Shining a Light on Blackouts - A Collaborative Approach

1. SHINING A LIGHT ON BLACKOUTS – A COLLABORATIVE APPROACH South Tees Blackout Team

2. James Cook University Hospital South Tees NHS Foundation Trust

3. Cardiac Rhythm Management (CRM)/Blackout Team • 5 Consultant Cardiologists • 1 Consultant Neurophysiologist • 6 CRM Specialist nurses • 1 Epilepsy Nurse Consultant • 1 CRM Nurse Consultant 8 Cardiac Physiologists (7 wte) • 2 Health Care Assistants • 3 Administrative Assistants • Specialist nurses – At least masters level/non medical prescribers, clinical skills, arrhythmia/syncope module, competency based in house training

4. Drop attacks Falls Epilepsy Catoplexy Cardiac Syncope Epilepsy Psychogenic Syncope Reflex Syncope Metabolic disorders Intoxication

5. Key Drivers • NICE TLOC Guidelines • European Society of Cardiology Guidelines for the Management of Syncope • NSF Chapter 8 Arrhythmias and Sudden Cardiac Death • No dedicated pathway for patients experiencing blackout • Local audit showed delayed patient pathway and over use of diagnostic testing

6. The Beginning……….. Identify a coordinator Audit to examine existing pathways/process map Look at other established services Develop business case Liaise with key stakeholders/steering group

7. South Tees Blackout Team

8. South Tees Blackout Service • Commenced in December 2010 • 1 year pilot funded by Middlesbrough, Redcar & Cleveland primary care trust • Evaluation concluded that the model was efficient and cost effective • Tariff agreed

9. Initial Results • Comparison of admission rates for patients presenting with non complicated syncope May 2010 – November 2011 and December 2010 – June 2011 - Average reduction of 19.5 admissions per month - Approximate saving of £140,000 per annum - Reduction of 409 bed days over 31 week period - Approximate saving of £74,000 per annum • Reduced waiting times - Cardiology 8.3 weeks to 5.9 weeks - Epilepsy 5 weeks to 4 weeks - First fit 4 weeks to 2.8 weeks

10. Effective referral pathway • Easier access to specialist review • Eliminates clinical uncertainty, misdiagnosis and inappropriate treatment and unnecessary financial cost • The South Tees blackout clinic has a clear referral pathway used by A&E / AAU / GP practices Ali et al (2009); NICE (2010)

12. Referrals • Accident and Emergency 52% • Primary Care 39% • Other 9 %

13. South Tees Blackout Service • Nurse triage of all referrals/Nurse led Clinics • Same day access to Consultants • 3 new clinic per week – 18 slots, 1 review clinic per week – 12 slots • One stop shop offering: -History taking/Witness Accounts -Clinical examination -ECG -Echocardiogram -Holter monitoring -EEG/MRI/CT (not same day)

14. How do we achieve the right diagnosis? • Effective triage • Structured history taking – medical model • Systematic approach – blackout service database • Witness accounts • Investigations - ECG, ECHO, Holter monitoring, EEG, CT / MRI • Exclusion of red flags

15. ‘Red flags’—indicators of high risk of a seriousadverse event, needing specialist assessment • Cardiac red flags • Abnormal 12-lead ECG • Presence of structural heart disease • Family history of sudden cardiac death (SCD) aged <40 years • Blackout occurring during exercise • Neurological red flags • History of brain injury • Features which strongly suggest epilepsy • New neurological deficit • NB No red flags = patient at low risk of a serious adverse event (NICE, 2010)

16. Is the South Tees model effective?

17. Comparison of waiting times • The median waiting times for the blackout clinic was 25.5 days, the first fit clinic 48.5 days and the general neurology clinic 91.5 days.

18. Comparisons • Hospital admissions • In areas without access to a blackout service admissions were 100% & 54.5% compared to 17.6% in the South Tees area. • Investigations • 100% of patients seen via the blackout clinic model had ECG performed compared to 35.7% attending the first fit clinic and 16.7% attending general neurology.

19. Diagnosis at first appointment • At the first appointment in the blackout and first fit clinics 91.8% and 88.1% respectively received a diagnosis compared to 69.4% in the general neurology clinic.

20. Pre blackout service – 46 year old gentleman presents to A&E with blackout • 2001 – A&E (ECG, NAD – discharged, with no further follow up) • 2005 – Re presents to GP with further episodes of blackout • 2005 – GP refers to Consultant Physician (CT head and chest, ECG, bloods, CXR – NAD) advises GP to refer to Neurologist • 2005 – GP refers to Neurology • 2005 – Consultant Neurologist (EEG, ECG, Bloods, Tilt test) Cardiac cause suspected and referral advised. No evidence of this happening in notes. • 2009 – Re presents to A&E following RTA after having blackout - Re referred to Neurology • 2009 – Neurologist again advises referral to cardiology • 2010 – GP refers to cardiology • 2010/2011 – Seen by cardiologist who suspects cardiac cause. ECG, 7 day ambulatory ECG NAD. Implantable loop recorder (ILR) implanted • 2011 – Ventricular pauses evident on interrogation of ILR • 2011- Permanent pacemaker implanted

21. Post blackout service – 66 year old gentleman presents to A&E with a blackout (2 episodes) • February 2011 – A&E (ECG NAD) refer to blackout service • February 2011 – Blackout clinic (triage, history taking, cardiac cause suspected - ECG, 72 hr ambulatory ECG NAD). Discussed with cardiologist and listed for ILR • April 2011 – ILR implanted. Ventricular pauses evident on analysis • June 2011 – Permanent pacemaker implanted

