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  • 1. Background paper 7: Cardiology services Current services The Institute for Cardiac Services at The Townsville Hospital provides a superspeciality cardiology and interventional cardiology service, and a level 3 cardiothoracic surgery service as defined by the Queensland Health Clinical Services Capability Framework Version 2.0 (Queensland Health 2005) (Appendix 1). As at June 2009 services provided by the Institute for Cardiac Services include: • cardiology inpatient services (Medical Ward 3 with 22 allocated beds including 14 telemetry beds) • Coronary Care Unit with 10 beds (including two beds for angioplasty) • chest pain assessment service with four beds (located in the Coronary Care Unit) • Cardiac Catheter Laboratories (two) and day procedures (two procedure rooms and six dedicated day beds) • cardiac investigations • cardiac patient education and rehabilitation service • heart failure service • electrophysiology clinic • research • cardiac and medical clinics. Private cardiology services within the Townsville Health Service District (HSD) are available at the Mater Misericordiae Hospital Pimlico (Townsville) which provides cardiology, interventional cardiology (two cardiac catheter laboratories), cardiothoracic surgery and cardiac rehabilitation. Planned services The Institute for Cardiac Services is planning to increase outreach services to Mt Isa HSD residents commencing May 2009. A cardiologist is currently conducting outreach clinics in Mt Isa once a month and the number of clinics is planned to increase following the appointment of a second cardiologist to outreach services and by implementing telehealth clinics four days per week. Current and future demand Burden of disease Coronary heart disease was the largest specific cause of burden of disease in Queensland in 2003 accounting for 10.2 per cent of the total burden of disease. Within the Townsville HSD there was an average of 236 coronary heart disease deaths per year between 2002 and 2005. The mortality rates for coronary heart disease for the Townsville, Cairns and Hinterland and Mackay HSDs were not statistically significantly different from the Queensland mortality rates over the same period 1 . In contrast, the rates of coronary heart disease mortality in the Torres Strait and Northern Peninsula Area, Mt Isa and Cape York HSDs were higher than the Queensland mortality rate. In comparison to the state average, the standardised mortality ratio for residents from Torres Strait and Northern 1 Burden of Disease-Townsville HSD Tropical Population Health Service, Queensland Health 2008 Page 1 of 18
  • 2. Peninsula Area HSD were 42 per cent higher (111% higher for females), Cape York HSD 18 per cent higher and Mt Isa HSD 33 per cent higher. 2 Between 2002/03 and 2005/06 there was an average of 1766 coronary heart disease separations each year in Townsville HSD with the separation rates declining slightly for both the District and Queensland during this period1. Hospital separations for coronary heart disease increase with age from 35 years of age and after 40 years of age coronary heart disease is higher for males than females1. District demand for cardiology services Residents from the Townsville HSD access both public and private cardiology services. During 2006-07 residents of the District accessed more public cardiology services overall (65%) (with The Townsville Hospital accounting for 41%) than private cardiology services (35%) (Table 1). Table 1: Townsville HSD resident flows for cardiology services 2006/07 Cardiothoracic Cardiology Interventional Cardiology Surgery Hospitals Overnight Overnight Overnight % Day Bed % Day Bed % Bed % Total Seps Seps days Seps Seps Seps days Seps Seps days Seps Seps Townsville 419 1115 3998 48.8 9* 284 1277 20.7 156 1748 58.3 41.1 Ingham 35 164 544 6.3 0 0 0 0.0 0 0 0.0 4.1 Ayr 43 226 742 8.6 0 0 0 0.0 0 0 0.0 5.6 Charters 26 149 482 5.6 0 0 0 0.0 0 0 0.0 3.6 Towers Private 126 383 2335 16.2 401* 700 2693 77.6 98 1184 39.3 35.4 Other 109 342 1064 14.3 0 <5 23 0.2 <5 5 0.2 9.4 Public Prince <5 5 18 0.3 <5 18 69 1.5 5 69 2.3 0.7 Charles Total 761 2384 9183 100.0 413* 1005 4062 100.0 260 3006 100.0 100.0 Source: Queensland Health Admitted Patient Data Collection 2009, acute patients aged 15-85+ NB: 2006/07 Data was used as the cardiothoracic unit was suspended during 2007/08 * a significant number of angiograms are undertaken in an outpatient capacity this table shows admitted patients. Regional demand for cardiology services During 2006/07, adult residents of North and North West Queensland HSDs accessed 69.9 per cent public cardiology services and 30.1 per cent private cardiology services (Table 2). The Townsville Hospital provided 16.7 per cent of the cardiology service group separations. Other major providers for the cardiology service group for these residents were Mackay Base Hospital (14.8%), Cairns Base Hospital (12.7%) and private hospitals (15.7%). For the interventional cardiology service group, private provision increased significantly accounting for 72.4 per cent of all regional separations. The Townsville Hospital provided 18.8 per cent of separations for interventional cardiology services for residents of the broader catchment region. Other major providers of interventional cardiology for these residents were private hospitals (72.4%) and the Cairns Base Hospital (4.6%). The Townsville Hospital provided 54.1 per cent of the cardiothoracic surgery for residents of the region. The major outflows for cardiothoracic surgery were to private hospitals (37.6%) and The Prince Charles Hospital (4.2%). 2 Queensland Health. Health Indicators 2009-North Queensland. Tropical Population Health Service. Cairns 2009. Page 2 of 18
