Wales Abdominal Aortic Aneurysm Screening Programme Proposal Paper

14 Pages·2011·0.53 MB·English

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

Date: 2nd December 2011 Version: Final Draft Page: 2 of 14
Public Health Wales Development of Elective Vascular Networks
in Wales

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
Date: 2nd December Version: Final Draft Page: 3 of 14
2011
Public Health Wales Development of Elective Vascular Networks
in Wales

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).
Date: 2nd December Version: Final Draft Page: 4 of 14
2011
Public Health Wales Development of Elective Vascular Networks
in Wales

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. “
Date: 2nd December Version: Final Draft Page: 5 of 14
2011
Public Health Wales Development of Elective Vascular Networks
in Wales

(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.
Date: 2nd December Version: Final Draft Page: 6 of 14
2011
Public Health Wales Development of Elective Vascular Networks
in Wales

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:
Date: 2nd December Version: Final Draft Page: 7 of 14
2011
Fig 1. Draft Elective Vascular Network
Organogram
Spoke Unit:
Referrals from AAA
Outpatients
Screening
Imaging
Programme &
Day surgery cases
Primary Care
Pre operative Assessment &
Follow up
Rehabilitation from arterial
surgery
Support for affiliated
specialities
Spoke Unit:
Outpatients
Imaging
Referral
Day surgery cases
Triage and Pre operative Assessment &
Vascular Hub: distribution Follow up
Rehabilitation from arterial
surgery
•AAA surgical and Support for affiliated
specialities
radiological Spoke Unit:
Outpatients
procedures
Imaging
•In patient surgery
Day surgery cases
•MDT Meetings Pre operative Assessment &
Follow up
Rehabilitation from arterial
surgery
Surgeons / Radiologists / Support for affiliated
Anaesthetists / Specialist specialities
Care Practitioners /
Vascular Nurses

Date: 2nd December 2011 Version: Final Draft Page: 8 of 14
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.
Date: 2nd December 2011 Version: Final Draft Page: 9 of 14
Public Health Wales Development of Elective Vascular Networks
in Wales

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.
Date: 2nd December Version: Final Draft Page: 10 of 14
2011