Phyllis Murphie Lead Respiratory Nurse NHS D&G 31 st March 2010. Service Improvement –Evolution of Sleep Medicine Service in NHS D&H. Service Outline Background Referral handling Booking processes Reporting Managing DNAs. Service Outline. 430 patients on CPAP therapy
Lead Respiratory Nurse
31st March 2010
Service Improvement –Evolution of Sleep Medicine Service in
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.
common sleep disorder caused by repetitive upper airway obstruction during sleep
characterized by pauses in breathing during sleep often accompanied by oxygen desaturation
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.
Service Consequences for OSAHS diagnosis and treatment
One of diagnostic tests that has referral to treatment standard of 18 weeks
To be achieved by 2011
Clinical teams/18 week teams working together
Innovative ideas to increase the number of outpatient based diagnostic sleep studies.
PDSA - Service redesign projects
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
Acknowledgment letter regarding referral sent to patient
Requesting they contact secretary to book appointment for sleep study
No response 2 weeks
No response 2 weeks
Refer back to GP
Remove from W/L
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
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.
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 required- development bid unsuccessful
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.
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
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
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
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
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