AAA 2016 networking day final presentations

Welcome and programme

optimisation Jonathan Earnshaw, Clinical Lead, NHS AAA Screening Programme, Public Health

England

Part of Public Health England

Abdominal Aortic Aneurysm

NHS AAA Screening Programme

Network meeting June 2016

Jonothan J Earnshaw

Clinical Lead

Results

• 1.3 million men invited

• 1,019,480 men screened (uptake 79.5%)

• Almost 13,000 AAA (>3cm) detected

• Prevalence 1.3%

•Almost 12,000 men in surveillance

• Some 1923 men referred for surgery

results available https://www.gov.uk/topic/population-

screening-programmes/abdominal-aortic-aneurysm

Large AAA (>5.4cm) detected

1025 65-year-old men first scan

898 men from surveillance

49% EVAR

51% Open repair (OR)

(3:1 EVAR:OR rate in UK overall)

Intervention rate around 91%

Mortality rate 0.9%

Update on Programme optimisation:

Health Improvement Analytical Team, Department of

Health

• Reducing surveillance

• Reinviting men with subaneurysmal aorta

• Inviting women

Surveillance intervals Option A

2year, 3month

Option B

1year, 6month

Option C

2year, 6month

Option D

3year, 3month

Cost Savings per man invited

(£) 2.57 1.51 3.45 3.78

QALY Gain per man invited (£)⁺ -1.25 -1.41 -2.46 -3.28

Net Benefit per man invited (£) 1.33 0.10 0.99 0.50

Total Cost Saving from fewer

Screens per invited cohort (£)⁰ 680,000 480,000 1,110,000 960,000

Fewer Scans per invited cohort 12,000 8,750 20,000 17,000

⁰ Total savings associated to invited cohort of 300,000, discounted at

3.5% per annum

⁺QALYs monetised at £20,000

Increasing detection of AAA

Subaneurysmal aorta – 25 year data from Gloucestershire

0.2

.4.6

Cu

mula

tive

Incid

ence

0 5 10 15 20 25

Time (years)

Initial Diameter: 2.6-2.9cm Initial Diameter: 3.0-5.4cm

with mortality as a competing outcome

Cumulative Incidence Function for Progression to 5.5cm

0.2

.4.6

Cu

mula

tive

Incid

ence

0 5 10 15 20 25

Time (years)

<3cm+ 5 years after first scan 3cm+ 5 years after first scan

with mortality as a competing interest

Cumulative Incidence Function for Reaching 5.5cm+

Subaneurysmal aorta

>2.9cm % 0f 1156 >5.4cm % 0f 1156

Within 5 years 541 47% 7 0.6%

Within 10

years

659 57% 71 6%

Within 15

years

674 58% 138 12%

Within 20

years

674 58% 151 13%

Latest results from the Gloucestershire and Swindon AAA Screening

Programme (unpublished)

Health Improvement Analytical Team Recommendations:

Surveillance intervals for men with small AAAs should be extended so that

scans are performed biennially, as opposed to annually. This will lead to a more

cost-effective programme and 12,000 fewer rescans per invited cohort.

The NSC is asked to give careful consideration to the existing published

evidence relating to sub-aneurysmal aortic dilation. A rescan at 5 years would

require an additional 6,500 scans per invited cohort.

There is not currently enough evidence to justify the introduction of AAA

screening for women though this issue should be revisited in future years.

Optimising AAA screening

• Evidence review

• NAAASP Strategic and Research Groups

• NAAASP Directors, and other interested parties

• NAAASP Advisory Board

• Costing options DH Health Improvement Analytical Team

• 4 Nations Group (June 2015)

• Advice to obtain more independent evidence

• National Screening Committee (Oct 2016)

• Department of Health and Public Health England

• Implementation (2018/19)

Other programme matters

Equality and diversity policies

4 nations results

Uptake of screening and aneurysms

detected by decile of deprivation

Equality and diversity report

Jo Jacomelli Conclusions:

• Uptake affected by social deprivation

• AAA prevalence affected by social deprivation

• Uptake affected by ethnicity – need to improve recording

• AAA prevalence may be affected by ethnicity (confounder is

relationship between ethnicity and deprivation)

Improving uptake

• Inequalities research

• Local solutions

• NAAASP toolkit (4 nations approval)

National update Lisa Summers, Programme Manager, NHS AAA Screening Programme, Public Health

England

NAAASP National Networking

and Information Day

Lisa Summers

NHS AAA Screening Programme Manager

June 2016

Public Health England leads the NHS Screening Programmes

2016-17 Objectives

Review optimisation of AAA Screening Programme

Specify and re-procure national IT screening system to support existing

programme

Improve the dissemination of data to support local screening programmes,

commissioners and QA linking in programme specific operating model for

QA and inequalities reports for local programmes and commissioners

20 ISF UPDATE

Headline data 2015-2016 (provisional)

21 ISF UPDATE

Reports

• Pathway standards

• Quarterly/annual standards reports

• Quarterly waiting times

• KPIs

• Death proformas

22 ISF UPDATE

IT

• SMaRT:-

• Training for Co-ordinators/Admin

• Training for SQAS staff

• Version 9.4

• User Group

• Northgate Helpdesk

23 ISF UPDATE

New Qualification

• Structure

• Assessment

• Awarding organisations and centres

• Costs

• Re-accreditation

24 ISF UPDATE

Nurse Practitioner Group

• Develop, implement and monitor best practice guidelines

• Best practice guidelines to support AAA Nurse Specialist

• Develop and introduce nursing Standard Operating Procedures

25 ISF UPDATE

Screening Quality Assurance Service

• Visit schedule

• PSOM

• PCAs and PCA training

26 ISF UPDATE

Screening in Prisons

• PHE/NHSE/NOMs

• Interim Solution

• Pathways

• AAA SOPs - Annexe

Communications

GOV.UK:

User Survey – professional-facing screening content

Shared Leaning Policy:

https://www.gov.uk/government/publications/nhs-population-screening-

submitting-a-case-for-shared-learning

Accessible information standard:

Implementation - 31 July 2016

Information resources expert group

28 ISF UPDATE

https://www.gov.uk/government/publications/nhs-population-screening-submitting-a-case-for-shared-learning



















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Coming up….

