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

2. 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.

3. 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)

4. 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)

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

6. 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 people.

7. 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

8. 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

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

10. Top End Surgical Candidates

11. 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

12. 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

13. /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

14. FMC FLOWCHART

15. Pre Operative Work Up

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

17. Top End Valve Procedures - Timeframes
Range 13 – 523 Days

18. 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.

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

20. POST CARDIAC SURGERY FMC DOCUMENTS
NT INR TARGET

21. 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.

22. EAST ARNHEM VALVE SURGERY PATIENTS
EAST ARNHEM VALVE SURGERY PATIENTS % 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) , 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
year old Male RHD, no previous surgery, Mitral Valve Repair October 2016
year old Male RHD, previous MVR (Bioprosthetic Valve, MVR (Mechanical Valve) July 2016

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

24. 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) , 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
year old Male RHD, no previous surgery, Mitral Valve Repair October 2016 – Bilateral pleural effusions
year old Male RHD, previous MVR (Bioprosthetic Valve, MVR (Mechanical Valve) July 2016 – End stage renal failure

25. CASE STUDY

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

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

28. CASE STUDY

30. 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.

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

32. 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.

33. Thank you for your attention and time !