Nurses and other non-medical staff have reduced a 42 week waiting time for myocardial perfusion imaging to just two weeks. The trust reveals how
Lizelle Bernhardt MCur, BCur, RGN, is a senior specialist sister; Lisa Ross RGN, is a senior specialist sister; Claire Greaves, MSc, BSc, MIPEM, CSci, is a consultant clinical scientist and head of nuclear medicine, all at the University Hospitals of Leicester Trust.
Bernhardt L et al (2010) Enhancing nurses’ roles to improve quality and efficiency of non-medical cardiac stress tests. Nursing Times; 106: 43, early online publication.
Myocardial perfusion imaging (MPI) is a test that aids the diagnosis of coronary heart disease, of which pharmacological stress is a key component.
An increase in demand had resulted in a 42 week waiting time for MPI in Leicester. This article looks at how implementing non-medically led stress tests reduced this waiting list. It discusses the obstacles involved and the measures needed to make the service a success.
Keywords New ways of working, Non medical stress, Enhancing roles
- This article has been double-blind peer reviewed
- Non-medical staff have been trained to perform pharmacological stress tests – a task previously performed by doctors.
- Support for extended roles from practice development leads, clinicians and the pharmacist is required if the scheme is to be implemented successfully.
- Protocols and procedures need to be written and ratified by the trust. These should follow guidance from professional bodies where this is available.
- Knowledge and experience beyond basic registration is required to undertake training. A training package needs to be established and competence assessed and maintained.
- A continuous process of audit should be put in place to monitor patient safety.
Nuclear medicine is a technique that uses unsealed radioactive materials in the diagnosis or treatment of a wide range of conditions, including coronary heart disease. Patients with suspected CHD are often referred for diagnostic tests that allow the cardiologist to determine the most appropriate course of treatment.
One of the diagnostic procedures is nuclear medicine myocardial perfusion imaging (MPI). During this procedure, the patient’s heart is put under stress using intravenous adenosine or dobutamine, followed by the administration of a radioactive tracer when the heart is at maximal stress. This tracer is distributed within the heart muscle according to the blood flow. A gamma camera is then used to acquire images of the heart at stress, which is repeated with the patient at rest. This allows a radiologist to diagnose the presence and extent of any disease.
In 2003, the National Institute for Clinical Excellence performed an MPI technology appraisal, which recognised the role of MPI and predicted that 4,000 MPI scans would need to be performed per million population in the UK (NICE, 2003). NICE has recently published a clinical guideline (NICE, 2010), evaluating the diagnostic options for patients with suspected CHD, and functional imaging continues to have a key role in the diagnostic pathways.
The NHS improvement plan (Department of Health, 2004) set the target to reduce the time from GP referral to treatment to 18 weeks, which had to be met by December 2008. The National Imaging Board was set up identify how the 18 week target could be met, and brought in targets for diagnostic waiting times. These were 13 weeks by April 2007, and six weeks by March 2008. University Hospitals of Leicester Trust then agreed a local target of two weeks with the Leicestershire primary care trusts, to be met by December 2008.
Identifying the problems
In Leicester, the waiting time for MPI had reached 42 weeks in 2005, with activity at 40 tests per month. The stress component of the test was performed by junior medical staff as they rotated through cardiology, along with a part time medical officer.
The trust consists of three hospitals that merged in 2000, with a nuclear medicine department at each site.
The radiology and nuclear medicine teams within the trust worked together to identify potential service improvements. After an evaluation of service provision, the following problem areas were identified:
- The bottleneck associated with the stress component for MPI;
- Uneven use of equipment and staff across the trust;
- The silo approach to patient appointments – each site managed its own referrals independently, which resulted in longer waiting times for studies at some sites than at others.
The root causes of the bottleneck were the number of stress sessions and the number of patients who could be booked into a session.
The use of junior medical staff to perform the stress component of the MPI study had several disadvantages:
- There were a limited number of sessions because not enough staff were available;
- Medical staff had other clinical commitments that pulled them out of the department during stress sessions;
- Training to perform the stress component of the procedure was limited;
The implementation of the European working time directive had reduced the maximum working hours of junior doctors (Pickersgill, 2001).
Tackling the problems
A proposed solution to these difficulties was to develop new roles for nurses and technical staff to allow them to perform the stress component of the procedure, instead of medical staff.
CHD funding for additional staff paid for a post for a consultant radiologist with a specific interest in cardiology, and two band 6 posts that were open to nursing or technical staff with cardiac experience. Two nurses were appointed from a background of coronary care and cardiac intensive care.
