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

2. 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

3. Cardiology Audit July 2010

4. (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

5. (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

6. (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

7. 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

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

9. (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

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

12. 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

13. 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 per annum

14. 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

15. (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

16. 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

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

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

19. 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

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

21. 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

22. (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

23. 1st prize Affiliates section
ECHOCARDIOGRAPHER TECHNICIAN LED VALVE FOLLOW-UP CLINIC (VALVE CLINIC)
1st prize Affiliates section

24. 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

25. 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

26. 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

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

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

30. 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

31. 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

32. 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

33. Valve Clinic Follow Up Criteria
Patients remain in active follow-up in the Valve Clinic until the age of years
Valve lesion being followed
Severity of valve lesion
Patients discharged back to their GP

34. Valve Clinic Results
Audited: feasibility, safety and efficiency

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

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

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

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

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

40. 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

41. 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

42. 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.

43. 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

44. (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