• Four Nations

• PHE Annual Conference

• Programme optimisation

• Programme Directors meeting – November 2016

• National Research Meeting – Spring 2017

30 ISF UPDATE

Research update Jonathan Earnshaw, Clinical Lead, NHS AAA Screening Programme, Public Health

England

NAAASP research

• External to the Programme (Research Lead: Tim Lees)

• Programme research/evaluation

- Self referred men

- Prevalence monitoring

- Safety in surveillance

- National mortality rates

Approvals

Prehabilitation

Diet & AAA

Understanding non-attendance

Cardiovascular risk reduction –

feasability study

Drug study – reducing growth

Aardvark

Pre-operative exercise

Data to inform treatment risk algorithm

UKAGS

Metabonomic analysis serum & urine

Multimodal assessment of AAA

pathogenesis

Programme evaluation – growth rates

& surveillance data

Self referral

Reducing prevalence

Screening year Tested Aneurysm % aneurysm

2009/10 17,133 249 1.45

2010/11 30,549 490 1.60

2011/12 98,529 1,378 1.40

2012/13 183,034 2,463 1.35

2013/14 235,409 2,941 1.25

2014/15 224,517 2,674 1.19

Reducing prevalence of AAA

BJS, 2015

AAA screening of 65

year old men remains

cost effective to a

prevalence of 0.35%

Safety in surveillance

Total 12,804 men in surveillance

Follow-up 24,127 person years

Risk of rupture:

3-4.4cm (7 ruptures) – 0.03 (c.i. 0.02-0.07) per 100 person

years

4.5-5.4cm (8 ruptures) – 0.42 (c.i. 0.21-0.85) per 100

person years

NAAASP Research day

January/February 2017

Reducing AAA-related mortality

Anjum et al. BJS 2012

Deaths with mention of AAA in men and women in

England from ONS statistics

Deaths from ruptured AAA in men and women per

100,000 population from ONS data

Deaths from ruptured AAA in men in England from ONS

statistics according to age

Hospital admission with code for ruptured AAA in men

and women in England according to age

Conclusion

NHS AAA Screening Programme is feasible and cost

effective.

Referral threshold safe

Still room for optimisation

On target to reduce deaths by up to 50%

Data information Jo Jacomelli, Data and Information Manager, Screening, Public Health England

Data and Reporting

AAA networking day, 28 June 2016

Programme specific operating model

47 Data and reporting

Aim – To describe the activities of the Screening Quality Assurance Service

Data chapter

• Outlines the indicators used by SQAS for visits and ongoing

activities

• Cover key points in the screening pathway

• Information on sources, data sharing, reporting and data requests

https://www.tumblr.com/search/cute%20possums

PSOM indicators

National / retired standards

• Ineligible men

• Incorrect contact details

• Eligible men excluded

• Men with an aorta ≥ 3.0cm on initial screen

• Referrals deemed fit for intervention at first assessment post referral

• Operative procedures on AAA <5.5cm at last ultrasound

• 30 day mortality following elective surgery

• One year any cause mortality following elective surgery

• One year AAA cause mortality following elective surgery


PSOM indicators

Invitation and attendance standards

• Men declining screening

• Men who DNA their first appointment

• Men who attend after not attending first appointment

• Men with an aorta 3.0 – 4.4cm on initial screen

• Men with an aorta 4.5 – 5.4cm on initial screen

• Men with an aorta ≥5.5cm on initial screen

Internal QA

• Percentage of scans sent for IQR

• Percentage of men recalled following internal QA

• Delay between scan and QA review

Surveillance men

• Percentage of men lost from surveillance by reason


Process for PSOM data

• Collected from routine SMaRT data

• Produced quarterly on a programme level

• Draft report will be signed off by QA steering group

• Will be piloted with the SQAS (regions) to ensure it is fit for purpose and

obtain a baseline

• No thresholds initially

• Will be made available to programmes through SMaRT


Inequalities report

• Available through SMaRT quarterly

• Tables of

• Eligible, offered, screened and declined by

• GP

• LSOA

• LA

• Ethnicity of men tested by

• Programme

• LA

• Ethnicity of men with aorta ≥3.0cm

• Line list of men referred for surgery by LSOA and ethnicity


Report table examples


How can this information be used?

How do I know if I have a particular ethnic group not attending screening?

