Wales Abdominal Aortic Aneurysm Screening Programme … DRAFT... · 2015. 11. 14. · As part of...

Date: 2nd December 2011 Version: Final Draft Page: 1 of 14

Wales Abdominal Aortic Aneurysm

Screening Programme

Proposal Paper: The

Implementation and Development

of Elective Vascular Networks Authors: Mr Rhys Blake; Mrs Llywela Wilson; Dr Rosemary Fox; Dr Gareth Davies; Mr Louis Fligelstone

Date: 2nd December 2011 Version: Final draft

Publication/ Distribution:

WAAASP Project Board

WAAASP Surgical Capacity Planning subgroup

WAAASP Project Team

Vascular Clinicians in Wales

Health Board Directors of Planning

Health Board Implementation Teams

Review Date: Ongoing

Purpose and Summary of Document:

This document summarises drivers for change in the organisation and delivery of vascular services, and work undertaken to develop elective vascular networks in

Wales. It puts forward proposals for the implementation and further development of such networks. It aims to tie up strategic direction with practical

steps for implementation in advance of the launch of the AAA programme in Wales in December 2012.

Work Plan reference: AAA project plan


1 BACKGROUND AND

INTRODUCTION ...................................................................... 3

2 REQUIREMENTS ...................................................................... 3

3 NETWORK DEFINITIONS......................................................... 5

4 NETWORK STRUCTURES AND DELIVERY IN WALES ................ 6

4.1 Volume outcome and network organisation .............................. 7

4.2 Multidisciplinary Team ........................................................... 9

4.2.1 Membership of MDTs: ...................................................... 9

4.2.2 Meeting Frequency: ......................................................... 9

4.2.3 Location: ....................................................................... 9

4.2.4 Function: ..................................................................... 10

4.2.5 Management ................................................................ 10

5 BARRIERS AND OBSTACLES TO DEVELOPMENT ..................... 11

6 CONCLUSIONS AND NEXT STEPS .......................................... 11

6.1 Short term .......................................................................... 11

6.2 Medium term....................................................................... 12

6.3 Long term ........................................................................... 12

APPENDIX 1 SUMMARY OF FIRST ELECTIVE VASCULAR NETWORK

DEVELOPMENT ...................................................................... 13

Public Health Wales Development of Elective Vascular Networks

in Wales

Date: 2nd December

2011

Version: Final Draft Page: 3 of 14

1 Background and Introduction

In February 2007, the National Screening Committee approved the introduction of screening men aged 65 for Abdominal Aortic Aneurysm

using abdominal ultrasound scanning. In light of the risks associated with surgical repair of screen detected aneurysms, (a 5-6% mortality rate from

all elective AAA repairs) the committee added the provisos that men should be provided with clear information about the risks of elective

surgery, and that networks of vascular surgical services should be created in order to undertake the surgical repair of screen-detected aneurysms.

The resultant formation of surgical networks to deliver surgery to men

with screen detected aneurysms, has led the Vascular Society of Great Britain and Ireland (VSGBI) to publish its Framework for Improving the

Results of Elective AAA repair, aiming to half the elective surgical mortality rate for AAA to 3.5% by 2013.

In May 2010, the Screening Division of Public Health Wales was asked to plan an AAA screening programme for men in Wales. As part of the

planning for the introduction of Wales Abdominal Aortic Aneurysm Screening Programme (WAAASP), the Project Team must therefore ensure

that men diagnosed with aneurysms as a result of screening are referred for treatment to services meeting the Vascular Society’s Quality

Improvement Framework. One requirement of the framework is participation in a network.

In addition, the AAA Project Team have been asked by Chief Executives in Wales to facilitate the development of elective vascular networks for all

other vascular referrals on their behalf.

Elective Vascular networks will need to be functional in advance of December 2012 ready to receive referrals from the screening programme,

since WAAASP must only refer men into a quality assured service that has auditable quality outcomes that meet the required national standards.

Wider vascular service development within these networks will be a longer term and ongoing development.

2 Requirements

To receive referrals of men with screen-detected aneurysms, networks must meet certain minimum standards/criteria. The requirements initially

laid out in the VSGBI AAA QIP initially allowed for the possibility of major arterial surgery taking place on more than one site in the network.

However, it is now recognised that networks involving arterial intervention on more than one site often result in reduced quality of care for patients

out of hours. For this reasons, the VSGBI’s current strategies require that

all arterial interventions are performed in larger volume hospital sites, with intervention provided on those sites by vascular surgeons and


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2011


interventional radiologists from both the central and network hospital sites.