  • 3. Table 2: North and North West HSD adult resident cardiology separations and bed days 2006/2007 The Townsville Other Public Private Total Hospital Hospitals Hospitals Enhanced Service Related Group Seps Days Seps Days Seps Days Seps Chest Pain 545 743 2,345 3170 453 855 3343 Unstable Angina 237 527 693 1718 132 637 1,062 Heart Failure and Shock 170 1,128 791 4572 185 1640 1146 Non-Major Arrhythmia and 209 598 910 2469 433 1362 1552 Conduction Disorders AMI without Invasive Cardiac 105 688 670 2880 64 465 839 Investigative Procedures Other Cardiology 395 1237 1289 3597 294 1472 1978 Cardiology 1661 4921 6698 18,406 1561 6431 9920 Invasive Cardiac Inves Proc 288 1262 191 896 1702 3861 2181 Percutaneous Coronary Angioplasty 253 703 18 41 394 1559 665 Other Interventional Cardiology 71 284 76 259 256 1160 403 Interventional Cardiology 612 2249 285 1196 2,352 6580 3249 Coronary Bypass 274 2993 8 108 130 1693 412 Other Cardiothoracic Surgery 105 1191 50 640 133 1393 288 Cardiothoracic Surgery 379 4184 58 748 263 3086 700 Total 2652 11,354 7041 20,350 4176 16,097 13,869 Source: Queensland Hospital Admitted Patient Data Collection 2009. Separations classified by Cardiothoracic Surgery, Cardiology and Interventional Cardiology groups. All North Queensland residents 15 to 85+ years. Current supply There has been an increase in number of total separations for cardiology services at The Townsville Hospital (20.6%) (Table 3). For the period between 2003/04 to 2007/08 separations for the cardiology service group increased by 41 per cent; cardiothoracic surgery separations increased by 19 per cent and interventional cardiology increased by 14.2 per cent. The largest reason for separation was the chest pain enhanced service related group (ESRG) which increased by 81 per cent from 2003/04 to 2007/08. Page 3 of 18
  • 4. Table 3: Total supply (separations) of cardiology services at The Townsville Hospital 2003/04- 2007/08 ESRG 2003/04 2004/05 2005/06 2006/07 2007/08 Chest Pain 536 626 632 572 971 Unstable Angina 173 214 144 242 165 Heart Failure and Shock 150 166 132 175 212 Non-Major Arrhythmia and Conduction 193 194 212 220 227 Disorders AMI without Invasive Proc 105 93 94 108 167 Other Cardiology 326 337 305 409 352 Cardiology SRG Total 1477 1627 1518 1726 2094 Coronary Bypass 221 233 214 282 75 Other Cardiothoracic Surgery 107 112 136 107 58 Cardiothoracic Surgery SRG Total 328 345 350 389 133 Invasive Cardiac Investigative Procedures 432 309 296 301 479 Percutaneous Coronary Angioplasty 195 293 271 267 303 Other Interventional Cardiology 126 97 113 79 78 Interventional Cardiology SRG Total 753 699 680 647 860 Grand Total 2558 2671 2548 2762 3087 Source: Queensland Hospital Admitted Patient Data Collection 2009 (all patients). District resident supply In 2007/08, residents of the Townsville HSD accounted for 90 per cent of the cardiology service group separations; 50 per cent of the interventional cardiology and 31 per cent of the cardiothoracic surgery separations (Table 4). The higher use of the cardiothoracic surgery services by residents from catchment HSDs reflects an appropriate flow as The Townsville Hospital is the only public provider of cardiothoracic surgery in the region. Page 4 of 18
  • 5. Table 4: Total supply (separations) of cardiology services by HSD residence 2006/07-2007/08 2006/07 THSD C&H MHSD 2007/08 THSD C&H MHSD ESRG Total HSD Total HSD Chest Pain 572 531 <5 5 971 911 11 9 Unstable Angina 242 224 <5 8 165 149 <5 <5 Heart Failure and Shock 175 163 0 <5 212 193 0 7 Non-Major Arrhythmia and 220 186 5 11 227 193 5 13 Conduction Disorders AMI WI Invasive Cardiac 108 90 <5 <5 167 143 <5 7 Inves Proc Other Cardiology 409 324 22 21 352 288 13 21 Cardiology SRG Total 1726 1518 38 50 2094 1877 35 60 Coronary Bypass 282 101 94 58 75 20 34 13 Other Cardiothoracic 107 42 30 22 58 21 20 12 Surgery Cardiothoracic Surgery 389 143 124 80 133 41 54 25 SRG Total Invasive Cardiac Inves Proc 301 149 25 82 479 284 20 96 Percutaneous Coronary 267 82 89 64 303 121 87 57 Angioplasty Other Interventional 79 33 15 17 78 24 26 20 Cardiology Interventional Cardiology 647 264 129 163 860 429 133 173 SRG Total Grand Total 2762 1925 291 293 3087 2347 222 258 Source: Queensland Hospital Admitted Patient Data Collection 2009. Regional and other supply In 2007/08 the largest non district resident patient