Sources of ethnicity data

• Office for national statistics

• NOMIS :

https://www.nomisweb.co.uk/query/construct/summary.asp?mode=constru

ct&version=0&dataset=651

• NOMIS uses 2011 census data – most up to date

You can create a table and chart comparing the breakdown of men you have

tested by ethnicity and the percentage of men in that ethnic group in the

population


https://www.nomisweb.co.uk/query/construct/summary.asp?mode=construct&version=0&dataset=651



Table


Area tested perc tested testedtot population pop total perc_pop

1 0 0.00 608 6 5821 0.10

2 0 0.00 1087 3 9094 0.03

3 0 0.00 1470 5 10323 0.05

4 0 0.00 1768 14 17150 0.08

5 0 0.00 1147 8 9148 0.09

6 0 0.00 1186 13 8906 0.15

7 4 0.25 1611 87 11681 0.74

8 0 0.00 1057 3 8588 0.03

9 15 1.54 973 160 8454 1.89

10 3 0.12 2426 224 20420 1.10

11 0 0.00 2303 17 17811 0.10

12 0 0.00 1231 57 12036 0.47

13 1 0.07 1521 43 11027 0.39

14 1 0.08 1303 16 9547 0.17

15 3 0.18 1711 73 14051 0.52

16 4 0.29 1401 220 11135 1.98

17 9 0.50 1814 91 16213 0.56

18 121 1.85 6540 3398 60611 5.61

19 1 0.10 978 30 7633 0.39

20 1 0.10 1052 8 8533 0.09

Scatter chart – national black or black

British: Caribbean


Scatter chart – national black or black

British: Caribbean


Deprivation

How do I know if men in particular areas aren’t attending?

Sources of information:

Office for national statistics:

http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/

populationestimates/datalist

Link to IMD2015 by LSOA

https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

Look at areas of low uptake and see if they are in areas of deprivation


http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datalist













Can anyone help me with this?

Yes!

We will produce a template to help with the ethnicity comparison and

deprivation

Your commissioners can help with interpretation

Look at issues in your area in order to decide which interventions are the most

suitable


8 week waiting time – 2014/15 Breakdown of men referred to and not declining surgery by outcome for the 8

week to treatment standard, by programme


8 week waiting time – Q1 to Q3 2015/16 Breakdown of men referred to and not declining surgery by outcome for the 8

week to treatment standard, by programme


Improvements

2014/15 Q1-Q3 2015/16

England % men

operated on in 8 weeks 56.9% 75.5%

England % breach -

patient comorbidity 24.8% 12.8%

England % breach -

hospital factors 18.3% 11.7%

Number of programmes

reaching acceptable 16 14

Number of programmes

reaching achievable 5 19


Learning from serious

incidents Jane Woodland, Regional Head of Quality Assurance, Midlands and East, Public Health

England

Julie Till-Wylie, Quality Assurance, Midlands and East, Public Health England

Managing and learning from

incidents in the AAA screening

programme

Jane Woodland: Regional Head of Quality Assurance, Midlands and East

28 June 2016


• Why this is important

• What we like you to know and do

• Examples for discussion

Why this is important

• Ethical duty

• Statutory requirement

Mid Staffs

Duty of candour

• Improve quality and safety of screening programmes –

locally and nationally

65 Managing Safety Incidents in NHS Screening Programmes

Learning from incidents


National learning

• The 2015-16 national service spec was updated to reflect programme

responsibility to track referrals

• All screen positive AAA referrals are tracked using the SMaRT referral

tracking application which was installed as part of release 9 software

upgrade in July 2015

• The national programme checks AAA death proformas and ensures that a

copy is sent to QA if not already done so

• National “blogs” and previous newsletter articles, and enquiries made to

programmes via QA teams

• Refining the process for dealing with queries/incidents involving the national

software

……huge learning and a safer service for patients

What we’d like you to know

The policy framework

The Policy framework Managing Safety Incidents in NHS Screening Programmes

(MSI in NSP)

https://www.gov.uk/government/publications/managing-safety-incidents-in-

nhs-screening-programmes

(October 2015)

NHS England Serious Incident Framework (SIF)

https://www.england.nhs.uk/patientsafety/serious-incident

(March 2015)

68

Managing Safety Incidents in NHS Screening Programmes

https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-screening-programmes


















Screening safety incident Screening safety incidents include:

• any unintended or unexpected incident(s), acts of commission or acts of

omission that occur in the delivery of an NHS screening programme that

could have or did lead to harm to one or more persons participating in the

screening programme, or to staff working in the screening programme

• harm or a risk of harm because one or more persons eligible for screening

are not offered screening.

Refer to: Section 1.5 ‘Definition of a screening safety incident’ Managing

Safety Incidents in NHS Screening Programmes

69


http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&ved=0ahUKEwiI3aGtvLjLAhWE1BoKHWcND60QjRwIBw&url=http://www.becomingminimalist.com/scratch-paper/&bvm=bv.116573086,d.ZWU&psig=AFQjCNGIa-43pX0V6jDWqSMrHqyEdykFnw&ust=1457780104183492


• Serious incidents in

screening programmes

have consequences that

are so significant that

they require a heightened

response

• Avoidable severe harm or

death if situation

continues

• Case by case judgement

and expert advice needed

Serious incidents in NHS screening

programmes

Serious incidents in screening programmes Organisation unable to deliver acceptable quality of healthcare services

Examples include

Serious data loss/information governance related incident

Where the potential for harm may extend to a large population

Systematic failure to provide an acceptable standard of safe care

Major loss of confidence in the service including prolonged adverse media

coverage or public concern about the quality of healthcare or the

organisation

0eRefer to: Section 1.6 ‘Definition of a serious incident ’ Managing Safety Incidents in NHS

Screening Programmes


http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&ved=0ahUKEwiI3aGtvLjLAhWE1BoKHWcND60QjRwIBw&url=http://www.becomingminimalist.com/scratch-paper/&bvm=bv.116573086,d.ZWU&psig=AFQjCNGIa-43pX0V6jDWqSMrHqyEdykFnw&ust=1457780104183492


Providers

SIT / responsible

commissioner PHE QA

Accountability, roles &

responsibilities

What we’d like you to do

Reporting, management and investigation

Screening incident assessment form

The screening incident assessment form (SIAF) is to be used for suspected

safety incidents and serious incidents in NHS screening programmes.