22. Pre blackout service - 26 year old female presents to GP after 2 episodes of blackout • July 2008 – GP refers to Cardiology. (ECG, Tilt test, 72 hour ambulatory ECG, NAD). Cardiologist suggests referral to Neurology • Nov 2008 – GP refers to Neurology • Jan 2009 – Neurology – (EEG, CT scan, history taking, witness account). Epilepsy diagnosed. Medication commenced

23. Post blackout service – 47 year old gentleman presents to A&E with blackout • March 2012 - A&E. Patient self discharges • Feb 2013 – A&E. Further episode of blackout. (ECG, NAD). Referred to blackout service • March 2013 – Blackout clinic (Triage, history taking, first hand witness account obtained. Epilepsy suspected). Liaise with Consultant Neurophysiologist for same day assessment • Consultant Neurophysiologist – Epilepsy confirmed, anti-epileptic drugs commenced. Lifestyle advice given

24. Benefits of a collaborative approach • Clear referral pathway • Less need for hospital admission • Reduced waiting times • Appropriate & focused investigations • High rate of diagnosis at first appointment

25. Benefits of a collaborative approach • One point of access to multispecialty and multidisciplinary diagnostic and treatment service including neuropyschology • Change in culture within Neurology / Cardiology in terms of the management of blackouts • High levels of patient satisfaction • Strong links with A&E / MAU • Closer liaison with elderly care / falls service

26. Development and Future Plans …. • Service expansion to cover North Yorkshire/North Tees. June 2018 • Nurse led ILR implant and follow up has already commenced further streamlining the service

27. Specialist Nurse-led Implantable Loop Recorder [ILR]Service

28. Background • ILRs have increasingly been used for the clinical evaluation of unexplained syncope in the last decade. • ILRs are used for long-term heart rhythm monitoring to diagnose unexplained syncope or for detection of suspected atrial and ventricular arrhythmias. • Detection of arrhythmias, the most common cardiac causes of syncope, is important, because of the associated mortality risk. • ILRs have been shown to have a high diagnostic yield and shortened the time to diagnosis [43 and 52% with ILR while conventional tests have a diagnostic yield of 6–20%] [Krahnet al 2001 & Farwell et al 2004].

29. Cost comparison of two implantable cardiac monitors in two different settings: Reveal XT in a cath lab vs. Reveal LINQ in a procedure room [Kanters et al 2015] • This study documents that miniaturization of technology saves hospital resources. • The insertion of a miniaturized cardiac monitor [ILR] is simpler and faster than the implantation of the previous version. • Owing to the miniaturized size and specifically designed insertion kit, the procedure no longer needs to take place in a cath lab, but can be performed in a less resource intensive setting – procedure ‘clean’ room. • The procedural efficiencies and change in implant location could lead to cost savings although variable in different centres.

30. Cost comparison of two implantable cardiac monitors in two different settings: Reveal XT in a cath lab vs. Reveal LINQ in a procedure room [Kanters et al 2015] • Labour costs were lower for Reveal LINQ, owing to shorter preparation, procedure time, and reduced recovery time. In addition, physicians could be substituted by less-qualified, and hence, less costly personnel. • Depreciation costs for instruments and equipment were considerably lower for a procedure room as well as overhead costs. • Excluding hospital admission costs there was an estimated 384 euro saving per patient

31. Pathway Comparison

32. Quality Assurance [QA] Audit 2016 • Evaluation of new process/way of working • 12 months of data – 125 patients • Comparison of old ILR process vs new nurse-led ILR service • No. of devices • Referral reason/source • Referral to implant date • Implant date to diagnosis • Diagnosis to device implant time • Diagnostic outcomes • Endpoint of cardiology diagnosis i.e. PPM / ICD • Old ILRs no. of automated events vs pt. activated events] • Infection rates • Evaluation of the remote monitoring software used to gain diagnosis • Non formal feedback from patients/carers

33. Pathway Comparison Over 12 months

34. Positive benefits of new nurse-led service • Pro-active vs reactive • Carelink software allows for prompt evaluation of symptom correlation / review of automated events • Immediate action regarding significant automated events • Specialist nurse knowledge enhances process • Expedited diagnostic / treatment plan • Listing for appropriate device • Weekly ILR list • Whole process much swifter than old ILR service

35. Positive benefits of new nurse-led service Nurse – led ILR Implant time saved by taking procedure out of the cath lab: ILR [old] – 45 mins [45x103/60=] 77 hrs Equating to: • PPM – 90 mins = 51.5 cases • ICD – 90 mins = 51.5 • CRT – 180 mins = 25.75 • EPS – 90 mins = 51.5 • AF cryo ablation – 150mins = 30.9 • AF RFA – 240 mins = 19.3

36. Summary • The wireless data transmission capability of the Reveal LINQ could lead to savings in staff time when patients are monitored remotely • Less need for face to face appointments • Quicker diagnostic times • Increased flexibility and therefore access to this service • Provision of a more cost effective service • Non-medical personnel performing ILR implants enables focus on more complex procedures • Provision of a specialist service in ILR monitoring provides continuity of care

37. Other aspects of service/Future plans • Implant of ILRs for urgent cases [inpatients before discharge] has commenced • Nurses now explanting devices • Formal patient questionnaire / feedback. Audit in progress • Development of the service to sister hospital. Begins this month • Training of further staff to implant devices – SpN to assist with programming • ILR for detection of AF in cryptogenic strokes

38. Blacked out? Come to James Cook! We know what we’re doing!!