inflows were from Mackay (8.3 %), Cairns and Hinterland (7.3 %) and Mt Isa (3.7 %) HSDs. Unmet demand Based on standardised mortality ratios for cardiovascular deaths in each HSD, there is currently under utilisation of cardiology services by residents of Cape York, Torres Strait and Northern Peninsula Area, and Mt Isa HSDs. The commencement of the Statewide Rheumatic Heart Disease Program will lead to an increase in the identification, treatment and management of rheumatic fever and rheumatic heart disease in all HSDs and an increase in referals for cardiac investigations and treatment. Service providers have reported that the current supply of cardiothoracic procedures does not give a true representation of the demand for these services due to inadequate staffing levels, particularly in 2007/08, to provide the full range of cardiology services and outreach clinics. Staffing at The Townsville Hospital has now stabilised and the number of cardiothoracic procedures in the last eight months has increased with the cardiothoracic team performing approximately 35 procedures per month. If current practice were to remain constant, over a year this would be 420 procedures. Page 5 of 18
  • 6. Waiting list demand The number of North and North West HSD residents waiting for cardiothoracic surgery at all hospitals in Queensland has reduced each year and this is particularly evident with the number of ‘long waits’ (which reduced from 20 in 2006 to 5 in 2008). Cardiothoracic surgery waiting times at The Townsville Hospital decreased with the number of patients waiting longer than recommended for their surgery reducing from 84 in 2005 to 17 in 2008. Stay types Same day In 2007/08 the number of admitted same day separations for the cardiology service related group increased by 52.1 per cent from 2006/07 (Table 5). During the same period the numbers of admitted same day interventional cardiology separations have decreased by 34.8 per cent. Table 5: Supply of same day cardiology services by ESRG ESRG 2003/04 2004/05 2005/06 2006/07 2007/08 Chest Pain 177 180 205 235 487 Unstable Angina 29 24 17 45 46 Heart Failure and Shock 7 10 12 10 14 Non-Major Arrhythmia and Conduction Disorders 39 26 54 65 54 AMI without Invasive Cardiac Investigative 7 10 3 9 24 Procedure Other Cardiology 69 59 66 104 82 Cardiology SRG 328 309 356 468 707 Source: Queensland Hospital Admitted Patient Data Collection 2009. Some of the reduction in same day angiograms is a result of changes in admitting practice. The Townsville Hospital reports a practice where 388 angiograms in 2007/08 were not admitted and conducted on an outpatient basis (Table 6). Page 6 of 18
  • 7. Table 6: Outpatient angiogram attendances by payment class (public/private) by District of residence Jul 04 to Jun 05 Jul 05 to Jun 06 Jul 06 to Jun 07 Jul 07 to Jun 08 Health Service District Residents Priv Pub Total Priv Pub Total Priv Pub Total Priv Pub Total Cairns and 11 13 24 11 6 17 6 8 14 3 14 17 Hinterland Cape York 0 0 0 <5 0 <5 0 <5 <5 0 0 0 Mackay 45 108 153 122 59 181 84 81 165 85 51 136 Mt Isa 12 19 31 23 10 33 25 24 49 18 23 41 Torres Strait & NPA 0 <5 <5 0 0 0 0 0 0 0 0 0 Townsville 136 169 305 186 114 300 130 102 232 55 131 186 Other QLD Districts 8 7 15 13 9 0 5 7 12 <5 <5 <5 Interstate 3 <5 <5 <5 <5 <5 3 <5 <5 <5 <5 <5 Overseas 0 0 0 <5 0 <5 0 0 0 0 0 0 Unknown 0 <5 <5 0 0 0 0 0 0 0 <5 <5 Total 215 319 534 360 201 561 253 227 480 164 224 388 Source: The Townsville Hospital Clinical Benchmarking Unit 2009. The total number of outpatient angiograms at The Townsville Hospital decreased from 2004/05-2007/08 by 37.6 per cent (Table 6). The majority of this can be attributed to the decrease in private patients seen at The Townsville Hospital (31.1 %). In 2007/08 residents from the Townsville HSD were the largest users of the outpatient angiogram service (47.9%) followed by Mackay HSD residents (35.1%) and Mt Isa HSD residents (10.6%). Overnight separations In 2007/08 there were a total of 2115 admitted separations for the cardiology service related group with 1400 (66.2 %) overnight and 715 (33.8 %) same day (Table 7). Page 7 of 18
  • 8. Table 7: Supply of overnight adult cardiology services by ESRGs 2003/04 to 2007/08 2003/04 2004/05 2005/06 2006/07 2007/08 ESRG Seps Bed Seps Bed Seps Bed Seps Bed Seps Bed days days days days days Chest Pain 359 699 446 953 427 795 337 546 484 713 Unstable Angina 144 475 190 698 127 407 197 490 119 315 Heart Failure and Shock 143 950 157 1179 120 790 165 1161 198 1267 Non-Major Arrhythmia and Conduction 154 522 168 619 158 579 155 555 173 560 Disorders Acute Myocardial Infarction without Invasive 97 639 80 527 91 595 99 697 143 792 Cardiac Investigative Procedure Other Cardiology 252 1232 278 1292 239 1214 305 1152 270 1342 Cardiology SRG 1149 4517 1318 5268 1162 4380 1258 4601 1387 4989 Coronary Bypass 221 2280 233 2507 214 2747 282 3082 75 998 Other Cardiothoracic 105 981 112 1322 136 1627 107 1215 57 778 Surgery Cardiothoracic Surgery 326 3261 345 3829 350 4374 389 4297 132 1776 SRG Invasive Cardiac Inves 301 1551 