The form should be accessed from the DH.gov.uk website at

https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-

screening-programmes

74

















Safety incident suspected

Provider informs QA & SIT

Fact Finding

Classification and handling plan in 5

working days

Serious incident declared

Reported on STEIS within

48hours

Serious incident team

Serious Incident team reports level

of investigation within 72 hrs

SI Report including incident chronology and

RCA & recommendations

QA disseminates lessons identified

Screening incidents – Actions

Incident team

Immediate actions – patient focus

Produce / implement Action plan

RCA – depth varies

Oversee implement

actions

Identify and share lessons learnt

Agree timescales for closure

76


Managing incidents

77


Data Gathering

Analysis

Solution

What’s happened? Investigation

Why did it happen? Determine root cause

What should we do to prevent

it happening again? Implement corrective actions

Adapted from CPA Standard H6.2

Safety Incident reports by SIAF classification

Safety incidents for internal investigation – no further QA action –

• Provider decides format in line with its governance process

• Screening and immunisation team may want to review

• Recorded on SQAS and SIT monitoring systems

Safety incidents internal investigation and RCA

• QA advise that a one page report is produced – suggested template

available

• SIAF included as an appendix

Safety incident (multi-organisation/disciplinary, investigation panel and

RCA

• QA advise that NPSA concise report with SIAF included as an appendix

78


Escalation

79


http://www.bronsonsafety.com.au/safety-signs/braille-signs/braille-escalator-up.html

Scenarios for discussion

Is this a -

• safety incident

• a serious incident

• not an incident

What immediate actions would you take?

80

Managing Safety Incidents in NHS screening Programmes

Activity

Categories


Not an incident

Screening safety incident

Serious incident

Questions – Slide 1 (10 mins to discuss)


Scenarios around 8 week breaches

1 Patient cancelled surgery date which was offered within 8 weeks (due to

his daughters wedding), and then AAA ruptured before next offered

surgery date.

2 Stent was not available within 12 weeks and patient’s AAA ruptured

3 Surgery cancelled due to ITU bed availability. Surgery re-scheduled for

after 12 weeks. Patient AAA ruptured in the interim but patient recovered

well from emergency surgery.

4 Surgery scheduled outside of 12 weeks due to shortage in interventional

radiologists. Patient died of a AAA rupture before surgery date.

5 AAA repair conducted successfully. Patient died post operative within 30

days.

Questions – Slide 2 (10 mins to discuss)


Scenarios within the screening pathway

1 Images saved to incorrect patient file

2 Images lost during upload to SMaRT

3 Patient appointments cancelled due to staff sickness on day of

clinic

4 Scanner stolen from technician’s front seat of car after a busy

clinic day

5 Last weeks 2nd DNA letters to GP did not generate and SMaRT

shows an error

6 A number of surveillance patients were not being routinely

called to 3 monthly surveillance appointments over an annual

period.

Any Questions?

Breakout session one: • Waiting Times - Jonathan Earnshaw, Clinical Lead, AAA Screening Programme, NAAASP

• Management of self-referrals - Lewis Meecham, Specialist Registrar, Vascular Surgery,

Black Country Vascular Unit

• UKAGS and screening in women - Matthew Bown, Professor of Vascular Surgery,

University of Leicester

• Previous aortic surgery? Exclusions/Non-visualisation - Jonathan Earnshaw, Clinical Lead,

AAA Screening Programme, NAAASP

• 2017 Research meeting - Jonathan Earnshaw, Clinical Lead, AAA Screening Programme,

NAAASP

Self referral to the NHS Abdominal Aortic

Aneurysm Screening Programme

Lewis Meecham, Jo Jacomelli,

Arun D. Pherwani, Jonothan Earnshaw

Introduction & Aims

• NHS abdominal aortic aneurysm screening programme introduced in England 2009

• Fully operational since 2013

• All men are invited for screening in 65th year

• Men aged more than 65 years are allowed to self –refer for screening

• Currently screening approximately 300, 000 men per annum

• The aim was to provide a descriptive analysis of men who self refer to the NAAASP from 2009 to August 2014

Demographics

• 2009 to Aug 2014

• 58,999 self referrals (700,816 invited in same time period)

• Mean age 73 years (range 47-100).

• 82% with smoking history

• Incidence of AAA was 4.13% (n = 2,438), in contrast to 1.4% in the invited cohort (age 65)

• Of these 7.6% (n=186) were 5.5cm or greater.

Small AAA (3-4.5cm)

Large AAA (5.5cm and greater)

P Value

Aspirin 41.7% 43.0% 0.416

Statin 64.9% 61.3% 0.681

Results

Self referrals have increased year on year

Monthly increase in self referrals with noticeable spikes

Results

Type of surgery

N Percentage

Open 39 38.8%

EVAR 84 55.3%

Outcome Percentage

Surgery 81.7% (n=152)

Declined 5.4% (n= 10)

Unfit 4.8% (n = 9)

Died in referral pathway

1% (n=2)

30 day operative mortality – 0% 8 Week referral to surgery target –(n = 88) (57.9%) Mean time from referral to surgery was 69 days (2 – 361 days)

Discussion • NAAASP 65 currently 1.4% 1

• MASS trial incidence 4% (screen age 65-74)2

• US veterans affairs incidence 7% (mean age 72)3

• We found in self referrals an incidence of 4.13% likely due to (age (73 years), smoking (82%), ethnicity (96% white), low compliance with BMT)

• Self referral element is cost effective

• Role of future publicity from local / natinal programme

1. http://aaa.screening.nhs.uk/news.php?monthye=0713 2. Thompson SG, et al. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the

randomised Multicentre Aneurysm Screening Study. BMJ 2009;38:2307 3. Chun KC, et al. Risk factors associated with the diagnosis of abdominal aortic aneurysm in patients screened at a regional

Veterans Affairs health care system. Ann Vasc Surg. 2014 Jan;28(1):87-92.

