Sheffield Teaching Hospitals NHS Foundation Trust

Directorate of Medical Imaging and Medical Physics

The introduction of a Health Care Professional (HCP) role has successfully reduced the pressure on junior doctors and also improved throughput and reduced waiting lists in Sheffield Teaching Hospitals NHS Foundation Trust.

Background: The section of Nuclear Medicine, part of the Medical Physics department within the Medical Imaging and Medical Physics Directorate of Sheffield Teaching Hospitals NHS Foundation Trust, has departments at the Royal Hallamshire, Northern General and Weston Park Hospitals. This department uses myocardial perfusion scanning to assess the degree of coronary heart disease amongst patients. The investigation is in two parts so that the patients heart can be assessed under stress conditions (part 1) and under resting conditions (part 2) The stressing is performed using intravenous pharmacological stressing agents and previously was performed in clinician-led sessions run in collaboration with doctors from the Cardiothoracic Services Directorate.

To increase the flexibility of the service, shorten waiting time and reduce the burden on junior cardiac doctors, the Nuclear Medicine department developed an extended Health Care Professional role to take over the pharmacological stressing sessions. This involves working within clear protocols and although a cardiothoracic doctor is on standby in case they are needed, the need for a doctor to be present during this stressing session itself has been removed.

The challenge
The development of a Health Care Professional-led myocardial perfusion pharmacological stress test presented many challenges; Christine Taylor, Senior Chief Technologist commented that the main challenge was “getting to grips with the implications of an extended role”. This included a culture change to overcome the different working methods employed by the two departments, nuclear medicine and cardiology. This was achieved by finding a middle ground, a different way of working which was effective for both teams.

Development of protocols
A key element to the project was developing new protocols. This investigation is performed at the two major hospitals within the Trust and this previously involved two different ways of referring patients and performing the test. There were also different expectations and constraints within the different hospitals. A single protocol was developed across the Trust, with the assistance of the different staff groups involved in this process (including medical consultants). This has resulted in a clearly defined Health Care Professional-led stress protocol which is written to cover a wide set of scenarios.

Key points include

• All requests for a myocardial perfusion study have to be authorised by a chief nuclear medicine technologist following delegated authorisation guidelines agreed by consultants from both departments. The senior cardiothoracic doctor must sign prescriptions written for each patient
• Two Health Care Professionals normally run the stressing sessions jointly and take clinical lead. Sessions only commence if adequate numbers of suitably trained staff are available. The cardiothoracic doctor covering the session is informed that the session is due to begin. The doctor will carry a fast bleep and will attend the stressing room immediately if required.

A new patient leaflet giving full instructions has also been designed and integrated with the new protocol

Risk assessment
Before the new procedures could begin, the Trust required a risk assessment to be undertaken as the Health Care Professional role replaces medical supervision during the stressing session. The risk assessment highlights and addresses the decision points in the myocardial perfusion stress test. This ensures every angle is covered and contingency plans are in place.

Training to support the new ways of working The objective of the training was to provide all the staff groups with all the practical skills and the underpinning knowledge needed for this new role. They follow a training plan and once each Health Care Professional feels confident and competent they proceed to a formal assessment in each core skill. Competency is maintained by annual updates on equipment and regular rotation into the various aspects of the role. Individuals from the department also now attend Trust recognised master trainer programmes so that in future all training pertinent to the staff group can be provided in–house.

Outcomes and impacts As a result of introducing the Health Care Professional role; the service is now managed more effectively. The number of patients having the test has increased as the departments are no longer reliant on busy doctors to do the test and there is increased capacity. Four years ago the waiting list was 18months and now is on target to meet the national 13 week waiting list target in early 2007. The pressure on junior doctors has been released and this helps to contribute to the move towards WTD 2009 compliance. The role has also benefited members of staff. “Staff feel empowered and more in control and as a result feel more involved in the process,” explains Christine.

Eight members of staff with various backgrounds have been successfully trained and a master trainer programme is now under development to enable cascade training within the multi disciplinary team.

Key lessons

1.Realistic plans – Don’t underestimate the length of time an initiative like this can take

2.Engage- ensure all key stakeholders are involved and there is a shared objective at the start of the project

3.Training – the department found itself dependent on other groups and departments for training. A “train the trainer” approach would have been useful in the initial tranche of learning.

Contact: Christine Taylor - Senior Chief Technologist