Innovative Service Delivery of Computed Tomography Coronary Angiography (CTCA) by Advanced Practice Specialist Radiographers Norfolk & Norwich University NHS Foundation Trust

Karen Reid Senior Radiographer UKRC 10th June 2014

Background 

First line imaging of coronary arteries in patients with suspected stable coronary artery disease (NICE 2010)

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Cardiac scans are often complex in nature

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New initiative: radiographer-led CT cardiac service

Rationale 

Train radiographers  Autonomous practice in scanning CT coronary angiograms

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Minimal or no radiologist input  Blurring of traditional boundaries to increase capacity to NHS services (DH 2000)

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Benefits  Cost effective service delivery  Reducing need for radiologist input/time  Continuity of care

British Society of Cardiovascular Imaging

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“...a cardiac CT service should be of demonstrably high quality irrespective of where or by whom it is delivered.” (BSCI 2012)

How did we do this? 

Recruitment

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Formal education 

Harefield Cardiac Radiographers CT course

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Cardiac CT Trainers Partnership Level 1

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In house ECG training

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One to one coaching

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CPD lectures for radiographers

Protocol Development 

Standardised scanning protocols

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CTCA reference document

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Process mapping

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Team work & ownership

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Collaboration with all team members

Patient Group Directives   

Intravenous Metoprolol Tartrate Glyceryl Trinitrate (GTN) Radiographer-led service  Heart rate control within boundaries of patient group directive  Scan planning, image review & assessment  Efficient service delivery

The ‘Perfect’ Heart 

Low, steady heart rate

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Normal sinus rhythm

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Optimum contrast & timing

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Good vessel opacification

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Adequate exposure

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Minimal motion artefact

ECG Trace & Heart Rates 

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Recognising a normal trace

Awareness of abnormalities

Heart rates which contraindicate ß-blocker

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Decision pathways 

Administration of ß-blockers

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Contraindications

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The anxious patient

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Radiographer autonomy

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Adaptation of protocols

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Flash acquisition vs prospective gating

Calcium Score 

Calcification of coronary arteries can be quantified with low radiation exposure

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Issues arise: 

Software places calcium outside vessel

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Knowledge of anatomy

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Patients with complex anatomy

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Do not proceed

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Proceed to coronary angiogram

Contrast Timing & Vessel Opacification

Optimum Contrast Low enhancement of the pulmonary artery and high enhancement of the aorta

Poor Contrast High enhancement of the pulmonary artery and low enhancement of the aorta

Vessel Opacification

Right Coronary Artery

Left Anterior Descending

Circumflex

Motion Artefact Assess why the movement occurred:

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Increased or irregular heart rate 

Consider ß-blocker

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Consider repeat area with wider range 30-70%

Step/mis-registration 

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Coronary vessels are obscured

Occurs on adapt scans

Beam hardening/blooming 

Areas of dense calcium or metallic stents

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Consider extra recons with different kernels

Image Review 

Assessment of images 

What is acceptable?

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Adaptation of protocols

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Options for further assessment

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Image acquisition choices

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Knowing anatomy is crucial

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Recognition of pathology

How does it work in practice? Audit of Practice

Impact for Radiology

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Identify individual training needs

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Significant decline in the need for radiologist input

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Heart rate control beyond scope of patient group directive

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Consistent with radiologists

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Medication queries relating to contraindications to ß-blockers

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No patients have been recalled

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Increase in confidence and levels of competency

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CTCA scans are reported within the consultant PA

How does it work in practice? Audit of Radiation Dose

Impact for Radiology

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216 consecutive cases

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New local standards have been set for future audits

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Mean effective dose for all examinations is 5.86mSv

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Data supplied to the British Society of Cardiovascular Imaging database

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Reduction of 0.74mSv in patient dose since previous audit

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No negative impact on patient doses

Radiologist View 

New opportunities

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Advanced work which challenges & rewards

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Uniformity & high standards

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Cost-effective use of staff

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Financial investment is reasonable

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Effective utilisation of staff

Radiographers View of Advanced Practice

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Change in professional responsibility

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Benefit to patients

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Increasing profile

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Breaking boundaries

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Increased clinical judgement skills

Future 

Maintain efficiency without compromising excellence

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Promote aspects of cardiac imaging

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Training model for others to follow

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Radiographers image post processing

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Radiographers performing vessel analysis

References 

British Society of Cardiovascular Imaging (2012) “CT Coronary Angiography Service Specification”. Available at www.bsci.org.uk

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Department of Health (2000) “The national health service plan, a plan for investment, a plan for reform”. Available at www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguid ance/dh_4002960

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National Institute for Health Care and Excellence (2010) ”Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin”. Available at www.publications.nice.org.uk/chest-pain-of-recent-onsetcg95