Conclusion

• Self-referral has yielded higher detection rates than the invited cohort, more than justifying its cost.

• Now that NAAASP is fully operational it is important to continue media campaigns and publicity to target the high risk men over 65 who would otherwise miss the benefits of AAA screening.

• Self referrals increased with increased publicity – could this be channeled to target more at risk individuals

• Publicity should be targetted to high risk individuals

UKAGS and Research on Screening Women

Matt Bown

University of Leicester

www.le.ac.uk

UK Aneurysm Growth Study

Background

• Prospective cohort study of men screened for AAA

• Circulation Foundation/British Heart Foundation funded

• Sample size: 10,000 controls, 5000 AAA

• Postal consent

• Various invitation methods

– Invitation card at screening/surveillance clinic

– Mailshot

– Direct contact (media)

– Non-NAAASP surveillance clinics

Recruitment

Sep-1

1

No

v-1

1

Jan-1

2

Ma

r-1

2

Ma

y-1

2

Jul-1

2

Sep-1

2

No

v-1

2

Jan-1

3

Ma

r-1

3

Ma

y-1

3

Jul-1

3

Sep-1

3

No

v-1

3

Jan-1

4

Ma

r-1

4

Ma

y-1

4

Jul-1

4

Sep-1

4

No

v-1

4

Jan-1

5

Ma

r-1

5

Ma

y-1

5

Jul-1

5

Sep-1

5

No

v-1

5

Jan-1

6

Ma

r-1

6

Ma

y-1

6

0

2000

4000

6000

8000

10000

12000

14000

Cumulative AAA

Cumulative Controls

Original recruitment Revision

Recruitment

Sep-1

1

No

v-1

1

Jan-1

2

Ma

r-1

2

Ma

y-1

2

Jul-1

2

Sep-1

2

No

v-1

2

Jan-1

3

Ma

r-1

3

Ma

y-1

3

Jul-1

3

Sep-1

3

No

v-1

3

Jan-1

4

Ma

r-1

4

Ma

y-1

4

Jul-1

4

Sep-1

4

No

v-1

4

Jan-1

5

Ma

r-1

5

Ma

y-1

5

Jul-1

5

Sep-1

5

No

v-1

5

Jan-1

6

Ma

r-1

6

Ma

y-1

6

0

500

1000

1500

2000

2500

3000

3500

Cumulative AAA

Original recruitment Revision

Female AAA Screening

Projects

1. Screening Women for abdominal aortic ANeurysm (SWAN)

2. Female Aneurysm screening STudy (FAST)

SWAN

• NIHR HTA commissioned project

• Project team

– Simon Thompson (PI)

– Mike Sweeting

– Janet Powell

– Edmund Jones

– Pinar Ulug

– Matt Glover

– Jonothan Michaels

– David Sidloff

SWAN: Rationale

SWAN: Methods

• New programmable statistical/economic model

• Wide range of parameters required

• Data sources

– Literature

– Databases (NVR, HES-ONS, Vascunet)

– Male (screening) data

SWAN: Outputs

• New model

• Estimate of clinical effectiveness

• Economic analysis

• Value of information

FAST

• NIHR RfPB (researcher led)

• Pilot of AAA screening for women

• Leicestershire, Rutland and Northamptonshire

FAST: Methods

• GP read codes used to identify cohorts at GP practices

– Smoking (current or ex)

– History of coronary heart disease (MI, PCI, CABG)

– Ethnicity

– Healthy (non-smokers and no CHD)

– First-degree relatives of patients with AAA

• 65 to 74 year-old women

FAST: Methods

• GP read codes used to identify cohorts at GP practices

– Smoking (current or ex)

– History of coronary heart disease (MI, PCI, CABG)

– Ethnicity

– Healthy (non-smokers and no CHD)

– First-degree relatives of patients with AAA

• 65 to 74 year-old women

FAST: Methods

• NAAASP type invitation

• Consent at clinic for screening

• Consent for research at the same time as screening

• Data collection

– Screening outcomes

– Basic demographics/biometry

– QoL

– Linkage (GP, hospital, HES-ONS)

FAST: Sample size

0

500

1000

1500

2000

2500

3000

Sam

ple

siz

e

Prevalence estimate

FAST: Sample size

n

• Smoking: Current smokers 2626

Ex-smokers 2626

• History of coronary heart disease 1700

• Ethnicity 1000

• Healthy (non-smokers and no CHD) 1000

• First-degree relatives of patients with AAA 1003

FAST: Outcome measures

• Primary

– Attendance

– Prevalence of AAA

• Secondary

– Accuracy of primary care read codes for AAA risk

– Long-term outcomes

FAST: Timeline

• Project start: 1st Aug 2016

• Screening start: 1st Nov 2016

• Project end: 31st Dec 2017

FAST: Timeline




FAST: Timeline (not so FAST)

• Original application: 16th Sept 2014

• Rejection: 23rd March 2015

• Revised application: 18th May 2015

• Acceptance: 26th Nov 2015

• Pre-project bureaucracy: 7 months!




