What Is Physiological Measurement? - Bscn .uk
82109-COI-Physiological Meas 22/5/0716:07Page ofciWhat isPhysiologicalMeasurement?A guide to the tests and proceduresconducted by Physiological Measurementdiagnostic services
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82109-COI-Physiological Meas 22/5/0716:07Page iWhat isPhysiologicalMeasurement?A guide to the tests and proceduresconducted by Physiological Measurementdiagnostic servicesMay 2007
82109-COI-Physiological Meas 22/5/0716:07Page iiDH INFORMATION READER atesPerformanceIM & TFinancePartnership WorkingDocument purposeFor InformationGateway reference6233TitleWhat is Physiological Measurement?’A guide to the tests and proceduresconducted by Physiological Measurementdiagnostic servicesAuthorDepartment of HealthPublication dateMay 2007Target audiencePCT CEs, NHS Trust CEs, SHA CEs, Care TrustCEs, Foundation Trust CEs, Medical Directors,Directors of PH, Directors of Nursing, LocalAuthority CEs, PCT PEC Chairs, NHS TrustBoard Chairs, Special HA CEs, Directors ofHR, Directors of Finance, Allied HealthProfessionals, GPs, Communications Leads,Emergency Care Leads, Those collating datafor the national diagnostic censusCirculation listDescriptionA practical guide for a range of audiences.It is designed to promote basicunderstanding of these services and assistin working towards achieving 18 weeksreferral to treatment times. It provides acomprehensive overview of the eight areasinvolved, including a breakdown of all thekey diagnostic procedures.Cross referenceN/ASuperseded documentsN/AAction requiredN/ATimingN/AContact detailsMark CohenPhysiological Measurement Policy andImplementation18 Weeks – Commissioning Directorate4N14 Quarry HouseLeedsLS2 ain true&load ArticleViewerFor recipient’s use
82109-COI-Physiological Meas 22/5/0716:07Page iiiContentsSectionI.Introductioni.Physiological Measurement and 18 Weeks6ii.Physiological Measurement Services6iii.Physiological Measurement Workforce9iv.Physiological Measurement and Children10v.‘What is Physiological Measurement?’10II. The eight areas of Physiological Measurement1.AudiologyAudiology Tests Summary14162.Cardiac PhysiologyCardiac Physiology Tests Summary26293.Gastrointestinal (GI) PhysiologyGastrointestinal (GI) Physiology Tests Summary34374.NeurophysiologyNeurophysiology Tests Summary39425.Ophthalmic and Vision ScienceOphthalmic and Vision Science Tests Summary45496.Respiratory Physiology (including Sleep Physiology)Respiratory Physiology (including Sleep Physiology) Tests Summary56597.UrodynamicsUrodynamics Tests Summary67708.Vascular TechnologyVascular Technology Tests Summary7275Acknowledgements78iii
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82109-COI-Physiological Meas 22/5/0716:07Page 1ForewordProfessor Sue Hill – CBiol, FlBiol, Hon MRCP, OBE: Chief Scientific Officer & National ClinicalLead for Physiological Measurement, Department of HealthPhysiological Measurement is one of fourdiagnostic programmes at the Departmentof Health, central to the delivery of the 18weeks implementation programme. The term‘Physiological Measurement’ has been adoptedto reflect those services that predominantlyfocus on assessing the function of majororgan systems (e.g. neurophysiology involvesinvestigating the function of the central andperipheral nervous system and the impact ofdifferent pathologies). In some instances, theseservices may also restore function through arange of therapeutic intervention strategies.Locally, the clinical services that are includedwithin this term may be dispersed acrossprovider organisations and are not usuallypart of a distinct physiological measurementdepartment or unit.Access to diagnostic services is recognised asa major rate-limiting step in achieving the 18week patient pathway by December 2008,which encompasses all stages that lead up totreatment, including outpatient consultationsand diagnostics tests/procedures. Significantfocus has now been given to resolvingbottlenecks caused by long waits fordiagnostics, including PhysiologicalMeasurement services. These services havetraditionally had a low profile and been poorlyunderstood, often embedded within blockcontract arrangements and not recognisedas an integral service entity. However,Physiological Measurement is a major areaof the diagnostic service portfolio, providinga wide range of specialist investigations andelements in the care pathway that are essentialin achieving more rapid treatment for patients.This document provides