The department also had an existing technologist with a background in cardiac nuclear medicine who had undertaken some preliminary training at Guy’s and St Thomas’ Foundation Trust.
Developing new roles
The newly appointed consultant radiologist worked with a radiographer to develop and roll out an in house training package.
The process was supported by the trust through the extended role committee, the practice development lead, the pharmacy department, clinical governance leads and directorate management.
The stress team, comprised of the two nurses and the technologist, were initially trained to perform adenosine stress tests following a narrow protocol, as a limited extension of their role.
The following procedures and protocols were written:
- Clinical protocols and work instructions;
- Authorisation for cardiac studies under Ionising Radiation (Medical Exposure) Regulations (IRMER) (DH, 2007);
- Protocol detailing areas of responsibility for performing pharmacological stress;
- Pathway for authorisation of MPI referrals;
- Pharmacological stress questionnaire.
Training components included:
- Principles of adenosine stress testing – safety aspects, observations and interpretation, knowledge and safe administration of stress drugs, patient needs and documentation;
- Immediate life support;
- IRMER/radiation protection;
- Pharmacology – indications and contraindications, properties and interactions, pharmacokinetics and pharmacodynamics;
- Clinical assessment – taking a patient history (safety questionnaire) and obtaining the patient’s consent.
The practical component involves supervised practice. It is difficult to state a definitive number of stress tests needed to provide adequate experience – this is influenced by the trainee’s background and ability (Jones et al, 2007).
The practical training requirements included:
- A minimum of 100 stress tests with direct supervision;
- A minimum of 50 stress tests with remote supervision in the department;
- A trainee should have demonstrated the ability to manage at least one of each of the more common complications of the stress test.
When new roles are being planned and developed, the highest priority is delivering a safe and effective service to the patient. Evidence suggests the likelihood of an adverse event for non-medical health professionals – nurses, radiographers and clinical technologists – is similarly low to those conducted by medical staff (Jones et al, 2007)
As the stress team gained more experience and safety audits reflected safe practice, the nurses were keen to take the opportunity to develop further. Additional training was identified that would allow them a broader scope of practice. This included:
- Advanced life support;
- Principles of dobutamine stress testing – safety aspects, observations and interpretation, knowledge and safe administration of stress drugs, patient needs and documentation;
- Pharmacology – indications and contraindications, properties and interactions, pharmacokinetics and pharmacodynamics;
- Advanced ECG interpretation.
Clinical protocols and work instructions were updated to reflect this change in practice. This meant the initial restrictive remit of the role was effectively removed, allowing the post to develop to an advanced practitioner level.
The role expansion included a broadened scope of practice for adenosine stress tests and the use of dobutamine as a stress agent. A key part of this role was that stress tests could be carried out without immediate medical cover within the department.
The additional changes brought several benefits including the provision of a robust, seamless service, which ensured minimal disruption due to annual, sick, and study leave. The changes also allowed medical staff to be released for other clinical duties, increasing job satisfaction and improving staff retention.
Developing an advanced practitioner role addressed the delay at the stress component of MPI. We were able to increase our throughput dramatically (Table 1), and managed to reduce the waiting times (Table 2) from 42 weeks in April 2005 to two weeks in March 2010. We now have a robust system that enables us to maintain waiting times for MPI at about two weeks.
Achieving and maintaining waiting times at two weeks is not without its difficulties and we have had to face several obstacles.
Assessing and maintaining competence/numbers
Assessing competence is not always straightforward. British Nuclear Medicine Society guidelines (Jones et al, 2007) give indicative numbers, but the actual experience required will depend upon the range of patients seen and the individual undertaking the training. Ongoing competence then needs to be maintained.
Again, it is difficult to quantify the number of tests required, but it has been suggested that, if fewer than 100 are performed in a 12 month period, formal reaccreditation should be undertaken each year (Jones et al, 2007).
We have a largely female workforce and have to cope with absences due to maternity leave. With our small pool of staff, this has a significant impact. Accessing funds for locum staff was not possible (and we were also aware that finding staff with the skills to slot into the stress team would be unlikely).
Once staff return from maternity leave, a programme of retraining followed by reaccreditation is required.
Recruitment and retention
Two members of staff left the trust within this period – the consultant radiologist and the radiographer who had supported the training. Another radiologist with cardiac expertise stepped in to support the team.
By this time, the nursing staff had completed their extended training and taken on the additional roles. They were also able to add training to their repertoire and learnt how to authorise referrals.
The funds released from the radiographer post were used to regrade nursing posts and to finance a new band 6 position to backfill their posts.
