evolution of sleep medicine pathway in nhs d&h
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Phyllis Murphie
Lead Respiratory Nurse
NHS D&G
25th May 2010
Evolution of Sleep Medicine Pathway in NHS D&H
Snore , Snore Gasp, Choking Snore, Snore
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Introduction
Service Outline
Background
Referral handling
Booking processes
Reporting
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Obstructive Sleep Apnoea Hypopnoea Syndrome- OSAHS
OSAHS common sleep disorder caused by repetitive upper
airway obstruction during sleep
characterized by pauses in breathing during sleep often accompanied by oxygen desaturation
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Signs/Symptoms of OSAHS
Loud snoring
Excessive daytime sleepiness
Lack of concentration
risk factors for developing OSAHS include increasing age, obesity and being male.
Prevalence - 4% of middle-aged men and 2% of middle-aged women in the UK.
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Clinical Consequences of OSAHS
• 7-14 times more likely to have RTA in OSAHS •cardiovascular consequences - hypertension (high blood pressure) heart failure atherosclerosis (heart attacks, angina) atherosclerosis (stroke) atrial fibrillation ventricular arrhythmias pulmonary hypertension
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Service Outline
450 patients on CPAP/NIV therapy
Estimated growth of 80-90 patients per annum till 2012
> 350 referrals p/a requesting investigation.
nurse led review clinics –
Dumfries
Stranraer
Newton Stewart
Medical input on request
Outpatient based diagnostic service
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Background
The SGHD 18 Week referral to treatment standard to be achieved by December 2011.
Sleep studies are a diagnostic test included in this standard
Major challenge for Sleep medicine services in NHS Scotland
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Drivers for Redesigning the Care pathway
Demands of unscheduled care resulted in cancelled diagnostic inpatient tests -
Effect on service - increased waiting times
Inability to meet referral to treatment standard
Increased referrals from diabetes and weight management services
Increased demand/capacity for clinic review with increased caseload
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What have we done in NHS D&G
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Referral handling Pathway
Respiratory nurse triage of referrals
Routine/soon (vocational drivers)
All internal/external requests for sleep study on TOPAZ
Local referral guidelines developed with ENT/Max fax department
Electronic SCI referral being developed (now part of National Scottish Sleep Forum ongoing work plan
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Booking Processes Pathway
Acknowledgment letter regarding referral sent to patient
Requesting they contact secretary to book appointment for sleep study
No response 2 weeks
2nd letter
No response 2 weeks / Consultant decision to D/C
Refer back to GP
Remove from W/L
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Diagnostic redesign pathway
V 1- 45 minute appointment on day of test, clinical history, examination, routine bloods
V 2- 45min return appointment to obtain results/discuss further treatment options/interventions
V 2- Positive tests for symptomatic OSAHS -1-2 week trial of Auto CPAP
V 3- CPAP acceptable /effective next review, supplied with CPAP unit
V4 - Sleep clinic 3 - 6 months, 1 year, 2 years
Considering open access review in compliant patients
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Diagnostic redesign pathway
Where diagnostic uncertainty, patients reviewed 3-6
months in sleep medicine clinic for further
assessment of symptoms
Consideration of repeat limited sleep diagnostic
testing
Referral for full PSG to the Royal Infirmary
Edinburgh Sleep Medicine Unit.
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0
50
100
150
200
250
2007 2008 2009
2540
28
180
220208
50
15 15
Hotel Sleep study
Home Sleep study
IP sleep study
2007-2009 – Diagnostic tests
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Results of pathway Redesign
2007- 205 outpatient based sleep studies
2008- 260 outpatient based sleep studies
2009 – 251 out patient sleep studies
881 bed days saved over three year period amounting to net saving of £263,000 for NHS D&G
Outpatient based sleep studies are an appropriate/acceptable model of service delivery for majority of referrals
Current waiting time <12 weeks
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Current service limitations
People from West of region have to travel to Dumfries for IP/Hotel based sleep study – 150 mile round trip
No respiratory physiology staff input into scoring of sleep studies
Follow-up needs of the increasing numbers on CPAP is now limiting our ability to carry out new assessments.
Demand for service now greater that Medical/Nursing staff capacity
New service not sustainable long term with increased demand and new reduced targets
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Lean Principles Already Applied to Care pathway
Multi-diagnostic sleep sessions- Increased capacity and workflow
Reduced annual CPAP recall to 2 years –consider open access review
Diagnosis to established treatment reduced from 5 visits to 3
Referral protocol introduction to improve quality of referral and referral to correct service pathway/reduce inappropriate referrals
Auto CPAP trial reduced from 2 weeks to one week in most cases
Home auto titration in all patients – increased capacity and workflow
Home diagnostic/hotel diagnostic and auto titration services in almost all referrals
Consideration of sleep screening/diagnostic services closer to patients homes – discussions taking place re feasibility
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More Service Redesign Ideas
Development of recommended local/national referral, diagnosis, treatment and review standards
Better quality referral to ensure patient on correct pathway
Development of National Dataset with ISD to measure demand/access/equity of services
National SCI electronic referral system
Increased specialist nurse/physiology staffing
Investment in more diagnostic equipment
New ways of delivering diagnostic services closer to home – primary care – remote clinics
Open access review on request of non complex /complaint patients on CPAP to free up RNS time
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Questions?