Vascular Services

Model of Care

Released 2017 Final V1 This document is available at nsfl.health.govt.nz/national-services/national-services-service- specifications-and-service-improvement-programmes a. Acknowledgements

The model of care for vascular services has been developed with the input and expertise of the following members of the Vascular Service Advisory Group, who were nominated from a range of district health boards.

The Ministry of Health would like to thank all the people who contributed their time, experience and knowledge to develop the service model. The Advisory Group members are:

Allan Panting, Chair Andrew Holden, Auckland District Health Board Anika De Mul, Ministry of Health Fiona Unac, Hawke’s Bay District Health Board Gerry Hill, Southern District Health Board James Letts, Southern District Health Board Janice Donaldson, South Island Alliance Justin Roake, Canterbury District Health Board Keith Todd, Canterbury District Health Board Kes Wicks, Capital & Coast District Health Board Patrizio Capasso, MidCentral District Health Board Phillip Thwaite, Bay of Plenty District Health Board Rene van den Bosch, South Canterbury District Health Board Samantha Titchener, Auckland District Health Board Sue Perrin, Auckland District Health Board Thodur Vasudevan, Waikato District Health Board Tim Norman, Waikato District Health Board Contents

List of Figures

List of Tables b. Executive summary

In 2015 a Project Advisory Group was convened by the Ministry of Health, with the support of district health board (DHB) General Managers, Planning & Funding (GMs P&F). The intent was to develop a Tier Two Service Specification for publicly funded vascular services that describes minimum requirements for a DHB intending to deliver vascular services, to ensure an integrated and safe service for patients. As part of the development of the specification, it was necessary to describe a model of care for vascular services. The model of care will guide the types and locations of services, ensuring patients access the right level of care in a seamless and timely manner, to improve quality and patient outcomes.

Vascular services

Vascular services encompass specialist management of conditions relating to the vascular system, including diseases of arteries, veins and lymphatic vessels which may present a risk to life or which adversely affect quality of life. The service provides assessment and management of:

symptoms or signs, either chronic or acute, suggestive of vascular disease or dysfunction, (eg, intermittent claudication, varicose veins, lymphatic disorders, diabetic vessel disease, carotid artery stenosis) as well as some asymptomatic conditions such as abdominal aortic aneurysm provision of access to vascular circulation, eg, for haemodialysis, chronic administration of antibiotics or cancer chemotherapy.

Optimal assessment and management requires clarity of responsibility for care co-ordination and may require multi-disciplinary input. Surgery plays a variable role, depending on the specific needs of the patient. Interventional radiology, which is a subspecialty within Diagnostic and Interventional Radiology, plays an important role in delivering vascular services.

Vascular services should have effective links and working arrangements with a range of other service providers.

Vascular services are organised on a regional hub and spoke model. Patients access secondary care according to historical geographical flows and regional arrangements. Within each region there are at least two DHBs providing some degree of vascular surgery.

Vascular services are provided across the continuum of primary and secondary care, but only secondary care activity is reported in national collections. Vascular surgery, including endovascular procedures provided by interventional radiologists, makes up approximately two percent of hospital surgical discharges, 62 percent is provided to people aged 65 and over, and approximately 53 per cent is elective.

6 On average 7.5 people per 10,000 of population access elective vascular surgery in a 12 month period. However, there is wide variation between DHBs, ranging from a rate of 4 per 10,000 of population to 9.5 per 10,000, standardised for differences in the DHB’s population demographic. Assessing growth in access to vascular services is complicated by reporting changes in DHBs, but has increased by at least 38 percent since 2009/10.

The Vascular Model of Care

The model of care that is supported for vascular services is an integrated regional model that spans primary and hospital settings. Hospital services are organised around Level 5 and/or 6 specialist vascular centres that provide a comprehensive range of vascular and endovascular services for adults. Paediatric specialist vascular conditions are generally referred to Auckland, and some complex conditions are managed in some, but not all, Level 6 centres. Specialist centres are supported by Level 3 and 4 centres providing some vascular services, with all centres supporting primary and community care.

The goal of the model of care is to improve quality of care and outcomes for patients through four strategies.

Optimise prevention and detection Reduce clinical variation Enhance the intervention pathway Integrate services effectively.

Optimising prevention and detection

Optimising prevention, detection, and self-management of disease features clearly in the New Zealand Health Strategy and is a driver to improve quality. Some specific areas of opportunity to improve the prevention and/or detection of vascular disease have been identified.

Primary care plays an important role in caring for patients with vascular disease, particularly in optimising outcomes. Primary care also has an important role in preventing vascular disease, for example through supporting patients with life style decisions. Strengthening primary care, and providing appropriate access to diagnostic services will have a positive impact on patient outcomes, particularly for Māori and Pasifika, who are 3.3 and 2.9 times, respectively, more likely to have unmet need for a general practitioner (GP) compared to other population groups (Ministry of Helth, 2016).

While not a comprehensive list, some strategies for the prevention and detection of vascular disease have been identified.