a comprehensiveoverview of the tests and proceduresconducted by Physiological Measurementdiagnostic services. It has been developedto provide information about these servicesfor providers, commissioners and for thoseindividuals who have ultimate strategic andoperational management responsibility fordelivery. Crucial to the development of theseservices is a clear understanding of demandfor and capacity of current services and anexploration of how services can be delivereddifferently. Service transformation involvessynchronising technology, processes and theskills and competences of the workforce, allworking together to deliver efficient andeffective services for the patient. It also meansconsidering the broader agenda for deliveringservices closer to patients, as outlined in ‘Ourhealth, Our care, Our say’ (2005), and findinglonger term, sustainable solutions.As the National Clinical Lead for PhysiologicalMeasurement, I am delighted that NHScommissioners and providers of NHS servicesare now giving attention to PhysiologicalMeasurement services, which have perhapsbeen neglected in the past. I hope that thisdocument receives the wide circulation that itdeserves and that it helps people to understandthis complex area, which is crucial to improvingthe services we deliver to patients.1
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82109-COI-Physiological Meas 22/5/0716:07Page 3ForewordProfessor Dame Carol Black – FMedSci, FRCP, DBE: Chair of the Academy of Medical RoyalColleges and former President of the Royal College of Physicians. Co-chair of the PhysiologicalMeasurement Strategy Group, DH.Clinicians and patients will surely welcome thisdetermined approach to bringing PhysiologicalMeasurement forward into the thinking ofeveryone who has a part in improving servicedelivery and outcome. They will be glad to finda clear definition of the term. Measuring theblood pressure, body temperature, or the levelsof components of the blood are, of course,Physiological Measurements too but the term asused here means assessment of function ofmajor organ systems. No less than the morefamiliar tests that are part of normal clinicalcare, physiological measures are integral to theprocesses of diagnosis and therapeuticintervention, and to the experience of millionsof patients. It is time to give closer attention totheir key place in service improvement.It is a common experience that bottlenecks orrate-limiting steps (to adopt the term longused to describe the brake in biologicalpathways) are found in the patient journeythrough diagnosis, or interpretation of thepatient’s problem, to the point where thepatient and the doctor can make a properlyinformed decision on treatment. Frequently,not only are there long waits but patients mustreturn for physiological investigations often ata time and place inconvenient to them.Where the health benefits of PhysiologicalMeasurements can be foreseen there shouldbe no difficulty in principle in incorporatingthem within a regular planned clinical pathway,as is already expected and done duringpregnancy, for example. Similar planningshould become the norm in the range ofdisorders referred to in this document.We do not suggest that a completeinvestigative sequence can be arranged fromthe early stages when a patient presents with aproblem or seeks advice, but there is a rationalsequence of steps, informed by clinicaljudgement. Increasingly the adoption ofagreed clinical protocols or algorithms willallow the forward planning necessary to givethe unimpeded care pathways sought bypatients and their doctors.The document brings out more fully thanhitherto the complexity and sophistication ofphysiological measurement services and theiressential place in the patient pathway. It givesnew emphasis to the range of skills neededacross the healthcare team, and to the clinicalstandards and clinical governance proceduresagainst which performance should be assessed;and it points once more to the functions andsupport structures necessary for efficientclinical networks that work collaboratively toserve patients well.The statement brings yet new challenges tocommissioners and providers, to the HealthcareScientists who deliver many of these servicesand the clinicians who request them.3
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82109-COI-Physiological Meas 22/5/0716:07I. IntroductionPage 5
