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

Introduction

Service Outline

Background

Referral handling

Booking processes

Reporting

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

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.

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

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

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

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

What have we done in NHS D&G

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

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

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

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.

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

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

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

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

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

Questions?