Network requirements have therefore been refined by the VSGBI for approval at their AGM in November 2011, and state:

Vascular services need to be organised to allow reasonable elective activity to exist alongside an acceptable consultant emergency on call rota. This should be no more onerous than a 1 in 6, and for large centralised units, may be 1 in 8 or more. Units with fewer than 4 surgeons should no longer be performing arterial surgery and should merge or collaborate in a clinical network to achieve 24/7 emergency cover. Such networks should designate a single centre to provide all elective and emergency arterial intervention.

The Vascular Society recommends a service that would allow for all arterial interventions (including peripheral artery angioplasty and stenting) to take place in a high volume arterial hospital which can provide the following facilities:

a. A vascular on call rota of 1 in 6 or greater

b. 24/7 emergency on site cover for both vascular surgery and interventional radiology

c. A 24/7 dedicated critical care facility including ventilatory and renal support

d. Specialist vascular wards, with single sex bays or cubicles.

e. At least one theatre specification interventional radiology suite/endovascular theatre

f. A minimum of 32 elective aortic aneurysms per year (100 in 3 years)

g. Audited adherence to the NAASP guidelines for the treatment of abdominal aortic aneurysm.

h. The presence of a vascular MDT meeting involving vascular surgeons, interventional radiologists and anaesthetists.

i. An elective aortic aneurysm mortality of < 6% (open and EVAR).

j. An on site vascular laboratory

k. Mandatory submission of index cases to the National Vascular Database

These high volume arterial hospitals should be based on a population of 800,000, aligned to the NHS AAA Screening Programme and can involve a clinical network with a designated arterial hospital or a centralised service.

(Provision of Services for Patients With Vascular Disease 2011; Vascular Society of Great Britain and Ireland Draft).


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2011


3 Network Definitions

In order to meet the VSGBI requirements, and optimise clinical outcomes and sustainability of services, vascular clinical networks will be required.

A widely accepted definition of a clinical network is

…”linked groups of health professionals and organisations from primary,

secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing professional (and organisational) boundaries to

ensure equitable provision of high-quality and clinically-effective services. They are 'whole systems', partnership-based virtual organisations”.

Baker CD, Lorimer AR, Cardiology: The development of a managed clinical network. BMJ 2000; 321: 1152-3.

This is the definition that will be adhered to in Wales since it is acknowledged that networks are very effective at overcoming historical barriers to the delivery of appropriate care. They can address local issues

and problems with the recruitment of sufficient numbers of appropriately qualified staff; even out workload to ensure that all clinicians within the

network have the required and consistent caseload to maintain competency and to develop skills; provide robust peer support, sharing

experience and perspectives and enabling the development of sub

specialty that would otherwise not be possible due to service pressures.

The Vascular Society of Great Britain and Ireland further support this with their statement that:

“A clinical network exists when two or more adjacent hospitals collaborate to provide patient care. Such networks should decide upon a single hospital which will provide both elective and emergency arterial vascular surgical care. Networks might be based on a local aortic aneurysm screening programme, but it is required that all major arterial intervention is performed on the designated arterial site.

The majority of vascular patients do not require major vascular intervention and it is important that local protocols are agreed to provide high quality specialist care to patients at the non arterial network hospitals. A number of models exist, according to the level of vascular service in the participating hospitals. Clear written arrangements should exist for cover of inpatients and the transfer of emergencies out of hours.

All vascular consultants involved in a clinical network should be timetabled to provide out patient, ward and specialist vascular care to vascular patients within the non arterial network hospitals. This will include a service to amputees and to patients with chronic venous insufficiency and diabetic feet. Local models of care will be developed, and it may be appropriate to offer amputation and rehabilitation in designated non arterial hospitals. It is however important that all patients considered for amputation are fully assessed by a consultant vascular specialist and given the same opportunities for limb salvage as those in the high volume arterial hospitals. “


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2011


(Provision of Services for Patients With Vascular Disease 2011; Vascular Society of Great Britain and Ireland).

Therefore there will need to be a consolidation of surgical/radiological

interventions for aneurysm repair and other arterial interventions onto fewer sites and the introduction of a hub and spoke model of service

where pre assessment, minor interventions & follow-up can happen in a spoke (local) unit but the interventional/treatment procedure is

undertaken at the hub which may also host the MDT.

The development of clinical networks will enable the service in Wales to continue to provide higher specialist training to surgical trainees following

the imminent establishment of the separate specialty of Vascular Surgery, and can be expected to facilitate recruitment to specialist posts in the

future, improving the sustainability of vascular services in Wales.