291 1415 281 1493 292 1320 467 2775 Proc Percutaneous Coronary 195 614 292 838 267 806 263 772 301 1024 Angioplasty Other Interventional 121 483 92 323 109 500 69 314 77 405 Cardiology Interventional 617 2648 675 2576 657 2799 624 2406 845 4204 Cardiology SRG Source: Queensland Hospital Admitted Patient Data Collection 2009. Overnight separations for cardiology have increased by 20.7 per cent over the last five years to 2007/08 with the main areas of growth in the acute myocardial infarction without invasive cardiac investigative procedures (47.4%), chest pain (34.8%) and heart failure & shock (38.5%). In 2007/08, there were a total of 1248 patient separations for interventional cardiology with 845 (67.7%) overnight, 15 admitted same day and 388 outpatients (32.3% same day). The number of separations for overnight interventional cardiology services have increased by 37 per cent over the last five years with the main areas of growth being for invasive cardiac investigative procedures including angiographies (55.1% increase from 2003/04) and percutaneous coronary angioplasty (54.4% increase from 2003/04). Activity data from 2006/07 was used for the cardiothoracic surgery service group as the service was temporarily suspended in 2007/08. During 2006/07 there were a total of 394 separations for cardiothoracic surgery all of which were overnight stays. Between 2003/04 to 2006/07 overnight cardiothoracic surgery separations increased by 19.3 per cent and this is mainly due to growth in the coronary bypass which increased by 27.6 per cent. Length of stay For 2006/07 the average length of stay (ALOS) of non district residents (4.1 days) for cardiology services is higher than for Townsville HSD residents (3.6 days) (Table 8). For cardiothoracic surgery, Townsville HSD residents had a higher ALOS for coronary bypass Page 8 of 18
  • 9. (11.5 days compared to 10.6 days) and a lower ALOS for other cardiothoracic surgery (10.2 days compared to 12.2 days). Townsville HSD residents had a higher ALOS for all ESRGs in the interventional cardiology service related groups. However, the ALOS was only slightly higher for invasive cardiac investigative procedures. These differences in ALOS may be a reflection of referral patterns from the broader region. In comparison to Queensland ALOS, The Townsville Hospital generally had a higher ALOS for both cardiothoracic surgery and interventional cardiology, but a lower ALOS for cardiology separations. Table 8: State, District and non-district adult resident length of stay for overnight cardiology services 2006/07 Total Non THSD Townsville HSD QLD ESRG Seps Bed ALOS Seps Bed ALOS ALOS Days Days 06/07 Chest Pain 29 50 1.7 309 499 1.6 1.9 Unstable Angina 14 36 2.6 183 454 2.5 3.3 Heart Failure and Shock 14 139 9.9 151 1022 6.8 7.6 Non-Major Arrhythmia and Conduction 23 70 3.0 133 486 3.6 3.6 Disorders AMI without Invasive Cardiac 16 118 7.4 83 579 7.0 5.6 Investigative Procedure Other Cardiology 64 243 3.8 251 952 3.8 4.2 Cardiology SRG Total 160 656 4.1 1110 3992 3.6 Coronary Bypass 181 1920 10.6 101 1162 11.5 11.1 Other Cardiothoracic Surgery 69 845 12.2 43 440 10.2 10.9 Cardiothoracic Surgery SRG Total 250 2765 11.1 144 1602 11.1 Invasive Cardiac Inves Proc 148 692 4.7 144 692 4.8 3.6 Percutaneous Coronary Angioplasty 181 453 2.5 82 319 3.9 3.3 Other Interventional Cardiology 40 144 3.6 29 170 5.9 4.5 Interventional Cardiology SRG Total 369 1289 3.5 255 1181 4.6 Source: Queensland Hospital Admitted Patient Data Collection 2009. Projection methodology Queensland Health has nominated occupancy rates and planning benchmarks for the service planning of inpatient beds, chairs and spaces to facilitate a consistent approach to determining bed numbers. In moving towards a more consistent service planning methodology, these benchmarks will shortly be considered for formal endorsement by Queensland Health. Occupancy rates are a measure of bed utilisation in relation to the total bed capacity of a service, facility or ward. In order to ‘future proof’ services (allowing for high and low seasonal activity, and for future increases in activity) no unit is ever planned to be occupied at 100 per cent (all beds occupied at all times). Projected acute overnight medical bed requirements have been calculated at 85 per cent occupancy to build in capacity for the service to deal with peaks in activity. Planning beds at this occupancy rate means that the expected activity is accommodated, whilst allowing extra Page 9 of 18
