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                           Clinical Advisory Group
                          Wednesday 28th April 2010
                   Board Room, Bush House, Antrim Hospital

Attendees:          Dr John Riddell                   Chair
                    Pauline Seydak                    HSCB
                    Valerie McNiffe                   WHSCT
                    Albert McNeill                    WHSCT
                    Nigel Ruddell                     NIAS
                    Gillian Wells                     HSCB
                    Lynne Charlton                    BHSCT
                    Lorraine Adair                    SHSCT
                    Alastair Graham                   BHSCT
                    Trish McKinney                    BHSCT
                    Patricia Black                    WHSCT
                    Bernard Coultous                  Patient Rep
                    Billy McClintock                  Patient Rep
                    Heather Jackson                   BHSCT
                    Carol Wilson                      BHSCT
                    Christine Hughes                  SEHSCT
                    Mary McGeough                     BHSCT

1.    Apologies
Apologies were received from Adrian Mairs, Gavin Dalzell, Ian Menown and Colm

2.     Previous Minutes
The minutes of the meeting held on the 20th January 2010 were agreed as a true
record of the meeting following one adjustment. The telephone number for the NIAS
for non-clinically urgent transfers should read 90404021.

3.     Matters Arising
All matters arising are covered in the agenda.

4.    Updates

      a) Inter Hospital transfer “White Board”
      Dr John Riddell informed the group that all in-patients that required diagnostic
      or interventional Cath Lab procedures in the Belfast Trust were now being
      referred via the “White Board” This included patients that were inpatients in
      the Belfast.

      All technical and access problems have now been addressed. The “White
      Board” should now also be used for the referral of patients for in-patient

cardiac surgery and Clinicians were encouraged to start using this route as it
provided robust timely information to all parties.

Dr Hughes raised the issue regarding the time it took to compete the data set
however she was informed that the content had been discussed at length
throughout the development stage and although some of the details appeared
unnecessary they were required for BCIS returns. The availability of the 6 field
minimum data set was highlighted for Consultants that would be performing
the procedures themselves.

Staff had also been asked to check the “White Board” 3 times a day to any
change in referral status. If the referral was highlighted in red it was the
responsibility of the referrer to provide additional clinical information before the
referral could proceed. .

b) NIAS Update

Dr Ruddell advised that paramedic-administered thrombolysis has been
available on all rapid response cars and paramedic-staffed Accident and
Emergency ambulances. From the middle of March and a number of patients
had already received thrombolysis administered by paramedics.

Dr Ruddell also tabled a protocol developed by NIAS to help Trusts to make
best use of the ambulance services when arranging non-emergency transport.
This was welcomed by the group and it was agreed that it would be circulated
to all cardiology wards and departments. Dr Ruddell will forward the final
version electronically to the group.

Dr Ruddell voiced several concerns on the part of NIAS about communication
both outward from the regional group about processes to be implemented and
also the lack of clear communication to NIAS about various developments
within the Trusts which were impacting on the ability of NIAS to respond to
these and other requests.

In relation to communication from the group to trusts and ultimately ward staff
there had been several incidents recently where hospital staff had suggested
they were unaware of areas such as the Matrix for Ambulance selection
agreed by the group last year, resulting in inappropriate use of accident
emergency ambulance and even 999 calls to the service for non-emergency
transfers. More recently some CCU staff claimed they had never been told of
the paramedic thrombolysis project despite the regular NIAS reports to the
regional group and the personal visits to each of the coronary care units by
senior representatives from NIAS.

On the increasing workload Doctor Ruddell highlighted the increasing requests
for transfers from peripheral hospitals to regional centres for investigations
and interventions. While these are without doubt entirely justified clinically,
they are being performed centrally due to the lack of resources, staff and
facilities at the peripheral units but no account is taken on the pressure on
resources, staff or facilities that this places on NIAS which is subject to the

same efficiency requirements as other trusts. A recent example involved a
request for the transfer on one day of six cardiac patients from the Northern
Trust at less than 24 hours notice where the unit had expressed concern that
extra nursing staff was required to facilitate this due to the difficulty that NIAS
had in accommodating these requests. NIAS appreciates that slots for
interventions often come up at short notice but repeated previous concerns
that there was no consideration of these same difficulties faced by the
ambulance service.

NIAS has also received requests for developments including inter-trust PPCI
involving the Western and Southern Trust, and transport of patients within
trusts for PPCI which involved lengthy journeys that would be difficult for NIAS
to meet in terms of transfer times within optimum therapeutic windows and
would also result in decreased operational cover for other emergency calls.
Several trusts had also attempted to approach NIAS outside of the regional
group to obtain ring-fenced ambulance cover for cardiac transfers etc but this
was against similar requests from many other departments even within the
same Trust. Dr Ruddell expressed frustration on behalf of NIAS that such
arrangements were often presented late in the planning process with little or
no previous consideration of the burden on the ambulance service. On the
occasions where such communication had occurred, it had produced practical
outcomes and positive results.