82109-COI-Physiological Meas 22/5/0716:07Page 6I. Introductioni.Physiological Measurement and 18Weeks1.Reducing waiting times for diagnostics iscentral to delivering shorter, overall accesstimes for the benefit of patients. Acombination of record investment, thehard work of NHS staff and reform hasbrought waiting lists down to a recordlow.2.By 2008, the NHS will introduce amaximum wait for patients of 18 weeksfrom GP referral to hospital treatment,including any diagnostics. This is one ofthe most significant reforms in the historyof the NHS, ensuring all local healthproviders move patients as quickly aspossible through the different stages of aclinical pathway towards initiation oftreatment (www.18weeks.nhs.uk).3.Physiological Measurement diagnosticservices face some of the biggestchallenges in delivering the 18 weekspatient pathway, having some of thelongest waiting times and/or the largestnumber of people waiting. Despite thefact that these services are less well knownand have not featured explicitly in publicservice agreements to date, they have animportant role to play in the NHS todeliver key access targets, National ServiceFrameworks (NSFs) and the widermodernisation agenda, which is brieflyoutlined in Table 1. PhysiologicalMeasurement diagnostics are an intrinsic6part of many care pathways and reducingwaits for these tests will contribute to thetotal 18 weeks waiting time commitment.4.A number of symptom-basedcommissioning pathways have beendeveloped for each of the highest volumeclinical specialties to challenge existingpractice, utilise service improvementtools and techniques, and maximiseopportunities for transformational change,in order to deliver 18 week pathways. Thepathways are high-level service focusedpathways to help support and enablecommissioners. More information oncommissioning pathways and the roleof Physiological Measurement diagnosticsin these to help achieve 18 weeks canbe found oad ArticleViewer&ArticleId 645.ii. Physiological Measurement Services5.Physiological Measurement servicesmeasure and monitor a range ofphysiological parameters usually in majororgan systems, providing information onthe extent of disease or disability and theprovision and/or response to therapeuticinterventions, which may be an integralpart of the service provided. There arearound 300 specialist PhysiologicalMeasurement tests and approximately10 million procedures are carried outper year.
82109-COI-Physiological Meas 22/5/0716:07Page 7What is Physiological Measurement?Table 1: High-level overview of the eight Physiological Measurement diagnostic areas:DisciplineIndication of tests &services providedKey driversKey issuesAudiologyA wide range of hearing and balanceassessments to determine functionalability, possible pathologies and impacton related daily activities. 18 Weeks Public Service Agreement(PSA)*;‘Improving Access to AudiologyServices in England’ (DH, March2007);National Service Frameworks (NSFs)– Older People, Children;Modernising Hearing Aid Services;Newborn Hearing ScreeningProgramme (NHSP) / Early Support. Growing demand;Introduction of digital hearing aids;Phasing out old analogue hearingaids;Extending provision of cochlearimplants.Cardiac PhysiologyDiagnosis and management of patientswith known or suspectedcardiovascular disease incorporatinginvasive, non invasive andinterventional procedures 18 Weeks Public Service Agreement Increasing demand and prevalence(PSA)*;of some conditions e.g. heart National Service Frameworks (NSFs)failure;– Coronary Heart Disease (CHD), Impact of guidelines.Older People, Children; Range of National Institute forClinical Excellence (NICE) guidelines.Gastrointestinal (GI) PhysiologyFunctional assessment of the upper /lower GI tract and the management ofpatients with pelvic floor dysfunction. 18 Weeks Public Service Agreement Growing demand and increase in(PSA)*;prevalence of some conditions; National Service Frameworks (NSFs) Unsustainable service provision– Cancer, Older People, Children;models. National Institute for ClinicalExcellence (NICE) guidelines – faecalincontinence, dyspepsia.NeurophysiologyDiagnosis of a wide range of conditions 18 Weeks Public Service Agreementaffecting the central and peripheral(PSA)*;nervous systems. National Service Frameworks (NSFs)– Long Term Conditions (LTC),Neurology; Older People, MentalHealth; Forthcoming DH National StrokeStrategy (to be published laterin 2007) Increased demand for peripheralneurophysiology investigations.Ophthalmic and Vision ScienceInvestigations of the disorders of vision, 18 Weeks Public Service Agreementand diseases of the eye and the visual(PSA)*;pathway. National Service Frameworks (NSFs)– Long Term Conditions (LTC),Diabetes, Older People, Children; National Institute for ClinicalExcellence (NICE) guidelines –photodynamic therapy and othertreatments for maculardegeneration, diabetic retinopathy,laser refractive surgery. Increased demand for specialist testsand follow-up work; Crossover between NHS andindependent sector provision.Respiratory Physiology and SleepPhysiologyA wide range of diagnostic testing andtherapeutic services to patients withsuspected and/or confirmed respiratorydisease and/or sleep related breathingproblems. 