  • 10. capacity to accommodate peaks in demand. For example, a service with a projected requirement for 36,500 bed days in 2016/17 would require 100 beds if all beds were occupied all the time (100% occupancy). The same service would require 112 beds to achieve 85 per cent occupancy. It is important to note that the bed numbers are based on actual or projected activity, and do not represent the physical number of beds available. Further details of the projection methodologies, data sources and assumptions are included in Appendix 2: Projection methodologies and assumptions. Future demand Projected demand for cardiology services for North and North West Queensland Health Service District residents Flows for cardiology services at The Townsville Hospital from North and North West Queensland HSD residents is expected to change with the expansion of cardiology services at both the Cairns Base Hospital and Mackay Base Hospital. The Queensland Health Clinical Capability Targets (Cardiac) recommends a minimum volume of cases and staffing levels prior to the development of any new cardiac services. For an angioplasty or percutaneous intervention service to be established the minimum number of cases undertaken by a unit should be 200 per year with a minimum operator load of 75 per year. The throughput target for the operation of a diagnostic angiography service is recommended to be 900 cases per year. In addition to this throughput, the service requires facilities and staff which meet national standards as outlined by The Cardiac Society of Australia and New Zealand including the need for at least two interventional cardiologists. For further information refer to the Queensland Health Clinical Service Capability Framework Version 2 (2005). As at June 2009, the Cairns Base Hospital operated a cardiology services that combined the Coronary Care Unit (8 beds) and a 14-bed cardiology/oncology unit (with 8 telemetry beds). A Vascular Laboratory is currently located in the radiology department. The service provides diagnostic cardiology procedures including coronary, vascular and renal angiography however public patients needing permanent pacemaker insertions and angioplasties are required to travel to Townsville or attend a private hospital in Cairns. The demand for angioplasties from residents in the far North Queensland HSDs (Cairns and Hinterland, Cape York; and Torres Strait and Northern Peninsula Area) in 2006/07 was 228 procedures. The demand for angiographies for residents from these districts in 2006/07 was 840 with 719 of these procedures being performed at either the public or private hospital in Cairns. The cardiology service developments in Cairns are expected to effect flows to The Townsville Hospital. The Cairns Base Hospital Cardiac Catheter Laboratory is expected to be developed further as part of the hospital redevelopment and is expected to be completed by 2013. The public and private cardiology services are currently exploring a partnership to coordinate one interventional service for the Cairns and Hinterland HSD and wider catchment. The Cairns Private Hospital has upgraded its cardiac catheter equipment and planned to commence conducting angioplasties, angiograms and the insertion of pace makers by June 2009. As a result of these service developments the resident flows from Cairns and Hinterland, Cape York; and Torres Strait and Northern Peninsula Area HSDs for angioplasties were reversed by 90 per cent from 2016/17. It is expected that residents from Cairns and Hinterland, Cape York and Torres Strait and Northern Peninsula Area HSDs who are considered to require high risk angioplasty or require cardiothoracic surgery will continue to flow to Townsville or Brisbane for these procedures. The Mackay Base Hospital currently operates a coronary care service which is combined with the critical care unit with three dedicated beds for coronary care. The Mackay Base Hospital Partial Clinical Service Plan Review (February 2009) recommended that the Coronary Care Page 10 of 18
  • 11. Unit expand to 4 dedicated beds in 2016 and 6 dedicated beds in 2021. As a result of this service development the resident flow from Mackay HSD for the cardiology service group was reversed by 75 per cent in 2016 and 90 per cent in 2021. It is expected that residents from the Mackay HSD requiring services from both the interventional cardiology and cardiothoracic surgery services will maintain their flow to The Townsville Hospital or their preferred private hospital. Projected demand for overnight cardiology services Future activity for overnight cardiology services at The Townsville Hospital has been projected using the acute Inpatient Modelling (aIM) program (Table 13). The aIM modelling for cardiology services included variations at the ESRG level to relative utilisation, average length of stay and flow of patients. Relative utilisation has been varied where there is an established higher demand for a service in the Townsville HSD relative to Queensland as a whole. Average length of stay has been varied where The Townsville Hospital ALOS in 2006/7 was not representative of the trend over the previous years or, the aIM trend is unrealistic, or a change in length of stay due to a change on a model of care is anticipated. Patient flows have been adjusted according to known service developments at the Cairns and Mackay Base Hospitals. The projections have also maintained the current proportion of public/private usage within the district/region. By 2016/17 for overnight admissions, at 85 per cent occupancy it is projected that there will be a need for 20 cardiology beds, 12 interventional cardiology beds and 17 cardiothoracic surgery beds. Note that these bed numbers will require adjustment to reflect allocations for critical care services and emergency department short stay beds. Page 11 of 18
