Providing Access To Interventional Radiology Services .

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NHSImproving QualityProviding access to interventionalradiology services, seven days a weekBritish Society of Interventional Radiology

ContentsForeword3Executive summary4Introduction5Economic benefits8The Sheffield Experience9Focus on procedures10National picture - whereare we now and where arewe going?12Emerging themes19Appendix A21Appendix B22References24Contacts25Glossary26

ForewordForeword by Professor Erika Dentonand Professor Duncan EttlesMore than ever before, the NHS is attempting to focus care around theneeds of our patients, ensuring we offer them a safe environment inwhich to receive care and treatment, irrespective of the point in thepatient’s journey or indeed the day that they require that care.To this end we are looking at whole pathways of care across the system that may crossboth organisational boundaries, or between different types of provision across the healthand social care system.Providing access to Interventional Radiology services, seven days a week pulls together theresponses from three annual national Interventional Radiology (IR) surveys and intelligencegathering from across England. NHS Improving Quality have reviewed IR services acrossthe country and confirmed that more improvement work is necessary to ensure equitableaccess to IR services for patients seven days a week (1).Cutting across several clinical specialties this report explores some of the issues andchallenges in delivering high quality IR services both nationally and locally and seeks toshare good practice and innovations around novel delivery models. It provides practicalguidance for assessing your own service as well as service improvement ideas that somenetworks have adopted, which could be adapted to improve services further.The core purpose of this publication is to highlight key features that constitute a safe andeffective IR service. I recommend that you use it to review the IR services you provide orcommission to ensure delivery of an effective and sustainable IR service.Professor Erika Denton FRCP, FRCRNational Clinical Director for Diagnostics, NHS EnglandProfessor Duncan Ettles MB ChB (Hons), MD, FRCP (Ed), FRCRPresident, British Society of Interventional Radiology3

4Executive summaryExecutive summaryInterventional radiologyprocedures are low volume andhave a number of complexchallenges. The serviceconfiguration at each Trust differsand is dependent on the numberand the skill mix of interventionalradiology consultants in the Trust.It is a service that supports a widerange of clinical pathways.Based on the work of the NHSEngland Seven Day ServicesForum and NHS ImprovingQuality’s Seven Day ServicesImprovement Programme (SDSIP),the focus for the 2013/14interventional radiologyprogramme has been to developnetworks to deliver seven dayaccess for nephrostomy,embolisation for haemorrhageand embolisation for post-partumhaemorrhage. Nephrostomy is acore interventional radiologyservice required for patients witha potential to deteriorate andrequire urgent intervention.Embolisation for haemorrhageusually, but not exclusively, isperformed as an emergency/urgent intervention.Embolisation for post-partumhaemorrhage may involve predelivery planning and beperformed as an emergency/urgent intervention.KEY MESSAGESHigh quality interventional radiology services areessential for safe and effective patient careThere is variation in the provision of interventionalradiology throughout England, particularly forpotentially lifesaving emergency and out of hoursproceduresNetworked delivery models will be essential to improveaccess to interventional radiology. There are challengesin developing effective operational delivery networks,primarily due to the shortfall in the recruitment ofconsultant interventional radiologistsA good well resourced interventional radiology servicecan contribute to significant savings (both financial andnon-financial), as well as improve patient outcomes alongcare pathways in both planned and emergency care. (Seeexample of interventional radiology impact forperipheral vascular disease in diabetic patients)Understand your current service provision to support yourimprovement efforts (see Appendix B for suggested baselining templates)

