Cardiology service is so useful for heart patient according to Dr. Mubashar A Choudry MD. He is a good cardiologist and he does his work with passion.

1. IMPROVING ACCESS
TO CARDIOLOGY
SERVICES
MUBASHAR A CHOUDRY
MD

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
Echo Stats by Year
0
500
1000
1500
2000
2500
3000
3500
'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10
Year
PatientNumbers

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

10. 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

11. 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 60-70 per annum

12. 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

13. (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

14. 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

15. TECH LED GP ACCESS
TO ECHO
• Initially thought access limited to 3 areas
• Murmurs (new)
• A Fib
• ? LV function

16. TECH LED GP ACCESS
TO ECHO
• Access limited to 2 areas
• Murmurs (new)
• A Fib
• *

17. 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

18. GP ACCESS TO ECHO
0
5
10
15
20
25
Jan Feb Mar Apr May June July Aug Sept
Year '10
Patientnumbers
GP referrals to Echo '10 GP Educ. day
GP educ. day

19. 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

20. (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

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

22. EchoValve Follow Up Patient
Cardiologist
OPD
•Follow up organised
•Results/letter to GP
•Results/letter to notes
TECH LED VALVE FOLLOW-UP CLINIC
TRADITIONAL PATIENT-FLOW

23. EchoValve Follow Up Patient
Cardiologist
OPD
•Follow up organised
•Results/letter to GP
•Results/letter to notes
Valve Follow Up Patient
Valve Clinic
Echo
QOL
B/P
ECG
•Follow up organised
•Results to GP
•Results to notes
Echo review
TRADITIONAL PATIENT-FLOW VS
VALVE CLINIC

24. 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

25. VALVE CLINIC
• Patient aware that they will not see the Cardiologist
• Echocardiogram
• Short QOL questionnaire
• B/P
• ECG

26. SHORT QOL QUESTIONNAIRE
Change in symptoms
• Presyncope/syncope yes/no
• Increased SOB yes/no
• Chest pain yes/no
• Palpitations yes/no

28. ECHO REVIEW SESSION
Review Echo,
ECG, B/P, QOL
Valve Clinic
with reviewed
follow-up interval
Valve Clinic
Patient
symptoms/Echo
unchanged
Cardiologist OPD
Clinic visit
+/- Echo
Patient
symptoms/Echo
changed
Patient
Symptoms unchanged
Echo changed

29. 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

30. 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

31. VALVE CLINIC FOLLOW UP
CRITERIA
•Patients remain in active follow-up in the Valve Clinic until the age of
80-85 years
• Valve lesion being followed
• Severity of valve lesion
• Patients discharged back to their GP

32. VALVE CLINIC RESULTS
• Audited: feasibility, safety and efficiency

33. VALVE CLINIC RESULTS
• Feasible
• Absolutely feasible
• Echoes are not extra echoes
• Altered patient journey
• ‘Extra’ tests: ECG, B/P, QOL

34. VALVE CLINIC RESULTS
• Safe. No patient was admitted or seen acutely during
the period between Valve Clinic visits

35. VALVE CLINIC RESULTS
• Efficient
• Makes better use of Echo clinic times
• Makes better use of Cardiologist clinic times
• Fits department ethos on clinical efficiencies

36. VALVE CLINIC RESULTS
Nov ’06 to Sept ‘10: 715 pt visits
7
107
162
225
274
0
50
100
150
200
250
300
Patient Visits
06 07 08 09 10
Year
Valve Clinic Activity

37. VALVE CLINIC RESULTS
Nov ’06 to Sept ‘10: 715 pt visits
Valve Lesion Distribution
Aortic Stenosis
43%
MR
25%
AoVR
18%
AR
6%
MVR
6%
MS
1.5%

38. 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

39. 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

40. 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.

41. 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

42. (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

43. THANKS