  • 12. Table 9: Projected demand for adult overnight cardiology services 2016/17 2021/22 ESRG Seps Bed Beds* Seps Bed Beds * days days Chest Pain 623 888 820 1094 Unstable Angina 207 560 186 505 Heart Failure and Shock 198 1359 210 1420 Non-Major Arrhythmia and Conduction 244 865 305 1058 Disorders AMI without Invasive Cardiac Investigative 131 851 139 879 Procedure Other Cardiology 402 1718 469 1998 Cardiology SRG Total 1805 6241 20.1 2129 6954 22.4 Invasive Cardiac Investigative Procedure 391 1907 451 2327 Percutaneous Coronary Angioplasty 394 1113 537 1396 Other Interventional Cardiology 168 652 247 907 Interventional Cardiology SRG Total 953 3672 11.8 1235 4630 14.9 Coronary Bypass 286 3549 261 3422 Other Cardiothoracic Surgery 154 1637 180 1949 Cardiothoracic Surgery SRG Total 440 5186 16.7 441 5371 17.3 Grand Total 3198 15,100 48.7 3805 16,955 54.6 Source: aIM Scenario 2009. * Notional beds are calculated at 85% occupancy. * Data excludes children aged 0-14 years as they have been included in the paediatric bed count. Note that the total bed numbers above require adjustment to reflect allocations for critical care services and Emergency Department short stay beds. The above projections have not included changes in recent activity particularly in regards to increased cardiothoracic surgery. Data from The Townsville Hospital’s Cardiobase revealed that the number of cardiothoracic surgery procedures increased in the last eight months, with the cardiothoracic team performing approximately 35 procedures per month. If current practice were to remain constant over a year this would be 420 procedures by the end of 2008/09. In addition, the implementation of the Statewide Rheumatic Heart Disease program may lead to an increase in inpatient activity. This increase has not been accounted for here as there is no evidence of the degree to which demand will be affected. The impact of the program on cardiology services and bed projections will need to be reviewed following the full implementation of the program. Projected demand for same day cardiology services Future activity for same day cardiology services has been projected using the acute Inpatient Modelling (aIM) program (Table 10). The base data used the Queensland Health Admitted Patients Data Collection (QHAPDC) and the outpatient data supplied by the Clinical Benchmarking Unit at The Townsville Hospital. The linear projection based on the outpatient data for interventional cardiology indicated an unrealistic trend based on four years of data. It was assumed that the decline over the four years will plateau and the 2016/17 projection of 434 outpatient separations for angiograms is an average of 2006/07 and 2008/09 outpatient numbers. In order to calculate same day beds/ bed equivalents, the Queensland Health Page 12 of 18
  • 13. benchmark of 1.7 patients per day for 250 days per year (equivalent to 425 separations per annum) was used. Table 10: Projected demand for same day cardiology services 2016/17 2021/22 ESRG Seps Beds* Seps Beds* Chest Pain 457 612 Unstable Angina 99 140 Heart Failure and Shock 27 42 Non-Major Arrhythmia and Conduction Disorders 83 98 AMI without Invasive Cardiac Investigative Procedure 29 46 Other Cardiology 199 267 Cardiology Total 895 1205 Invasive Cardiac Investigative Procedure 11 12 Percutaneous Coronary Angioplasty 2 2 Other Interventional Cardiology 14 17 Interventional Cardiology Total 27 32 Add outpatient separations # 434 434 Grand Total 1356 3.2 1671 3.9 Source: aIM Scenario 2009. # supplied by Clinical Benchmarking Unit, The Townsville Hospital. * Notional same day beds are calculated at 1.7 patients per day, 250 days per annum (425 separations per annum). Projected demand for cardiac catheter laboratories As at June 2009 there were four cardiac catheter laboratories located within the Townsville HSD. Two are located at The Townsville Hospital and two at the Mater Pimlico (private). In order to assess future demand for cardiac catheter laboratories the number of angiograms and angioplasties in the QHAPDC data, analysed at the International Classification of Disease Version10 coding level was explored by HSD residents (Table 11). The Cardiac Society of Australia and New Zealand Guidelines recommend that to maintain competence a centre should perform at least 900 angiograms and 200 percutaneous coronary angioplasties per year. Based on this guideline Townsville and Mt Isa HSD resident’s use of interventional cardiology is sufficient to support two cardiac catheter laboratories until 2021/22. Table 11: Projections for HSD resident use of interventional cardiology services Year Cairns, Cape Townsville Mackay Regional Total & Torres & Mt Isa Angiograms PCI Angiograms PCI Angiograms PCI Angiograms PCI 2011/12 1339 361 1589 351 801 271 3729 983 2016/17 1611 541 1775 488 1017 404 4403 1433 2021/22 1950 763 1984 652 1283 568 5217 1983 Source: aIM projection by PCB Data Team plus 35% angiogram activity (to account for angiograms coded under other primary ESRG) plus 14.67% for Townsville and 18.67 % for Cairns and Mackay (to account for public sector non-admitted activity (based on trends 06/07 Page 13 of 18