Dr Riddell and Gillian Wells suggested that there had been no major service
model changes by the group that would have impacted on NIAS and the
general increase in volume of there were experiencing was similar to that of
the Trusts. Dr Ruddell pointed out the general increase in demand for such
transfers as well as a number of related developments including the changes
to paediatric cardiac surgery, proposals for transfer of primary PCI and other
direct requests from other Trusts and therefore outside of the discussion of the
regional group were all attempting to make use of the same limited resource of
ambulance cover. NIAS would welcome a more strategic view which he
believed the regional cardiology group was best placed to promote. He
stressed again the commitment of NIAS to try to assist the other Trusts in
improving patient care, but repeated previous requests for support from the
group when such services are being commissioned.

Dr Wilson assured NIAS of her support and both she and Dr Hughes
recommended the Ambulance Selection Matrix as a way of improving
appropriate use of resources. It was queried why intermediate care vehicles
were not specifically mentioned on the matrix but Dr Ruddell explained such
vehicles were part of the PCS fleet and selected on a case-by-case basis
depending on mobility. All NIAS vehicles now carry AEDs. Dr Ruddell agreed
to circulate a new copy of this matrix along with the advice on arranging
ambulance transport.

Mr McClintock suggested that the Trusts could explore the use of internal
ambulances or voluntary drivers / ambulances for the transport of low risk
patients as some Trusts already made use of voluntary car-driver schemes

c) In-Patient guidance for Cardiac Surgery

The referral criteria for patient that should remain in hospital waiting for
cardiac surgery were reviewed and it was agreed that these remained
clinically appropriate. Two additions were suggested and agreed. These

The MDT meeting should be available for the discussion of any patient that,
for clinical reasons, should stay in hospital to wait for urgent cardiac surgery.

All patients should be referred by the “White Board”

There followed a discussion regarding the structure and administration of the
MDT including how it could work for patients who have their angiography
undertaken by Consultants in the DGH’s. This would involve the use of video
conferencing facilities which were now available in each of the Trusts. It was
recognised that the meeting would require strong chairmanship and control
and it would also have an educational component. Some administration
resources would be required from the Trust for the set up of the meeting and
the recording of outcomes and this was currently being explored.

There was a suggestion that the “White Board” could be used for the MDT
report with some minor adaptions.

d) Cardiac Surgery Update

Cardiac Surgery has now transferred to Acute Services in the Belfast Trust.
The Director is Patricia Donnelly and it is hoped that in 2010-11 they will be in
a position to perform the 1000 major procedures as per their SLA. 912 major
operations had been undertaken in 2009-10.

ICU continues to be the major limitation of the service and it is recognised that
that there needs to be ongoing work to ensure throughput and maximise
capacity. There has been some success in the repatriation of patient to the
local ICU when clinically they not longer clinically need to be under the care of
the cardiology speciality.

The Trust had been successful in recruiting a Locum Paediatric cardiac
surgeon and two cardiac anaesthetists. There was no start date available for
the anaesthetists however they also hoped to appoint a locum once all
recruitment protocols were completed.

The was a discussion regarding the use of the Independent Sector Providers
and Mr Graham informed the group that this was currently ongoing however it
was anticipated that this will be stopped in the future. Gillian Wells informed
the group that the use of the Independent Sector would stop for all services
across Northern Ireland however there was awareness that the demand for
cardiac surgery was greater that the capacity in Belfast and discussions were
currently ongoing in relation to this.

      d) Models of Care

      Nil discussed as this sub group had not met since the last CAG meeting.

      e) Primary Angioplasty, Update
      This continues to be provided for patients in the Belfast Trust area and is on
      target for their anticipated numbers. The Trust recognised the commitment
      made by the NIAS and thanked them for this.

      The numbers treated to date are:-

      7th Dec/Jan   29 patients
      Feb           17 patients
      March         22 patients
      April         18 patients
      May           6 patients

      Dr Riddell tabled a letter that had been received from Dr Hunter, Mid Ulster
      requesting clarification regarding the service and the availability of PCI for
      rescue PCI. The individual case highlighted had been reviewed and there
      were no concerns regarding the clinical decision making. Dr Riddell tabled a
      draft response for approval by the group. (enc).

      Craigavon continues to perform primary angioplasty for their patient population
      within normal working hours. In the Year 2009-10 they performed 40 cases
      and approximately 80% of the clinically appropriate patients arrive in the 90
      minute time frame.

      At this point Dr McNeill stressed the importance of continuing with the models
      of care group to ensure that all geographical areas were covered for patients
      with STEMI with a high quality, timely service which would either be Out of
      Hospital lysis or Primary PCI

      f) Service Framework / Commissioning
      In the absence of Adrian Mairs, Gillian Wells informed the group currently the
      Trust performance against the standards were being measured and she would
      be in a position to update the group on these at the next meeting.

      In relation to funding / commissioning, there was at yet no agreement of the
      2010-11 budget.

5 Review of NIAS Transport Matrix
See point 4b.

Gillian Wells informed the group that funding had been secured for the next year to
undertake an audit of PCI outcomes. It was also agreed that part of the audit would
include a snapshot of the quality and completeness of data entry.

Dr John Riddell agreed to take the lead in this project.

Dr Carol Wilson raised the recently published NICE Chest Pain guidance and asked
it this was something that the group should be considering.

Dr Riddell informed her that this work was being taken forward by the Non Invasive
Diagnostic CAG, Chaired by Dr Harbinson.

8.    Date and Time of Next Meeting
The next meeting will be held on Wednesday 16th June 2010 at 2.00pm, Venue TBC


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