Phyllis murphie lead respiratory nurse nhs d g 31 st march 2010
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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

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Phyllis murphie lead respiratory nurse nhs d g 31 st march 2010

Phyllis Murphie

Lead Respiratory Nurse


31st March 2010

Service Improvement –Evolution of Sleep Medicine Service in


Service outline background referral handling booking processes reporting managing dnas

Service Outline


Referral handling

Booking processes


Managing DNAs

Service outline
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 syndrome osahs
Obstructive Sleep Apnoea Hypopnoea Syndrome- 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
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
Clinical Consequences of OSAHS

  • 7-14 times more likely to have RTA in OSAHS

Service consequences for osahs diagnosis and treatment

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

Service redesign
Service 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
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
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
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 redesign1
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.

Reporting of sleep studies
Reporting of sleep studies

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

Managing dna s
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
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
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
Benefits of Redesign of Service

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
Lean Principles Already Applied to Service

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

More service redesign ideas
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