  • 14. Service issues and strategies Service issues • Separations for all cardiology services have increased 20.6 per cent for the period from 2003/04 to 2007/08. • Service providers from HSDs outside of the Townsville HSD are experiencing difficulty receiving timely access to cardiology services. This may reflect that access may be hindered by bed blockages in the inpatient unit and transportation difficulties (both to and from Townsville). • Vacancies in cardiology staff specialists and scientists has impacted on the number and type of procedures which can be performed and have impeded the growth of the service. • The data revealed that the regional provision of interventional cardiology by the private sector is high, however The Townsville Hospital remains the major provider of cardiothoracic surgery for residents of the North and North West Queensland HSDs. • Residents outside of the District accounted for 63.6 per cent of all cardiothoracic separations in 2006/07. A review of average length of stay for other cardiothoracic surgery revealed that these patients are staying 2 days longer (12.2 days) than residents from the District (10.2 days) and 1.3 days longer than the Queensland average (10.9 days). • The average length of stay for overnight invasive cardiac investigative procedures was higher than the state average. Residents outside of the District stayed an average of 4.7 days, residents of the District stayed on average 4.8 days while the state average length of stay for invasive cardiac investigative procedures was 3.6 days. • The standardised mortality ratio for cardiovascular deaths is higher for residents of Mt Isa HSD (29 % higher), Torres Strait and Northern Penninsula HSD (42 % higher) and Cape York HSD (18% higher) compared to residents of the Cairns, Mackay and Townsville HSDs. This may indicate an issue with residents from these HSDs accessing cardiology services. • The introduction of the Statewide Rheumatic Heart Disease Program will lead to an increase in the identification, treatment and management of rheumatic fever and rheumatic heart disease in all HSDs as well as an increase in referals for cardiac investigations and treatment. • A review of the Queensland-wide waiting list data for cardiothoracic surgery for residents in the catchment area revealed that waiting times for cardiothoracic surgery have decreased. The number of patients waiting longer than recommended for their surgery reduced from 84 in 2005 to 17 in 2008. • The cardiothoracic surgery team have an allocated theatre four days per week (Monday-Thursday) which operates from 7:30 am to 5:00 pm. The team reported that they are performing 20 per cent of their surgeries on Friday or the weekends to cater for in-patient and urgent surgery demand. • The cardiothoracic surgery team reported that the current theatre size is not sufficient for the equipment required for procedures. • Comprehensive data analysis of interventional cardiology services is complex due to the various methods through which this data is captured. Some patients receiving angiograms are captured in the QHAPDC data as they are admitted whilst other patients are recorded as outpatients on the Hospital Based Corporate Information System (HBCIS). Page 14 of 18
  • 15. Strategies • Increase overnight beds in order to reduce bed blockages. • Develop a robust triage strategy so patients from all referring Districts can access cardiology services based on acuity at time of presentation. • Work with Queensland Clinical Coordination, the Royal Flying Doctors Service, the Queensland Ambulance Service and referring HSDs to address transfer issues to and from The Townsville Hospital. • Assess undifferentiated chest pain in the Emergency Medical Unit/Assessment unit and the Clinical Decision Unit. • Review the number of cardiology and cardiothoracic outreach clinics conducted to ensure that all catchment HSDs are receiving equitable and timely access. • Develop service agreements between the Townsville HSD, Cairns and Mackay Base Hospitals, and other major referral centres to improve and fast track appropriate return transfers for non-district residents and to maximise inpatient beds. • Develop service agreements between the Townsville HSD, Cairns and Mackay Base Hospitals, and other major referral centres to improve appropriate access to cardiology and cardiothoracic services for non-district residents including regular audits of access for these residents. • Review the average length of stay in comparison to the state average and explore avenues to reduce inpatient bed blockages. • Develop partnerships with the private sector to ensure that planned elective cardiology activity is delivered in a timely and resource efficient manner. • Work with the Northern Cardiac Network to address the current under utilisation of cardiology services by residents of Cape York, Torres Strait and Northern Peninsula Area, and Mt Isa HSDs. • Ascertain the impact of the Statewide Rheumatic Heart Disease Program on acute inpatient services. • Plan future theatre size to allow sufficient space for cardiothoracic surgery equipment. • Review methods for capturing data to ensure patient data is accurately and efficiently recorded. Page 15 of 18