18 Weeks Public Service Agreement(PSA)*; National Service Frameworks (NSFs)– Long Term Conditions (LTC),Older People, Children; Chronicobstructive pulmonary disease; National Institute for ClinicalExcellence (NICE) guidelines –Oxygen therapy. Increasing demand for somespecialist respiratory tests and sleepinvestigations; Provision of nasal ventilation, withpotentially large, yet unrecognised,demand.UrodynamicsAssessments that investigate bladderand lower urinary tract function. 18 Weeks Public Service Agreement(PSA)*; National Service Frameworks (NSFs)– Long Term Conditions (LTC),Older People. Increased demand; Unsustainable service provisionmodels.Vascular TechnologyInvestigation and monitoring ofdiseases of the arteries and veins. 18 Weeks Public Service Agreement(PSA)*; National Service Frameworks (NSFs)– Long Term Conditions (LTC),Diabetes, Older People, CoronaryHeart Disease (CHD); Forthcoming DH National StrokeStrategy (to be published later in2007). Increased demand for someemergency services e.g. Deep VeinThromboses (DVT); Increase in renal workload for fistulaaccess; Increased demand for fasterTransient Ischaemic Attacks (TIA or‘mini strokes’) referrals.* Public Service Agreement (PSA): NHS objectives agreed with the Treasury.7
82109-COI-Physiological Meas 22/5/0716:07Page 8What is Physiological Measurement?6.Within the national work programme forPhysiological Measurement, eight differentdisciplines or areas are recognised thatprovide services to almost all clinicalspecialities – Table 1 provides a high-leveloverview of these eight PhysiologicalMeasurement diagnostic areas andoutlines some of the key issues theseservices are currently facing.7.The tests and investigations undertaken inthe eight areas of PhysiologicalMeasurement comprise of a number ofdifferent processes that may be deliveredby a range of professionals within thehealthcare team. Many of the processesare embedded within complex carepathways. Understanding the componentparts is critical to the efficient and effectivedelivery of the service and in identifyingthe workforce delivering each activity andfunction. Appropriately matching the skillsand competences of the workforce to theservice needs, including conducting eachdiagnostic test component, is critical forthe delivery of 18 weeks, as outlinedbelow in Table 2.Table 2: Diagnostic Test Components:DECISION TO INVESTIGATE Information it will provide; How it will influence patient management; Requirement of evidence based care pathway.PATIENT ASSESSMENT(pre-testing) Contra-indications to test investigation being performed;Identification of pre-test requirements;Appropriateness of referral related to presenting symptoms;Information for the patient about test(s);Assessment of clinical status immediately prior to investigation.EQUIPMENT Preparation (can include environments);Calibration/verification and QA;Maintenance/repair;Operating safety (& impact on environments).PERFORMANCE OF DIAGNOSTIC‘TEST’(Simple, Routine, Specialist, Complex) Protocols/standards;‘Patient’ specific modifications;Technical acceptability;QA of ‘test’ performance/procedure;Technical acceptability (limitations).RESULTSINTERPRETATION & REPORTING Selection of result;Linked to presenting symptoms/provisional diagnosis;Pattern recognition;Comparison with internal QA within ‘sets’ of results.CLINICAL ADVICE & MANAGEMENT Support differential diagnosis; Directs treatment options and further investigations.8