Breakout session two: • New qualification

• Nursing SOPs

Patrick Rankin, National Education and Training Manager, Public Health England

NAAASP National Networking

and Information Day Patrick Rankin

National education and training manager


New qualification

• level 3 award on the regulated qualification framework (RQF)

• Level 3 is academic level not AfC

• Diploma for Health Screeners (DES/AAA/NBHS)

• provides clinical screening staff with a nationally recognised

qualification

• ensures clinical staff have the knowledge, skills and understanding

to work in a healthcare environment

• provides screening staff with a framework to develop knowledge

and clinical skills required for their specific screening programme

• opens up numerous career development opportunities for staff

within screening programmes

• can add additional screening programmes if required

Reaccrediation Update June 2016

Who needs to take the qualification….?

• from 1st April this is the required qualification for clinical staff in DES,

AAA and NBHS(2017)

• includes new all non-professionally regulated new clinical staff

• screening technicians in NAAASP

• previous qualification will remain valid and existing staff do not have

to undertake the diploma for health screeners

• can apply for recognition of prior learning


Structure of the qualification

• similar structure to NVQs

• work based qualification

• based on a number of units and evidencing work based

competency to an assessor

• assessors will need to have a qualification in assessing

• learners provide evidence of competency via local

assessments

• different method of delivery from current course


Mandatory units (13)

• provides screening programme staff with the basic understanding

and core knowledge and skills of working in a healthcare setting

• formalisation of learning that should already undertaken in

screening programmes

• should be covered in employee induction

• based on significantly on the care certificate

• provides confidence that all staff have the same induction - learning

the same skills, principles, knowledge and behaviours to provide

compassionate, safe and high quality health care

• resources available online that cover the majority of the learning

outcomes required for the mandatory units

• skills for care and skills for health websites have lots for

resources……..


Mandatory units • Engage in personal development in health, social care or children’s and young people’s settings

• Promote communication in health, social care or children’s and young people’s settings

• Promote equality and inclusion in health, social care or children’s and young people’s settings

• Promote and implement health and safety in health and social care

• Principles of safeguarding and protection in health and social care

• Promote person centred approaches in health and social care

• The role of the health and social care worker

• Promote good practice in handling information in health and social care settings

• The principles of Infection Prevention and Control

• Causes and Spread of Infection

• Cleaning, Decontamination and Waste Management

• Principles for implementing duty of care in health, social care or children’s and young people’s

settings

• Health Screening Principles



Core units

• 3 core units for AAA

• similar content and level to the previous qualification

• updated and combined

• based on feedback and survey from learners who have

undertaken the previous qualification

• allows local programmes to tailor the learning and

assessment for each individual learner

• Undertake role specific units………..


Core units AAA

• Principles of AAA screening and treatment

• Principles of ultrasound for AAA screening

• Undertake AAA screening • All staff that undertake screening within NAAASP need to undertake the

qualification


Unit structure • each unit has a number of learning outcomes

• these are statements that describe the essential learning that learners need to be

able to clearly demonstrate at the end of the unit

• Syllabus

• the learning outcomes can then be broken down into assessment criteria

• these list in further detail the content that the learner must be able to demonstrate

during assessment of the unit

• should be used to guide the learners in their study and as to what needs to be

covered

• the assessors will then also receive the indicative content

• this details what the learner must cover in their assessment of the unit

• learners must not see the indicative content

learning outcomes assessment criteria indicative content


Unit structure


Principles of AAA Screening and Treatment

1. Understand the circulatory system

2. Understand the medical terms relevant to Abdominal Aortic Aneurysm

Screening

3. Understand the pathophysiology and formation of arterial disease

4. Understand the treatment options for Abdominal Aortic Aneurysms

• 30 hours minimum

• An elearning package exists for this unit

• Significant supplemental learning will be required

• Use internal resources and supplement learning

• CST/assessor should have oversight of this


Principles of ultrasound for Abdominal

Aortic Aneurysm Screening

1. Understand the theory of diagnostic B-mode ultrasound

2. Understand the main functions of ultrasound equipment controls

3. Understand ultrasound safety and the potential biological effects

• Minimum 40 hours total learning hours

• Elearning package to compliment

• Significant supplemental learning required

• Oversight from CST/assessor


Undertake AAA Screening 1. Be able to minimise risk of injury within the health screening setting

2. Be able to assess the environment and equipment for an Abdominal Aortic

Aneurysm screening episode

3. Be able to prepare the individual for an Abdominal Aortic Aneurysm

screening episode

4. Be able to use an ultrasound transducer to acquire diagnostic images of the

abdominal aorta

5. Be able to manipulate the ultrasound equipment controls to optimise images

6. Be able to accurately save, record and store results of the screening event

7. Be able to follow agreed protocols following the screening event to

determine the appropriate course of action


• Practical unit

• Portfolio of experience on the CDP screening website

• Similar to previous portfolio

• Same competency levels

• Gateway one and two replaced with stage one and stage two

• Internal clinical assessments for each stage by CST

• External clinical assessment replaces the OSCE at Salford

• Internal and external CST complete the assessment

• 4 individuals (2 minimum to be aneurysmal)

• 300 hours of work based learning



Assessors • OFQUAL and Skills for Health requirement that there must be suitable

trained workplace assessors for this qualification

• level 3 Certificate in assessing vocation achievement (CAVA)