4 Network Structures and Delivery in Wales

An introductory workshop was held by WAAASP in April 2011 to initiate

the process of engagement with those clinicians currently delivering vascular services in Wales.

At the initial workshop, held in April 2011, clinicians (surgeons and radiologists) working in vascular services throughout Wales supported a

‘hub and spoke’ arrangement for networks, with major interventions being carried out on one site within each network. This fits well with the

approach taken by VSGBI, and would optimise clinical outcomes while preventing duplication and maximising utilisation of scarce staff and

equipment. It was felt that networks should be based around Multidisciplinary Teams (MDTs) and that support for these MDTs would be

essential to successful network functioning.

Potential areas of concern identified were the potential for destabilization

of small units, physical capacity at the ‘hub’ site impact on other services, in particular interventional radiology, and issues around communication of

the case for change.

Following the first service workshop, approaches were made by the WAAASP project team to Directors of Planning in LHBs in Wales, who

advised that two elective vascular networks should be developed. One for the north and one for the south (mirroring the arrangement for the

management of cancer networks in Wales).

This has been taken forward with Cardiff and Vale as the lead/host

organisation for South Wales and Betsi Cadwaladr for North Wales.

A second workshop held in October 2011 further refined and built on the

themes and requirements summarised in sections 1 & 2 of this paper.


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This workshop very rapidly defined a requirement for three regional Multi Disciplinary Teams (MDTs) to be formed. Two networked MDTs would not

be possible to co-ordinate due to availability, existing job plans etc.

These three regional MDTs will be organised as follows and delivered

under the umbrella of the two networks:

North Wales – Betsi Cadwaladr LHB

South West Wales – Hywel Dda & ABMU LHB

South East Wales – Aneurin Bevan, Cwm Taf and Cardiff and Vale LHBs

4.1 Volume outcome and network organisation

National and international level data presented at the October 2011 workshop evidences the direct link between volume and outcome.

Services with low throughput have a poor outcome and are unlikely to meet the minimum mortality rates required to accept screening referrals.

The volume outcome effect, combined with a need for high quality trauma services in England has led to the centralisation of Vascular Services.

Data gathered as part of the baseline review of Health Board vascular

services, and received from PEDW, highlighted differences in the volumes of cases in each Health Board which present serious clinical governance

risks. It is evident that there are issues with consistency in coding for vascular repairs.

Some units in Wales have a very low volume of certain major open abdominal aortic aneurysm operations being carried out in several

centres, where the volume of elective open abdominal aortic aneurysm repair equates to each surgeon carrying out one case per annum. This

appears to be similar for ruptured aortic aneurysm repair.

The following structure is required to meet the requirements of the VSGBI

and therefore WAAASP:


Fig 1. Draft Elective Vascular Network

Organogram

Spoke Unit:

Outpatients

Imaging

Day surgery cases

Pre operative Assessment & Follow up

Rehabilitation from arterial surgery

Support for affiliated specialities

Spoke Unit:

Outpatients

Imaging

Day surgery cases




Spoke Unit:

Outpatients

Imaging

Day surgery cases




Vascular Hub:

•AAA surgical and radiological procedures•In patient surgery•MDT Meetings

Referrals from AAA Screening Programme & Primary Care

Referral Triage and distribution

Surgeons / Radiologists / Anaesthetists / Specialist Care Practitioners / Vascular Nurses


4.2 Multidisciplinary Team

There is considerable evidence base in other disciplines (especially cancer services) that patients referred to an MDT have improved outcomes

compared to those referred to an individual clinician. The establishment of multi-disciplinary teams in elective vascular networks will be critical to

the safe governance and clinical delivery of these networks which are necessary for the Welsh population to receive services that comply with

nationally prescribed standards.

4.2.1 Membership of MDTs:

Vascular surgeons

Interventional Radiologists

Vascular Nurse Specialist

Anaesthetist

MDT Co-ordinator

Surgical Care Practitioner

Vascular Technician

4.2.2 Meeting Frequency:

WAAASP referrals (during the early part of the programme) alone will be

insufficient in volume to maintain a frequent MDT, however it is proposed that a weekly MDT is initiated in the first instance since it is widely agreed

that MDTs will become the vehicle for network business and development and early regular meetings will be required.

4.2.3 Location:

Initially meetings should be face to face and hosted at the unit where

arterial surgery is to be carried out. The development of the MDT will also

be supported with video and tele-conference facilities as commonly used in Cancer MDTs.