82109-COI-Physiological Meas 22/5/0716:07Page 9What is Physiological Measurement?8.Currently, most PhysiologicalMeasurement services are located in acuteTrusts with limited direct access todiagnostic provision for primary care (withsome notable exceptions, such as AdultHearing Services). Although innovation isstarting to occur, secondary care generallystill acts as a gatekeeper with diagnostictests often only accessed as part of alinear patient pathway and after anoutpatient attendance. There are manyopportunities to deliver PhysiologicalMeasurement services and tests differently,in particular by locating services in primarycare settings, or as one-stop serviceswithin outpatients, or exploring theprovision of e-diagnostic resources forprimary and secondary care. Theseopportunities need to be explored in thecontext of the care pathway and inachieving the 18 week access target.iii. Physiological MeasurementWorkforce9.Physiological Measurement testsare mainly carried out by healthcarescientists (HCS) (Clinical Scientists, ClinicalPhysiologists and associate/assistantpractitioners), with medical staff involvedin delivery of some elements of thediagnostic test components (e.g. decisionto investigate, or in more complex testing,or in reporting and interpreting). In someareas, a multi-disciplinary approach istaken (e.g. in Urology where specialistnurses, scientists and medics may beinvolved in different parts of thediagnostic pathway). The development ofnew roles to match the functions thatneed to be delivered and the high volumeof bundled test requirements is a key partof the solution to address waits for manyphysiological measurement diagnosticservices. New roles for scientific staff arebeing tested at sites across the NHSthrough other national programmes, suchas DH/Skills for Health, Healthcare ScienceProgramme. Further information relatedto Physiological Measurement workforcesolutions will be found at regularintervals on the 18 week websiteat www.18weeks.nhs.uk.10. Currently, only Clinical Scientists areregulated under statute by the HealthProfessions Council (HPC). Voluntaryregulation arrangements are in placefor Clinical Physiologists throughThe Registration Council for ClinicalPhysiologists (RCCP)(http://fp.clinphys.f9.co.uk) with amove to statutory regulation of practiceanticipated in the future. It is importantthat staff are registered appropriately,either as part of statutory or voluntaryarrangements.9
82109-COI-Physiological Meas 22/5/0716:07Page 10What is Physiological Measurement?iv. Physiological Measurement andChildrenv. ‘What is PhysiologicalMeasurement?’11. In many of the Physiological Measurementareas, some services will be set upspecifically for children and youngerpeople. These services may differ from theway diagnostic testing is carried out foradults by having specially skilled staff,specialist equipment and/or a specialistenvironment. Children will often undergomeasurement in areas dealingpredominantly with an adult population.Clinics or part of clinics specifically forchildren should be developed if possibleand the advice of paediatric staff includingplay therapists sought to develop a childfriendly atmosphere .There is often greatersensitivity required when dealing withchildren, which in turn may require longertimescales to conduct particular diagnostictests, or may require repeated tests.Children may also be on different carepathways to adults or be referred fromdifferent sources, such as social services oreducation. Many children will have longterm conditions where repeated diagnostictesting will be part of an ongoing cycle ofcare.13. This document is a guide for a range ofaudiences, including those providing theservice, managers and healthcare scientists(HCS). A range of specialties within Trustsand primary care providers could benefitfrom this document as could those whoare commissioning services in Primary CareTrusts (PCTs), Strategic Health Authorities(SHAs) and through practice-basedcommissioning. It provides a high leveloverview, which may be helpful for Boardmembers and senior management teams.It may also be used for communicationsin raising the profile of PhysiologicalMeasurement.12. It is important to consider all the abovepoints when referring to each of the eightPhysiological Measurement areas in thisdocument and particularly for each set oftest summaries.1014. This document has been developed inpartnership with medical staff, healthcarescientists and other members of the multi disciplinary team who are involved in thedelivery of Physiological Measurementservices. It is designed to promoteunderstanding of the diagnostic testsand procedures that are offered and wehave tried to ensure that the informationprovided is as accurate as possible.However, it is an explanatory documentand not intended to provide acomprehensive list of all tests that may beperformed, nor to dictate clinical practice.