• City and Guilds assessors without the CAVA qualification or equivalent will

need to undertake it

• PHE Screening and NOCN have developed a streamlined process at a

significantly reduced price

• work based distance learning/3 months to undertake

• recognition for prior learning and assessing

• completion of log book outlining previous experience

• final professional discussion with an external assessor

• Will provide assessors with nationally recognised assessor qualification,

role enhancement and CPD

• 1-3 per local programme


Assessment methods • feedback from programmes and learners was the assessment requirements

were too rigid

• now local programmes can tailor the assessments they use to the individual

learners

• will be quality assured by the awarding centre to ensure appropriateness of

assessments

• can use existing resources and assessments

Assessment methods

portfolio of evidence logbooks on-line tests

clinical assessments elearning assignments

case studies reflective practice short notes

course attendance one:one discussions recorded discussions

existing in-house resources


Technicians as assessors • Existing screening technicians can train to become assessors within their

departments

• Undertake the CAVA qualification locally

• Can assess parts of the qualification

• Must be occupationally competent in the learning outcome

• Funded by local screening programme

• Will need to be putting a new technician through the qualification whilst

undertaking the CAVA

• CAVA must be sourced and undertaken locally

• Liaise with Trust’s Learning and Development departments regarding the

CAVA initially


Funding

• Health Education England are funding the qualification

for 2016/17

• PHE Screening are administering it centrally

• only for new clinical staff within local programmes

• cost varies between awarding centres

• £800-1000/learner


How to register a new learner……


Further information


Nurse Specialist Best Practice Guidance

Background

• Role of the nurse has been varied across the country since inception

• The nurse specialist is an important role in the NHS abdominal aortic

aneurysm screening programme

• The role of the nurse practitioner/vascular nurse is to assess men and give

them appropriate advice on lifestyle changes

• They can also refer men on to other specialists and services, such as

smoking cessation.

• Links with other departments within the Trust to support these men

• All men found to have a small (3.0-4.4cm) or medium (4.5-5.4cm) aneurysm

are offered an appointment with their local programme’s nurse specialist

• Requirement for appointment within 12 months/3 months

• Phone appointments!!!


New guidance • Developed following consultation with nurse specialists, programme co-

ordinators, directors

• Programmes had been asking for further guidance and support

• 18 months to develop

• a document that encompasses the best practice guidelines for those nurses

undertaking the role of nurse specialist within a local provider of NAAASP

• Endorsed by Society For Vascular Nurses as best practice

• SQAS to use to benchmark Nurse Specialist service within local

programmes

• Not mandated via programme standards or service specification


Contents • Background and training of nurse specialists

• Staffing requirements

• Roles and responsibilities within the programme

• Clinic locations

• Timeliness of the nurse assessment

• What the nurse assessment should include

• Importance of face to face assessments

• Role of Screening technicians in nurse assessment


Background and Training • Registered general nurse

• 3 years post registration experience

• Appropriate knowledge of the management of vascular disease (AAA)

• Job description for their role including clinical accountability

• Links with other key clinicians within the programme

• Knowledge of the screening programme

• NAAASP don’t provide specific training

• Working towards the SVN ‘Advanced Nurse Competency’s’


Staffing requirements • 0.1 WTE as a minimum

• Highly recommend this time is ring-fenced

• Attend appropriate meetings of the screening programme and MDTs

• Provide training and support to screening technicians where appropriate

• Regular contact with the programme co-ordinator and director


Roles and responsibilities • Ensure all men have opportunity to attend face to face

• Provide support, advice, secondary prevention and referrals if appropriate

to screen positive men

• Use SMaRT system to record patient contact

• Attend training where appropriate

• Cannot screen unless they have completed the required training

• Cannot sign of screening technicians as competent or perform IQA of scans

unless they possess a post graduate degree in medical ultrasound


Operational requirements • Face to face appointment within 12 weeks

• Telephone consultation with those that can’t or won’t

• Reason for decline to be added to patient record

• Once they reach 4.5cm additional appointment to be offered

• Administrator should be utilised to book and contact patients

• Additional appointments can be given if requested

• 30 minute time slot for each appointment


Assessment • Measure and record weight and height

• BMI

• Smoking status

• Resting BP

• Review current medication

• Diet, exercise and alcohol consumption if appropriate


Assessment advice • Explanation of condition and brief overview of possible treatment options

• Surveillance programme and clinical preference

• Optimisation of BP

• Smoking cessation advice

• Determine and discuss any potential interventions required by GP

• Appropriate lifestyle advise in line with NICE guidelines

• Addressing emotional issues

• Discuss contact with DVLA

• Discuss familial risks with AAA

• SMaRT letter to GP and patient


• Following detection of an aneurysm technicians should actively encourage

men to attend

• Technicians should not be undertaking physiological measurements under

the auspices of working as a screening technician within NAAASP

• Not included in their scope of practice

• Appropriate training, QA, competencies would be requires if NAAASP was

to introduce this role enhancement

• Not recommended from NAAASP


More details • PHE Screening CPD website

http://cpd.screening.nhs.uk/cms.php?folder=5165

• PHE Screening blog

https://phescreening.blog.gov.uk/

• PHE Screening helpdesk

[email protected]






mailto:[email protected]

CST training • role of CST is integral to NAAASP

• improving the integration over the last 2 year into the programme

• updated the training of CST’s from May 2016 following discussions with

vascular scientists, CST’s and screening technicians

• training can now all be undertaken locally

• 7 elearning units

• 0.5 days shadowing an existing CST in clinic

• SMaRT/data session with co-ordinator

• assessor qualification (if appropriate)

• sign off from programme director

• must maintain their appropriate registration/accreditation with appropriate

bodies

• Do not have to attend for reaccreditation


Screening technician reaccreditation • Reaccreditation process updated April 2016