Once all staff have been trained, the capacity of the stress team will exceed the capacity of the gamma camera. We are identifying ways to alleviate this, for example by using equipment at one of the other hospitals, replacing existing equipment with faster models and extending the working days for technologists.
The financial climate is challenging as we are being asked to maintain and improve waiting times targets at the same time as saving costs. The rising costs of radiopharmaceuticals will add to this pressure.
To maintain service longevity, new post holders need to be allowed to develop professionally, not only promoting a safer patient service but also enhancing job satisfaction.
We were able to offer ongoing development opportunities; staff are initially trained to operate within a narrow adenosine protocol, then their role expands to performing advanced adenosine and dobutamine stress tests and working independently. This is followed by opportunities to develop in the areas of training and management of the stress team.
As staff develop and take on additional roles, backfill may be required for some of their existing work. This is often difficult as funds are not always available to support this. In our case, we took the opportunity when staff left the trust to reorganise to support this development.
Good succession planning is important – the nurse appointed to the band 6 post will, in the future, train to the higher level. The opportunities for progression should increase the likelihood that our existing staff feel rewarded and will stay with us, but we have a more robust system should anyone leave.
It is essential that the roles and responsibilities are clearly defined and understood. Developing new roles involves careful consideration of the following: clarifying role purpose; preparing for the role; building support for the role; ensuring that roles are understood by others; publicising the roles; and informing others about them (Levenson and Vaughan, 1999).
Managerial support is valuable in terms of championing an idea, having access to other appropriate professional groups within the trust, knowledge of existing procedures, experience from other areas and management of change.
Trust practice and development leads are extremely useful. This role provides expertise in new ways of working and advice in relation to legislation, policies and procedures and advanced practice.
The nursing staff who perform non-medical stress tests are managed by the service manager for radiology. However, they are professionally accountable to the senior practice development nurse. This arrangement allows them to access professional support during training and as their roles develop.
Clinical support is valuable in providing guidance, support for training, assessment of competence, delegated authority, education, training and professional development.
This extended role for nurses and technologists has been welcomed and supported by colleagues in other areas such as cardiology, where cardiologists quickly appreciated the potential benefits to the service.
Accessing funding for training within the NHS is not always easy, but the imaging directorate recognised the importance of this new role and the impact it would have on waiting times. This meant we received funding for training directly related to this role and expansion.
Economic impact of new posts
The posts allowed us to increase the capacity for stressing patients for MPI studies and meet waiting times targets.
In the past, we had performed a number of waiting times initiatives which had short term benefits but failed to resolve underlying problems. Examples included: appointing locum doctors; arranging for studies to be performed at other hospitals; and arranging a mobile MPI service. The costs of these initiatives were significant and they often meant we had to pay technical staff overtime for extended days to support them.
The new system allows an increased – but more consistent – throughput of patients, which does not require overtime payments or waiting list initiatives.
Effectiveness and outcomes
It is important to monitor team performance and clinical effectiveness using clinical audit. The safety of the non-medical stress team is of paramount importance, and this is continually monitored. Waiting times for investigations are monitored by the trust.
We are keen to ensure that, in our attempts to increase capacity, we do not lose sight of our patients and that the service meets their expectations.
The nuclear medicine service has access to a very supportive patient adviser. He has spent time talking to patients, and reported back to us positively on all aspects of service provision, and, in particular, how we communicate with the patients.
Having identified a key bottleneck in our service delivery, we have been able to look at new ways of working and train non-medical staff to take on a role traditionally performed by doctors. This has allowed us to improve our service, increase capacity and meet waiting time targets.
However, there are further challenges ahead as we need to maintain this level and quality of service with limited resources. We will continue to use the skills we have developed to critically review our service and identify areas for further improvement.
Department of Health (2007) The Ionising Radiation (Medical Exposure) Regulations 2000.
Department of Health (2004) The NHS Improvement Plan: Putting People at the Heart of Public Services.
Levenson R, Vaughan B (1999) Developing New Roles in Practice: an Evidence-based Guide. School of Health and Related Research, University of Sheffield.
National Institute for Clinical Excellence (2003) Myocardial Perfusion Scintigraphy for the Diagnosis and Management of Angina and Myocardial Infarction. Technology Appraisal 73.
National Institute for Health and Clinical Excellence (2010) Chest Pain of Recent Onset. Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin. NICE Clinical Guideline 95.
Jones I et al (2007) Clinical competence in myocardial perfusion scintigraphic stress testing: general training guidelines and assessment. Nuclear Medicine Communications; 28: 575-582.
Pickersgill T (2001) The European working time directive for doctors in training. British Medical Journal; 323: 1266.