82109-COI-Physiological Meas 22/5/0716:07Page 11What is Physiological Measurement?15. The subsequent chapters of this documentcover each of the eight areas ofPhysiological Measurement in more detailand provide the following information: Where the service is located; What services they provide; Where referrals come from and whotakes the decision to refer; Who currently delivers the service; A comprehensive summary of teststhat includes information about thenature of the tests involved (e.g.invasive or non-invasive), location (e.g.in-patient or out-patient), averagetime taken for the test to beperformed (including equipmentpreparation time), patient contact time(including any history taking), anyexplanation needed at the end of thetest, the actual test,interpreting/analysing/reporting time(if this is not an integral part of theoverall testing time), and finally – asummary of the function andindication of the test.16. The NHS has been set the followingmilestones for achievement in relation to18 weeks by March 2008: 85% of admitted pathways, and 90%of non-admitted pathways to reachclock stop within 18 weeks; All diagnostic tests including PhysiologicalMeasurement tests to be carried outwithin a maximum of 6 weeks.17. The Physiological Measurement tests thatare collected in the monthly nationaldiagnostic data collection and the quarterlydiagnostic census, to monitor deliveryof these milestones, have been basedon the test summary details within 'Whatis Physiological Measurement?'. Thisdocument should therefore act as a usefulguide for those involved in collectingsuch data. For further information onwaiting times data, the monthly datacollection and diagnostic census, visithttp://www.performance.doh.gov.uk.(Current data collection guidance is postedon UNIFY system news and steismain?readform&login 1).18. The vision for the future of PhysiologicalMeasurement diagnostic services is thatthey should: Be patient centred; Realise the benefits of new technology; Be streamlined and efficient withinReferral to Treatment (RTT) pathwaysof 18 weeks by Dec 2008; Be delivered closer to home; Provide excellent patient information; Be accessible from primary as well assecondary care.11
82109-COI-Physiological Meas 22/5/0716:07Page 12What is Physiological Measurement?19. This document is one in a series ofproducts that either have been, or are inthe process of being developed by thenational Physiological MeasurementProgramme as aids for the NHS and otherproviders of NHS services in delivering thisvision. For further information and regularupdating, visit www.18weeks.nhs.uk.20. The immediate priority is 18 weeks, whichwill in turn drive other elements of thevision set out above. In 2007/08, thefocus will therefore be on what the DHcan do to help front line staff involved inthe delivery of Physiological Measurementservices to achieve 18 weeks. The biggestchallenges for 18 weeks relate toaudiology, cardiac physiology,neurophysiology and respiratory/sleepphysiology and materials will be producedsetting out good practice in these areas.The commitments set out in ImprovingAccess to Audiology Services in England(DH, March 2007) will be taken forward.Information will be provided on workforceand leadership, which are crucial todelivery of 18 weeks and a series of casestudies across all physiologicalmeasurement disciplines will be madeavailable. A capacity tool will be placed onthe 18 weeks website for use byPhysiological Measurementservices/departments to review theirproductivity and model the potential thatthey could gain by working in differentways.12
82109-COI-Physiological Meas 22/5/0716:07Page 13II. The Eight Areasof PhysiologicalMeasurement
82109-COI-Physiological Meas 22/5/0716:07Page 141. AudiologyAudiology involves a wide range of hearingand balance assessments. These assessmentsdetermine functional ability, possiblepathologies and impact on related dailyactivities. Following assessment, an appropriatecare pathway is selected for treatment(e.g. surgery for cochlear implant) and support,but more often for rehabilitative supportstrategies (e.g. programmed digital signalprocessing (DSP or ‘digital’) hearing aids,counselling, assistive listening devices) toimprove the ability to participate in dailyactivities.What services do they provide?23. The major elements of audiology servicesinclude: Assessment of patient needs andselection of appropriate care pathways; Hearing function (including pure toneaudiometry – see below) and tinnitusassessments; Diagnostic audio vestibular function tests(i.e. balance tests and electrophysiologicaltests of hearing and balance); Assessment for implantable devicesthat aid hearing and communication(e.g. bone anchored hearing aids andcochlear implants) and for patientswith central auditory processingdisorders (provided by a small numberof centres, up to 20). Fitting of digital hearing aids to newand existing patients; Hearing and tinnitus patientmanagement and follow-up; Pure Tone Audiometry is a behaviouralassessment that determines thethreshold for hearing at a number ofpure tone