• More robust framework to help strengthen technician understanding of the

core principles of their roles

• Now consists of two sections

• Knowledge assessment

• Scanning assessment

• Knowledge assessment

• Two elearning modules

• Must be completed before they can register for scanning assessment

• Pass mark of 90%

• Scanning assessment

• Two scans to NAAASP requirements

• Recovery portfolio if unsuccessful

• Reaccreditation every two years


Feedback from external QA visits Mark Gannon, Vascular Consultant, AAA Screening, Heart of England NHS Foundation

Trust

Kim Kavanagh, AAA Screening Coordinator, Heart of England NHS Foundation Trust

Philippa Castell, Senior QA Advisor, Public Health England

AAA QA Visits

Process tips and outcomes


Visit in a nutshell 6 months - date agreed

- documentation sent for completion (contacts list, room

booking requirements and pre-visit questionnaire)

2 ½ months - return completed questionnaire to QA team

Day of visit - relax!

4-6 weeks post visit - factual accuracy comments required

8 weeks post visit – final report issued –start action plan

12 weeks post report published – exec summary published

Every quarter – progress against action plan required

12 months post visit – completed action plan requested

153 AAA QA visits tips and outcomes

Process tips • Use your QA advisors – they are there to help and support you

• Don’t be afraid to ask questions or ask for clarification

• Let your QA advisor know if there is something you are anxious about or

feel should be included as part of your visit

• Answer the questions in the pre-visit questionnaire as fully as possible and

wherever possible provide evidence (or state evidence can be provided if

required)

• Label and reference your evidence logically

• Don’t be worried about recommendations– we aren’t going to ask you to do

something for the sake of doing it

• Use the process to foster engagement with your wider team and to highlight

the good work you are doing or where you need support with you executive

level team and commissioning team


Process tips 6 months – date agreed and documentation sent to you so ideal time to think

about…….

Who is going to be the lead for the visit (usually falls to programme co-

ordinator)

Letting everyone know about the visit date – make sure those required for

interview will be available

How you will complete the pre-visit questionnaire – who will do what sections,

who will co-ordinate?

What venue will you use for the day, how many rooms can you book in

advance, can you provide lunch?

Post visit – establish task and finish group for producing action plan


Recommendation themes Staffing – organisational diagrams, job descriptions and wte, regular systematic

feedback on screener performance and quality of images, training,

attendance at team meetings

SOPs – document key work areas and appropriate formatting (version control,

review dates and sign off)

Risks – risks on programme register, clear governance and escalation

processes

Incidents – policy in line with national incident guidance, reporting of incidents

Treatment timelines - review of processes, monitoring, tracking and breach

reporting, actions identified and implemented

Non-visualisation – monitoring equipment and staffing against rates, timelines,

tracking and access of appointments

Audits – undertake DNA audits, audit NVR completion, share results and

actions from audits at boards


Recommendation themes


Programme board – quoracy, membership, participation, standard agenda

items, action logs, inclusion of compliments/complaints, user

representation,

Equipment - checks performed in line with NAAASP recommendations,

processes documented in a SOP, replacement plans, maintaining

competency on models, storage

Cohort information - review including information requests on transgender

males to females / translation / disability / mobility needs/additional support

when asking GPs for relevant information on their eligible cohort prior to

invitation, processes within prisons, home visits, risk assessments, user

surveys, requirement for early/late/weekend clinics

Shared learning themes Technicians – involved in audits, increased understanding of functionalities with

ultrasound machines, attending theatre to observe EVAR procedures and

vascular clinics, training in British Sign Language, dementia training,

opportunity to observe and scan aneurysms being imaged in the main

vascular laboratory to ensure regular exposure, physiotherapy support, left

and right handed scanning techniques, protocol for return to work after

absence, CSTs running educational and interesting case reviews

Service improvement - improving access for men with learning disabilities,

detailed analysis of uptake rates/dna rates and targeted initiatives with

lower uptake GPs, engagement with homeless shelters, summary language

sheet to identify requirement for information in another language, project

with traveller community to promote GP registration, GPs review cohort

lists, electronic warning alert added to hospital Trust systems for all men

detected with an AAA , card provided to surveillance men to carry which

states they have a AAA, men routinely opted in to a smoking cessation

service


Shared learning themes Health Promotion - ongoing encouragement strategy and promotion/screening

at various venues – golf clubs, bowling clubs, football/rugby/cricket clubs,

rotary clubs, round table events, DIY stores (on discount days for 50+),

betting shops, supermarkets, libraries, keep fit classes

Policies/Processes - Detailed overarching operational policy for the entire

screening programme, referencing all policies, procedures and governance

arrangements in one document, trackers developed for ensuring robust

failsafe of patients through referral, surveillance, non-visualisation and

incidental findings and production of waiting times, streamlined same day

assessment clinic for pre-operative investigations, decline forms for opting

out of surveillance and non-visualisation appointments

Programme Board - effective working relationships between providers and

commissioners, service user attending and contributing to the programme

board


Feedback Feedback through our questionnaire link is currently limited – please complete

the link provided to you after a visit so that we can evaluate and review the

process.

Overall, has been noted as a positive experience, better than expected and

that good support is provided.

To note: review of pre-visit questionnaire is taking place

review of screener technician input into process is taking place


Professional Clinical Advisor plea!

Being a PCA is really interesting, you learn a lot, is a great opportunity to

network and make friends, along with visiting a different part of the country

Opportunity for CPD – undertake national training

Plea for CSTs/QA Leads to become reviewers, please contact your QA advisor

if interested in becoming a PCA


Healthcare

AAA 2016 networking day final presentations