Abdominal aortic aneurysm screening – recommendations for screening are being considered by the National Screening Advisory Committee (NSAC). These recommendations will be considered in relation to the Vascular Model of Care when developed. Improving the detection of AAA will be an important factor in improving equity for Māori, who present with AAA at a younger age than non-Māori, have lower rates of survival and are less likely to present for elective repair (National Health Committee, 2016).

7 Cardiovascular risk assessment - the factors involved in the development of cardiovascular disease contribute equally to vascular conditions, including stroke and peripheral vascular disease, and affect similar high risk populations. Cardiovascular risk assessment is important in the prevention and detection of these vascular conditions and improving equity for Māori who are disproportionately represented in cardiovascular disease, with stroke still a leading cause of adult disability for people aged 65 and over.

In the context of prevention and detection it is therefore recommended that cardiovascular and peripheral vascular disease are considered together. To support and facilitate this, it is recommended that the next review of the Primary Care Handbook (New Zealand Guidelines Group, 2012) includes advice on peripheral vascular disease, developed with input from the Vascular Society, and other stakeholders, including the Royal Australian and New Zealand College of Radiologists (RANZCR), and primary care practitioners.

Increasing health literacy - opportunities to increase understanding and self-management of vascular conditions exist predominantly in primary care. Research has found that people with poor health literacy are less likely to use prevention services such as screening, are less likely to manage long-term or chronic conditions, and are more likely to use emergency services (Ministry of Health, 2006). The survey found that on average New Zealanders have poor health literacy skills, and that Māori tended to have the poorest health literacy across rural, income and workforce groups.

A “one team” approach can be adopted through Vascular Service providers working more closely with primary care to develop health pathways. This will not only enhance relationships, but will also increase the visibility of vascular conditions within primary care, contributing to more opportunity for patient involvement in managing their condition.

Imaging and screening - in respect to peripheral vascular disease ultrasound has an important role in confirmation of the diagnosis and defining the severity of the pathology. Consideration should be given to ways whereby this assessment modality can be made more readily accessible in primary care, either through inclusion in referral pathways (eg, Health Pathways or Map of Medicine) or through direct access to radiology programmes within DHBs. Health pathways will be an important tool to support primary care in determining the most appropriate tests and accessing these.

Where DHBs do not already have guidelines or criteria to improve primary care access to vascular ultrasound it is recommended they consider implementing the national criteria, outlined in the National Criteria for Access to Community Radiology (Ministry of Health, 2015),

Reducing clinical variation

Patients requiring hospital services should access these as close to home as clinically appropriate. Where services are provided will be determined by the patient’s clinical needs and the location of the appropriate vascular skills and infrastructure. The New Zealand Role Delineation Model (RDL) (Ministry of Health, 2010) has been used to define the expected patient and clinician characteristics, hours of access, inter-specialty relationships (eg, with

8 interventional radiology) and key vascular procedures or treatments for each level. It is important to note that while the RDL refers specifically to surgery, vascular surgeons and interventional radiologists each have a significant role in the provision of care.

The RDL provides a framework for describing the current capacity of centres to provide vascular services but is not intended to be a rigidly applied mechanism. The model should be used to identify gaps and where appropriate support investment to ensure adequately resourced, high quality, services. It is expected that centres will change their described capacity level in response to changing demographics and resource availability.

Six levels are identified along a continuum of care.

Level 1 – primary services Level 2 – community (general and convalescent services) Level 3 – hospital level care, provided primarily by general surgery Level 4 – hospital level care, provided by vascular and/or general surgery senior medical officers (SMOs) with vascular expertise, and/or interventional radiologists Level 5 – hospital level care, provided by vascular surgeons and/or interventional radiologists providing complex care in most circumstances Level 6 – hospital level care, provided by vascular surgeons, and/or interventional radiologists providing highly complex care in all circumstances.

It is recommended that a regional implementation plan is developed, which includes a determination of the level of vascular service able to be provided within each DHB’s facilities. The plan should include localised regional acute and elective referral pathways and formalised arrangements for acute service during normal and after hours.

As regions agree on the level of facilities within the region, acute and elective pathways should be aligned so that patients receive care in a facility with appropriate expertise and support services. National clinical leadership will be important to support a collaborative and patient outcome focused approach.

There are inconsistencies in the way vascular surgery is reported into national collections, with some DHBs continuing to include vascular surgery within the general surgery specialty.

Greater reporting consistency is required to allow a reliable understanding of patient access to services. This will support the assessment of equity of access and allow quality indicators to be developed and monitored. Where services are provided by a credentialed vascular surgeon, the activity should be reported against the vascular health specialty and purchase units, rather than being incorporated in general surgery reporting.

Quality improvement indicators will support greater consistency in service provision, and reduce clinical variation. Specific measures should be developed as part of implementing the model of care. Quality indicators in two areas are recommended:

9 national process and access indicators, developed from information reported to national collections – these will indicate whether services are being provided in a timely and equitable manner, and whether services are patient centred local clinical efficacy and outcome measures, developed from a recommended suite of outcome areas, and assessed as part of a regular vascular audit.

