ’10 trial period with covering letter to GP with echo result Up to 10 per month, estimate likely to double May ’10, GP education day. GPs notified Average 20 GP referrals per month

GP access to echo GP educ. day GP Educ. day

Tech Led GP access to echo Patient not seen by Cardiologist Limited to Murmurs (new) A Fib* Echo reviewed at cardiology review session Letter dictated by cardiologist to accompany echo report

(Echo) Technician Led Clinics Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service

1st prize Affiliates section ECHOCARDIOGRAPHER TECHNICIAN LED VALVE FOLLOW-UP CLINIC (VALVE CLINIC) 1st prize Affiliates section

Tech Led Valve Follow-Up clinic Traditional Patient-flow Valve Follow Up Patient Echo Cardiologist OPD Follow up organised Results/letter to GP Results/letter to notes

Traditional Patient-flow vs Valve Clinic Valve Follow Up Patient Echo Cardiologist OPD Follow up organised Results/letter to GP Results/letter to notes Valve Clinic Echo QOL B/P ECG Valve Follow Up Patient Follow up organised Results to GP Results to notes Echo review

Referral to Valve Clinic Initial enrolment into Valve Clinic made by the Cardiologist Assymptomatic mild, moderate and moderately-severe valve disease Aortic Stenosis Mitral Regurgitation Aortic Regurgitation Mitral Stenosis Tissue valve replacement

Valve Clinic Patient aware that they will not see the Cardiologist Echocardiogram Short QOL questionnaire B/P ECG

Short QOL questionnaire Change in symptoms Presyncope/syncope yes/no Increased SOB yes/no Chest pain yes/no Palpitations yes/no

Echo review session Patient symptoms/Echo Valve Clinic unchanged Symptoms unchanged Echo changed Valve Clinic with reviewed follow-up interval Review Echo, ECG, B/P, QOL Cardiologist OPD Clinic visit +/- Echo Patient symptoms/Echo changed

Valve 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 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 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 Results Audited: feasibility, safety and efficiency

Valve Clinic Results Feasible Absolutely feasible Echoes are not extra echoes Altered patient journey ‘Extra’ tests: ECG, B/P, QOL

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

Valve Clinic Results Efficient Makes better use of Echo clinic times Makes better use of Cardiologist clinic times Fits department ethos on clinical efficiencies

Nov ’06 to Sept ‘10: 715 pt visits Valve Clinic Results Nov ’06 to Sept ‘10: 715 pt visits

Nov ’06 to Sept ‘10: 715 pt visits Valve Clinic Results Nov ’06 to Sept ‘10: 715 pt visits

Nov ’06 to Sept ‘10: 715 pt visits Valve Clinic Results Nov ’06 to Sept ‘10: 715 pt visits <20% of patient’s disease progressed to warrant formal Cardiologist outpatient review >80% of patients entered into the valve clinic remain in active follow-up in the valve clinic

Valve Clinic Hugely reduced impact on Cardiologist clinic times Reduced patient waiting times More timely follow up of chronic valve conditions More control over echo sessions Appropriate access to appropriate funding Proven to be a safe process in which to follow-up valve lesions

Conclusion Within the framework of tight clinical governance the Echocardiographer Technician Led Valve Follow-up Clinic has improved patient care. Patient waiting times have reduced allowing tight, timely follow up of chronic conditions. In addition consultant clinic time has now been targeted towards the higher risk patients.

Valve Clinic Requirements/Tech Led Clinics Competent Echocardiographer/s Technically and clinically* Echo database (‘no notes’ dept) 100% support from Cardiologists Understanding of Cardiology Department funding streams

(Echo) Technician Led Clinics Tech Led PFO echo clinic Tech Led Contrast (bubble) echo clinic Tech Led Aortic Stenosis clinic Tech Led Exercise Stress Echoes Tech Led TOE service Tech Led GP access to echo Tech Led Valve Follow-Up clinic Tech Led paediatric echo service