Service Improvement –
Evolution of Sleep
Medicine Service in
NHS D&H
Phyllis Murphie
Lead Respiratory Nurse
NHS D&G
31st March 2010
•Service Outline
•Background
•Referral handling
•Booking processes
•Reporting
•Managing DNAs
Service Outline
• 430 patients on CPAP therapy
• 25 on home NIV therapy.
• Predicted annual demand estimated at 80 -100 new patients
commencing CPAP therapy and 12 new patients receiving NIV
therapy
• Ear Nose and Throat department used for in-patient based sleep
investigations
• Most limited channel studies done as outpatient based service.
• > 300 new referrals per year requesting limited
channel sleep studies.
Obstructive Sleep Apnoea Hypopnoea SyndromeOSAHS
• 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
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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
Service Consequences for OSAHS
diagnosis and treatment
•Sleep studies
•One of diagnostic tests that has
referral to treatment standard of 18
weeks
•To be achieved by 2011
What have we done in NHS D&G
vice Redesign
• Clinical teams/18 week teams
working together
• Innovative ideas to increase the
number of outpatient based
diagnostic sleep studies.
• PDSA - Service redesign projects
Referral handling
• Respiratory nurse triage of referrals requests
• All internal/external requests for sleep study on
TOPAZ
• Routine/soon (vocational drivers)
• 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
• 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
• Refer back to GP
• Remove from W/L
Diagnostic service redesign
•
V 1- 45 minute outpatient appointment on the day of sleep investigation, clinical history,
examination, routine bloods – Nurse Led
•
V 2- 45min - 1hour return appointment day to download and score sleep study and discuss further
treatment options /interventions – negative studies discharged back to referrer – Medical Input as
requested by RNS
•
V 2- Positive diagnostic tests for symptomatic OSAHS offered a 1-2 week trial of Auto CPAP
•
V 3- CPAP proven to be acceptable /effective next review, then supplied with fixed pressure CPAP
unit and delivery system
•
V4 - Reviewed in the Sleep clinic in 3 - 6 months,
1 year, 2 years,
Could consider open access review in compliant patients
Diagnostic service redesign
• Where diagnostic uncertainty, patients reviewed 3-6 months in
sleep medicine clinic for further assessment of symptoms
• Consideration of repeat limited sleep diagnostic testing may be an
option
• Referral for full PSG to the Royal Infirmary Edinburgh Sleep
Medicine Unit.
2007-2008 Service delivery
250
220
200
208
180
150
Hotel Sleep study
Home Sleep study
IP sleep study
100
50
50
40
25
15
28
0
2007
2008
2009
15
Reporting of sleep studies
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•
Service limitation – no physiologist input
Development bid 2009- unsuccessful
RNS – manually scores sleep studies where indicated
Result verified by Physician where indicated
More medical input to the service requireddevelopment bid unsuccessful
Managing DNA’s
• FA x 1 is given for DNA’s
• Letter sent to patient and copy to GP re DNA in case
of postal issue
• DNA rate usually low as patient focused booking with
Respiratory secretary.
• DNA’s in Sleep medicine clinics – same as above.
Patient Satisfaction with service
• Questionnaire of patient’s views of
service delivery
• Demonstrated overall satisfaction
with service provision and a
preference for home based testing
where possible
• Number of failed/repeat tests are
minimal
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
Benefits of Redesign of Service
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•
•
•
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 £263,00 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
Lean Principles Already Applied to Service
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Multi-diagnostic sleep sessions- Increased capacity and workflow
Reduce annual CPAP recall to 2 years –consider open access review
Diagnosis to treatment established reduced from 5 visits to 3
Screening 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
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?