Craigavon Area Hospital is a district general hospital within the Southern Health and Social Care Trust (SHSCT) in Northern Ireland. We run a busy echo department receiving approximately 300 echo requests every week, amounting to over 15,000 requests a year. Roughly one third of these are inpatient requests and we aim to complete all of these within British Society of Echocardiography (BSE) guideline recommendations.
Like so many across the UK our department has been significantly impacted by COVID-19. Collectively we have been managing the knock-on effects: recurrent staff absences, new ways of working, an unprecedented number of inpatient requests in COVID exposed patients and an ever-expanding outpatient waiting list.
In response to these new challenges, we have set up a new service improvement programme run by clinical and management staff with the goal of streamlining the echo service and maximising efficiency. In order to help understand, quantify and ultimately adapt to these new working conditions a clinical audit of inpatient echo requests was carried out.
All inpatient echo requests received over a two-week period from 1-14 March 2021 were reviewed. In total 200 requests were received and data was collected on the patients’ demographics; previous scans; the indication for echo and how long it took to perform the scan. This information was then audited against the BSE resource Clinical indications and triage of echocardiography.
Requests were graded 1-5 using this guideline:
- Emergency echo: within 60 minutes of the receiving the referral
- Urgent: within 24 hours of initiating the referral
- Indicated as an inpatient but not urgent: variable timeframe depending upon clinical need
- Not indicated as an inpatient
- Echo not indicated
Of the 200 requests, 177 were scanned as inpatients. Key findings as follows. Over one third of scans were completed on the same day the request was received and 80% were performed within one working day. Over 95% of scans were completed within the BSE recommended timeframe. These impressive results serve to highlight the hard work and dedication of our sonographers during such a trying time. However, through this audit we identified that 28% and 15.5% of requests were triaged Grade 4 and 5 respectively; meaning that over 40% of requests need not be scanned as an inpatient or even at all.
Extrapolating this data suggests that in excess of 2000 scans annually are urgently being performed as inpatient that could be cancelled or deferred to the OPD. In total only 4% of our requests were rebooked to the OPD.
As a consequence of these findings we have been able to use the Clinical indications and triage of echocardiography resource as a guide to help triage inpatient echo requests. It has given us the confidence to decline inappropriate requests or defer non urgent referrals in the knowledge that this is supported by the most up to date evidence.
It is clear that our team here in the SHSCT are not alone in the challenges we have faced due to the Covid-19 pandemic. This has been recognised nationally by the BSE, who together with National Health Service England (NHSE) and the British Heart Valve Society (BHVS) have produced new guidance on the delivery of an echo service.
This is an updated version of the “Clinical Indications of Echocardiography” summary and provides clear and concise recommendations upon triage of the appropriateness of echo referrals. In addition, there is clear guidance on when an echo request is not appropriate and should not be performed. This is a timely and very important piece of work that will help support and guide echo service providers to ensure a safe and effective service that is both sustainable and able to meet the demands of our patients.
Read the full article on Echo Research and Practice
A key message in this new guidance is that adequate time is set aside for appropriate clinical triage. In addition to inpatient requesting there are also recommendations for outpatient referrals, follow-up requests and even telephone triage. It is clear that the implementation of this new guidance will help streamline echo service provision in our departments, maximising productivity and helping to address and reduce back log issues.
We are extremely proud of everything that has been achieved within our unit across such trying times. As we move forward, we now need to focus on ensuring that our resources are targeted were they will bring most benefit while also continuing to secure time to support the professional development of all staff within the department.
The Clinical indications and triage of echocardiography resource provides an excellent evidence-based foundation for the ongoing development of our echocardiography department. Reducing unnecessary workload, maximising quality of patient care and staff satisfaction are our key priorities moving forward and this work supports our team in achieving this goal.
Dr Patrick Thompson, Cardiology Registrar and Dr Jude Tweedie, Consultant Cardiologist, Southern Health and Social Care Trust