Introduction 5IntroductionInterventional radiology is acomparatively new sub-specialtyof radiology, sometimes knownas ‘surgical radiology’. It is oftenmistakenly viewed as a purelydiagnostic radiology servicewhere patients and the clinicalcommunity are commonlyunaware of the benefits ofinterventional radiologytreatments. The proceduresrequire the use of imagingtechniques to guideinterventional instruments intoblood vessels and organs, todiagnose and treat a wide rangeof clinical conditions. Theseinnovative techniques can oftenprovide patients with a bettertreatment option to conservativemanagement or surgery, as thetechniques are minimally invasiveand reduce the physical traumato the patient and the infectionrisk, therefore, enabling thepatient to have an easier andfaster recovery often as a daycase. Interventional radiologyinterventions can also be highlybeneficial in urgent andemergency situations.Diagnostic radiologists sometimesperform some of the simpleimage guided procedures such asnephrostomy and abscessdrainage, but interventionalradiologists are sub-specialistswho perform the wider range ofinterventional procedures.Interventional radiologists arealso often required to work inclinical sub-specialties, whichmean that skill mix and numbersof interventional radiologistsavailable in each specialty can belimited as there is a nationalshortage of interventionalradiologists nationally, and thiscan hinder the level of service anacute hospital can provide.In December 2013, NHS Englandpublished Everyone Counts:Planning for patients 2014/15 to2018/19 (2). It included a numberof offers to NHS commissioners,to give them the insights andevidence they need to producebetter local health outcomes. Itstated, that the NHS will movetowards routine services beingavailable seven days a week. It issupported by; Towards BestPractice in InterventionalRadiology (NHS Improvement,2012)(3) , which sets out casestudies using interventionalradiology service delivery modelsthat provide benefits for patientsand staff.To support seven day woking,the National Medical Director,Professor Sir Bruce Keogh,established the NHS Services,Seven Days a Week Forum, toconsider the consequences of thenon-availability of clinical servicesacross the seven day week, andprovide proposals forimprovements to anyshortcomings. The Forum hasestablished thematic workstreamswhich include clinical standardsthat specifically relate todiagnostics and intervention/keyservices.

6IntroductionDiagnostic standardsThe supporting information forStandard 5 Diagnostics states,‘where a service is not availableon site (e.g. InterventionalRadiology / Endoscopy orMagnetic Resonance Imaging(MRI) clear patient pathwaysmust be in place betweenproviders.’Standard 6 Intervention/KeyServices states, ‘Hospitalinpatients must have timely 24hour access, seven days a week,to consultant-directedinterventions that meet therelevant specialty guidelines,either on-site or through formallyagreed networked arrangementswith clear protocols, such as: Critical care Interventional radiology Interventional endoscopy Emergency general surgery.To support this, NHS ImprovingQuality’s 2013/14 InterventionalRadiology ImprovementProgramme has focused onfacilitating the development ofinterventional radiology networksand the completion of the thirdannual national interventionalradiology survey.This has been with the support ofthe British Society of InterventionalRadiology (BSIR) and the BSIRSafety and Quality Group. TheBSIR has representation from theMedicines and Healthcare productsRegulatory Agency (MHRA) andthe Society of InterventionalRadiology Nurses andRadiographers. Whilst promotingbest practice, the BSIR has alsoidentified 15 exemplar sites acrossthe UK based on an agreed set ofquality standards (4).

Introduction 7CASE FOR CHANGENICE Guideline (CG119): Management of Diabetic FootNICE Guideline (CG141): Acute upper gastrointestinal bleeding overviewNICE Guideline (CG147): Lower limb peripheral arterial diseaseNICE Guideline (IPG127): Endovascular stent-graft placement in thoracic aorticaneurysms and dissectionsDH Clinical Policy: Cardiovascular Disease Outcomes StrategyThe Role of Emergency and Elective Interventional Radiology in PostpartumHaemorrhage (Good Practice No. 6), Royal College of Obstetricians andGynaecologists (2007)Investigation into 10 maternal deaths at, or following delivery at, Northwick ParkHospital, North West London Hospitals NHS Trust, between April 2002 and April 2005,Healthcare Commission (2006)Interventional Radiology: Improving Outcomes and Quality for Patients (Departmentof Health, 2009) and Interventional Radiology: a guide to service delivery(Department of Health, 2010) Annex C Adverse eventsThe NHS Atlas of Variation in Diagnostic Services (NHS and Public Health England,2013) he-nhs-atlas-ofvariation-in-diagnostics-services