  • 16. Appendix 1: CSCF table Service Level Hughenden Magnetic Is Collinsville Townsville Charters T Richmond Home Hill Ingham Palm Is Bowen Ayr Cardiology SS Cardio-thoracic surgery 3 Coronary care units 3 Page 16 of 18
  • 17. Appendix 2: Projection methodology and assumptions The aIM data was used to project expected separations and bed days to 2021/22. These projections were modified based on the following assumptions of cardiology services (for adults) at The Townsville Hospital, and the Cairns and Hinterland and Mackay Health Service Districts (HSD): • Data from The Townsville Hospital for cardio-thoracic surgery for 2006/07 was used instead of 2007/08 data as the service was suspended during this period and there was a reduction in supply. • 90 per cent of flows from Cairns & Hinterland HSD, Cape York HSD and Torres Strait and Northern Peninsula Area HSD for the ESRG of percutaneous coronary angioplasties was reversed from 2016/17 due to the development of these services at hospitals in Cairns. • It is expected that Cairns & Hinterland HSD, Cape York HSD and Torres Strait and Northern Peninsula Area HSD residents will continue to flow to Townsville for high risk angioplasties and the cardiothoracic surgery service related groups. • 90 per cent of North and North West Queensland HSD resident flows to Brisbane public hospitals for the cardiothoracic surgery service related group was reversed to Townsville from 2016/17. • 90 per cent of The Townsville Hospital inpatient flows from Mackay HSD for the cardiology service related group was reversed from 2016/17 due to the development of the Cardiac Care Unit at Mackay Base Hospital. • It is expected that Mackay HSD residents will continue to flow to Townsville for the interventional cardiology service related groups and the cardiothoracic sugery service related groups. • It is expected that residents in the catchment districts will continue to flow to Townsville or Brisbane for coronary bypasss. Based on the accepted Queensland Health benchmarks the following principals were applied: • The occupancy rate of 85 per cent has been applied to the actual and projected occupied bed days to calculate overnight beds required (number of projected bed days were divided by 310.25 days) • Same day beds were calculated at 1.7 patients per day, 250 days per annum (425 separations per annum). Overnight cardiology services Future activity for overnight cardiology services at The Townsville Hospital has been projected using the acute Inpatient Modelling (aIM) program. The aIM modelling for cardiology services included variations at the ESRG level to relative utilisation, average length of stay and flow of patients. Relative utilisation has been varied where there is an established higher demand for a service in the Townsville HSD relative to Queensland as a whole. Average length of stay has been varied where The Townsville Hospital ALOS in 2006/7 was not representative of the trend over the previous years or, the aIM trend is unrealistic, or a change in length of stay due to a change on a model of care is anticipated. Patient flows have been adjusted according to known service developments at the Cairns and Mackay Base Hospitals. Same day cardiology services Future activity for same day cardiology services at The Townsville Hospital has been projected using the acute Inpatient Modelling (aIM) program (Table 14). The base data used the Queensland Health Admitted Patients Data Collection (QHAPDC) and the outpatient data supplied by the Clinical Benchmarking Unit at The Townsville Hospital. The linear projection based on the outpatient data for interventional cardiology indicated an unrealistic trend based Page 17 of 18
  • 18. on four years of data. It was assumed that the decline over the four years (Table 10) will plateau and the 2016/17 projection of 434 outpatient separations for angiograms is an average of 2006/07 and 2008/09 outpatient numbers. In order to calculate same day beds, the Queensland Health benchmark of 1.7 patients per day for 250 days per year (equivalent to 425 separations per annum) was used. Cardiac catheter laboratories In order to assess future demand for cardiac catheter laboratories the number of angiograms and angioplasties in the QHPADC data (analysed at the ICD-10 coding level) was explored by HSD of residence. The Cardiac Society of Australia and New Zealand Guidelines recommend that to maintain competence a centre should perform at least 900 angiograms and 200 percutaneous coronary angioplasties per year. Page 18 of 18