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2011


4.2.4 Function:

Workshop attendees identified the following as recommended functions of

the MDTs

Provision of patient information

Radiology options

Assess urgency of radiological investigation

Discuss imaging results

Assess morphology of AAA

Discuss findings with vascular surgeons

Manage allocation of patients to clinicians

Assess suitability of patient for appropriate treatment

Audit – register of cases to provide proof of event

QA through completion of the NVD and adherence to WAAASP and

AAAQIP standards

Education and workforce development

Participate in national service meetings with the other MDTs

Service development

Local MDTs could still be run for uncomplicated straightforward cases Eg straightforward day-case procedures

4.2.5 Management

It is proposed that a post of MDT / Network coordinator is resourced for

each regional network initially from WAAASP as a fixed term investment. This will enable the MDT function for AAA programme referrals to be

appropriately resourced and coordinated whilst wider networks are

developed.

This post should be developed in the medium term as a network manager

and will lead and co-ordinate the wider development of elective vascular network services.


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2011


5 Barriers and obstacles to development

The attendees at both workshops identified commonly experienced barriers to the development of clinical services. These include:

Time constraints for managerial and medical/clinical professionals

Job Plans

Funding

Commitment (personal and organisational)

Resistance to change

Local politics

None of these barriers present an insurmountable challenge since the

VSGBI and WAAASP national standards require a change in the way services are delivered in Wales.

6 Conclusions and next steps

Reconfiguration of vascular surgery is required with consolidation of geographical workload onto larger centres. This would require the

development of two elective vascular networks (North Wales and South Wales) supported by three regional MDTs.

Geographical issues - The population of Powys LHB is likely to be referred to one of the three proposed MDTs. It is therefore

important to consider access to the MDTs and networks for all the population of Wales.

6.1 Short term

Report is circulated to workshop attendees

Representatives from AAA screening project to meet to discuss

report with identified Directors of Planning for North Wales and South Wales

Agree the way forward with the Director of Planning leads

Discuss report at implementation team visits

The role of MDT / Network coordinator is established, advertised and recruited with funding initially from WAAASP


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Three clinical leads must be identified for each MDT responsible for leading the development of the MDT function. In South Wales, the

two leads will be required to work together to ensure the two MDTs and supporting services are developed in a coordinated manner

Health Boards must initiate the regional MDT meetings in advance of the launch of AAA screening in December 2012 and develop service

design and delivery that meets or will meet all of the required standards agreed by AAAAQIP and WAAASP

Further workshop arranged around April 2012 to give progress

update

Ensure completion of the NVD

Undertake a retrospective coding exercise to establish actual volumes of AAA repairs in existing vascular services in Wales

Submit final report to AAA Project Board

6.2 Medium term

Health Boards to identify ongoing resource for MDT/ network

coordinator 2014/15 onwards.

Continued NVD compliance

6.3 Long term

Inclusion of all vascular cases in elective vascular network

Continued NVD compliance


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2011


Appendix 1 Summary of first elective vascular

network development

Outcomes of workshops

• General acceptance of the need for change & need for elective

networks

• Benefit of developing elective networks, impact wider than WAAASP

• Network development needed to deliver optimal quality assured outcomes

• Regional Networks

• Network design may vary to allow for unique regional issues

• Hub and spoke networks, generally accepted

• Local assessment/follow up

• Travel for quality outcome of interventions

• WAAASP Referral to Multidisciplinary Teams (MDT)

• Ensure all patients considered for open, endovascular, hybrid or

open complex surgery

• MDT support essential & Network MDT coordinators

• Impact on service acknowledged

• Financial benefits – prevent duplication and under utilisation of

facilities/capital equipment

• Link with allied specialties

Areas of Controversy

• Viability of units

• Poor acceptance of relationship between volume & outcome

• Management of MDT, service issues, job planning, funding

• Appropriate referral according to the patients need – potential

impact on patient flows

• One size does not fit all


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• Capacity limitation of existing service, service redesign

• Impact on other services

– Interventional radiology

– Support to other specialties (vascular mishaps/disasters

during other procedures)

• Political concerns – this must be patient focussed, optimal clinically

• Geographical impact cannot be ignored

• Changes made due to Centralisation/redesign and the impact on

existing services must be considered carefully

Areas of High Risk

• National Vascular Database compliance

Summary Message

• Regional Networks to be developed

• WAASP to support Health Boards with managing change required to develop the networks

• Regional Leads to be identified

• Ensure Compliance with data entry to National Vascular Database

• MDT Coordinators – Actions required

• Develop a clear strategy for the delivery of management for elective

aortic surgery

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