8 The Sheffield ExperienceThe Sheffield ExperienceBy using early re-vascularisation andinterventional radiology proceduresinstead of conservative management,Sheffield experienced a 70% reductionin the amputation rate.Patient pathwayReferralVS or IR ifrest ounddebridementDay caseFollow upFollow upVS - Vascular SurgeryIR - Interventional RadiologyMDT - Multidisciplinary team

Economic benefits 9Economic benefitsThe clinical and economical value ofearly re-vascularisation for peripheralvascular disease in diabetic patients.Burden of disease in the UK(diabetes 5% prevalence)Population sizeDiabetic population3,380,684Diabetics with peripheral vascular disease676,131Amputations - diabetic patients8,684Comparison of lower limb amputation rate indiabetic populationPercentage rateUK0.26%Germany0.21% (UK 38% higher)Italy0.16% (UK 17% higher)Comparison of procedures and hospital costsAngioplasty (IR) 1898Stenting (IR) 2393By-pass (surgery) 6460Amputation (surgery) 12,075

10 Focus on proceduresFocus on proceduresProcedureDescriptor1) NephrostomyAn artificial opening created between thekidney and the skin used to drain urine fromthe kidney to a bag outside the body2) Embolisation for haemorrhageA minimally invasive procedure which involvesthe selective occlusion of blood vessels toprevent haemorrhage3) Embolisation for post-partumhaemorrhageA minimally invasive procedure which involvesthe selective occlusion of blood vessels toprevent haemorrhage in childbirthPossible patient pathways - where interventional radiology procedures could be utilisedOBSTRUCTED KIDNEYSepsisRetrogradestenting(urologist)Acute ephrostomy(IR)Chronic renalfailureEffectivegroupPOSTPARTUM HAEMORRHAGEMedicaltreatmentIR - Interventional RadiologyD&C balloonSurgeryEmbolisation(IR)

Focus on procedures 11LOWER GASTROINTESTINAL HAEMORRHAGEPatientunstablePatient stable/controlled resuscitationBleeding sourcenot identifiedColonoscopyResuscitationUrgent Colonoscopy /and OGDBleeding source identifiedConservativetreatmentSurgeryIRSurgery (if IR fails)CT scanNegativeLaparotomyBleeding sourceidentifiedAngiography ifbleeding continuesIRSurgery (if IR fails)UPPER GASTROINTESTINAL HAEMORRHAGEEndoscopy (positive)Therapeutic endoscopydependant on skillsof operatorFailure at thisstage may triggerreferral to IRIR - Interventional RadiologyEmbolisation (IR)Endoscopy(negative)CT angiogramRepeatendoscopy

12 National picture - where are we now and where are we going?National picture - where are we nowand where are we going?Interventional radiology survey 2013A third annual interventionalradiology survey of all hospitalsin England, to demonstrate thelevel of access to 24/7interventional radiology serviceswas conducted in Autumn2013. The survey focused onthe 3 procedures (nephrostomy,embolisation for haemorrhageand post-partum haemorrhage),plus endovascular intervention(covering other coreinterventional radiologyprocedures). The selfassessment results confirmedimprovements in the 24 hourservice provision for 2 of the 3key procedures, nephrostomyand embolisation forhaemorrhage, as well as forendovascular intervention(covering other coreinterventional radiologyprocedures), and provided abase line for embolisation forpost-partum haemorrhage.Further improvements areexpected throughout 2014having gained an insight intoTrusts’ annual interventionalradiology plans.