frequencies and maps themonto an audiogram in a standardmanner. It requires active cooperationfrom the patient. Sound may beapplied monaurally by means of anearphone (air conduction audiometry),or vibrations may be applied to theskull by a bone vibrator (bone conduction audiometry).Where is the service located?21. The majority of acute Hospital Trusts aresupported by an on site audiologydepartment. However, audiology is acommunity-facing service with a highnumber of adult and paediatric outreachsites, some GP based services and anincreasing number of private sectorproviders. There is the potential for moreservices to be provided directly in primarycare settings. Paediatric audiology serviceswork in partnership with local authorityservices who provide the major ongoingrehabilitative support for parents and theirchildren.22. The majority of audiology tests need to beundertaken in quiet clinical rooms(background noise 35dBA), soundproofed rooms or electrically shielded andsound proofed rooms.14
82109-COI-Physiological Meas 22/5/0716:07Page 15What is Physiological Measurement?AudiologyWhere do referrals come from and whotakes the decision to refer?24. The majority of referrals to audiologycome directly from GPs, self referrals fromexisting hearing aid patients, with theremainder from ear, nose and throatdepartments (ENT) and other internaldepartmental referrals i.e. from audiologistto hearing therapist, or from ‘repair clinic’to hearing aid assessment clinic. Childrenmay also be referred to paediatricaudiology services through the NewbornHearing Screening Programme (NHSP), ahealth visitor or school nurse.25. Referrals from specialties other than ENThave a significant impact on the totalpatient journey. These referrals particularlyimpact on some of the lower volume testsprovided by audiology services. Forexample, many patients that requirevestibular/balance assessment andrehabilitation associated with dizziness orfalls may be referred from a range ofspecialties, but often do not reach audiologyuntil quite late in the patient pathway.26. Audiology services work closely with arange of agencies, including Education &Social Servic
82109-COI-Physiological Meas 2 2/5/07 16:07 Page 1 Foreword Professor Sue Hill - CBiol, FlBiol, Hon MRCP, OBE: Chief Scientific Officer & National Clinical Lead for Physiological Measurement, Department of Health Physiological Measurement is one of four diagnostic programmes at the Department of Health, central to the delivery of the 18
table of contents introduction to alberta postpartum and newborn clinical pathways 6 acknowledgements 7 postpartum clinical pathway 8 introduction 9 physiological health: vital signs 12 physiological health: pain 15 physiological health: lochia 18 physiological health: perineum 19 physiological health: abdominal incision 20 physiological health: rh factor 21 physiological health: breasts 22
The physiological impacts of operational demands can impair worker cognitive functioning. Awareness-based models of physiological and cognitive performance impacts can be taught and can influence subsequent activity. The ability to record and transmit physiological variables from first responders has been available for
2.0 Human Thermal Physiological Numerical Model 2.1 Description The NREL Human Thermal Physiological Model, a three-dimensional transient finite element model, contains a detailed simulation of human internal thermal physiological systems and thermoregulatory responses. The model consists of two kinds of interactive systems: a
perform cycling activities as well as explain how exercise improves the physiological capabilities. To perform in cycling, the body has three major physiological systems to support the exercise. These are the Cardiovascular, Energy and Muscular systems. Types of physiological systems: I. Ener
Robert Heinlein’s 1959 book “Starship Troopers” provided a scientific concept of wearable physiological monitoring that inspired earlier Army research 9 4 Then and Now - physiological monitoring outside of the laboratory (“in the wild”) 11 5 Body temperature
The MassTrak AAA Solution is a total system for the analysis of physiological amino acids for research use only. It provides a robust, reliable, less time consuming tool allowing higher sample throughput for physiological amino acid analysis. The analys
research, with the proviso that the topic focus related to the adolescent life stage. The main variables of interest were theories and hypotheses related to physiological development during adolescence and relationships with health-related behaviour. Physiological development was defined as encompassing a broad range of biological
Although adventure tourism is rapidly growing South Africa, research on the subject in this region is relatively limited. A few studies have examined issues and challenges facing the adventure tourism industry as a whole. Rogerson (2007) noted some of the challenges facing the development of adventure tourism in South Africa. One was the lack of marketing, particularly marketing South Africa .