National picture - where are we now and where are we going? 13National RAG status for nephrostomyNephrostomy in hours service provision 2012Nephrostomy in hours service provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustRED: No core serviceprovisionAMBER: Plan in place toprovide service/formalpathway within the next 12monthsWHITE: No dataRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataData as at 10 January 2014Number of responses 151 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012Nephrostomy out of hours service provision 2012Nephrostomy out of hours service provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustRED: No core serviceprovisionAMBER: Plan in place toprovide service/formalpathway within the next 12monthsWHITE: No dataRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataData as at 10 January 2014Number of responses 151 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012

14 National picture - where are we now and where are we going?National RAG status for embolisation for haemorrhageEmbolisation for haemorrhage: generalin hours service provision 2012Embolisation for haemorrhage: generalin hours service provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustRED: No core serviceprovisionAMBER: Plan in place toprovide service/formalpathway within the next 12monthsWHITE: No dataRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataData as at 10 January 2014Number of responses 151 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012Embolisation for haemorrhage: generalout of hours service provision 2012Embolisation for haemorrhage: generalout of hours service provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustRED: No core serviceprovisionAMBER: Plan in place toprovide service/formalpathway within the next 12monthsWHITE: No dataRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataData as at 10 January 2014Number of responses 151 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012

National picture - where are we now and where are we going? 15National RAG status for endovascular interventionEndovascular intervention in hoursservice provision 2012Endovascular intervention in hoursservice provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustRED: No core serviceprovisionAMBER: Plan in place toprovide service/formalpathway within the next 12monthsWHITE: No dataRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataData as at 10 January 2014Number of responses 151 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012Endovascular intervention out of hoursservice provision 2012Endovascular intervention out of hoursservice provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustRED: No core serviceprovisionAMBER: Plan in place toprovide service/formalpathway within the next 12monthsWHITE: No dataRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataData as at 10 January 2014Number of responses 151 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012

16 National picture - where are we now and where are we going?National RAG status for postpartum haemorrhageEmbolisation for postpartum haemorrhagein hours service provision 2013Embolisation for postpartum haemorrhageout of hours service provision 2013KEYKEYGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustGREEN: Core serviceprovision on site or formalnational pathways to anagreed recipient trustAMBER: Plan in place toprovide service/formalpathway within the next 12monthsAMBER: Plan in place toprovide service/formalpathway within the next 12monthsRED: No core serviceprovision and no plans toprovide in the next 12monthsRED: No core serviceprovision and no plans toprovide in the next 12monthsWHITE: No dataWHITE: No dataData as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012Data as at 10 January 2014Number of responses 122 out of 151100% response rate over 2011/2012The national survey askedproviders what they consideredto be the rate limiting step innot providing a comprehensiveinterventional radiology service.Rate limiting factors for not deliveringservice at present time (England)New interventionalradiology facility5%Network approachto service %Interventionalradiographer rota17%Interventionalnurse appointments18%Interventionalnurse rota19%

National picture - where are we now and where are we going? 17Delivering and sustaining 24 hour interventionalradiology services - percentage units providing24 hour service cover for key procedures90%80%Nephrostomy70%Embolism forhaemorrhage general60%Endovascularintervention50%Embolisation forpostpartumhaemorrhage40%30%20122013The survey also askedinterventional radiology servicesto comment on whether theywere planning to deliver servicechanges within the next 12months. Encouragingly it wasthe intention of many servicesto deliver more comprehensiveservice delivery models.However, considering the ratelimiting steps as described byproviders, it would require afurther survey to determinewhether they are successful intheir ambitions.Next 12 monthsThe development of networkedapproaches and solutions withfive regions in England hasfocused on the comprehensivebaselining of services. Templatesto support such work can befound in Appendix B, enablingproviders to progress withdefining and formalisingpathways of care to ensurepatients have access tointerventional radiology services,seven days a week. Strongcollaborative working betweenTrusts and good practiceexamples were particularlyevident within the East Midlandsnetwork, where work isunderway to address many ofthe challenges faced byinterventional radiology serviceproviders, such as therecruitment and retention ofconsultant interventionalradiology radiologists.

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Interventional radiology is a comparatively new sub-specialty of radiology, sometimes known as ‘surgical radiology’. It is often mistakenly viewed as a purely diagnostic radiology service where patients and the clinical community are commonly unaware of the benefits of interventional radiology

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