Enhance the intervention pathway

Acute pathways should consider the most appropriate pathway for patients to access the right level of care as quickly as possible. In some cases these may include stabilisation at the closest emergency department, while in other circumstances patient outcomes will be optimised by direct transfer to a more specialised vascular service provider. Pathways should include clinically appropriate repatriation or transfer of care if the vascular provider is not the patient’s local DHB.

Elective pathways within a region should be developed with the goal of facilitating equitable access to vascular care, as close to home as possible. Patients referred for vascular care should be prioritised for both first specialist assessment (FSA) and elective treatment using an agreed set of prioritisation criteria. This will support greater consistency and equity of access to care.

It is important to strongly support primary care, and care provided in Level 3 centres. Health pathways guiding diagnostic work-up and referral are being used in a number of regions. Where these are not in place, support to disseminate and localise pathways will be important to ensure patients are appropriately assessed prior to referral to a vascular centre. Key stakeholders, such as primary care and RANZCR, should be involved in localising referral pathways.

Integrating services effectively

Vascular care should be well integrated with a multi-disciplinary approach. The multi- disciplinary team for vascular will encompass a range of disciplines, including some where there have historically been shortages, eg, vascular sonographers. Specialised training in some areas, including sonography and nursing, will provide opportunities to further integrate patient care.

As part of implementing the regional model of care for vascular services, it is recommended that there is a local assessment of each region’s work force and technology needs. Local business cases will be required to address identified gaps.

Multi-disciplinary meetings (MDMs) should be implemented in all Level 5 and 6 vascular centres to support decision making and optimisation of care. MDMs should be implemented at a regional level, with participation from those involved in the patient’s care. The MDM process should be formalised to meet quality and safety requirements (see Section 15 and Appendix 5).

Implementation of the model of care is recommended using a regional approach with a clinical network, supported by change agents.

A summary of recommendations to achieve the high-level strategies are provided below.

10 Recommendations

There are a number of Recommendations identified relating to the Model of Care for vascular services. These are identified and detailed in Part 1 and 2.

The key recommendation, Recommendation 2: (Part 2, page 22) is that a vascular services implementation plan is developed that supports achievement of the strategies to improve the quality of vascular care, specifically to:

optimise prevention and detection reduce clinical variation enhance the intervention pathway integrate services effectively.

The proposed vascular services implementation approach is included as Part 3 of the model of care.

The table below summaries the other recommendations. The recommendations appear in this summary section numbered in accordance with their numbering and location in Part 1 or 2 of the document. Strategy 1: Optimise prevention and detection Outcomes Recommendations

Increased health Recommendation 3: (Part 2, page 27) literacy To increase opportunities to improve prevention and early detection of vascular disease, it is recommended that cardiovascular and Lifestyle advice and peripheral vascular disease (arterial and venous) are considered changes together. To support and facilitate this, it is recommended that: Cardiovascular risk assessment The next review of the Primary Care Handbook includes advice on peripheral vascular disease, developed with input Access to diagnostics from the Vascular Society and other relevant Colleges, eg, the RANZCR Vascular service providers work more closely with primary care to develop health pathways which will enhance relationships, increase the visibility of vascular conditions within primary care, and contribute to greater opportunity for patient involvement in managing their condition Where not already in place, DHBs consider opportunities to improve primary care access to vascular ultrasound, in line with the national criteria and referral pathways Recommendations for screening of AAA that are endorsed by the NASC should be incorporated into the National Criteria for Access to Community Radiology.

11 Outcomes Recommendations

Strategy 2: Reduce clinical variation Outcomes Recommendations

Standardised Recommendation 1:Recommendation 1: (Part 1, page 21) processes to improve quality and Inpatient vascular services, particularly where provided by a surgeon outcomes employed within the vascular specialty, should be reported using purchase unit code S750001 – Vascular Surgery – Inpatient Services Enhanced (DRG). management through best Outpatient vascular services should be reported using one of the practice guidelines following valid purchase unit codes:

Whole of system S75002 - Vascular Surgery Outpatient - 1st attendance protocols that define S75003 - Vascular Surgery Outpatient - Subsequent roles and attendance accountabilities S00008 - Minor Operations S00011 - Surgical non-contact First Specialist Assessment - Any health specialty S00012 - Surgical non-contact Follow Up - Any health specialty MS01001 - Nurse Led Clinic.

Vascular services (inpatient and outpatient) should be reported using HSC S75 – Vascular Surgery, particularly when reporting against a non-vascular purchase unit (eg, S00008).

Recommendation 4: (Part 2, page 35)

A regional hub and spoke model of care is recommended for vascular services, based on six levels of vascular service provider – two primary/community and four providing acute and elective hospital care.

The model should strengthen relationships within the region to foster closer collaboration with patient needs at the centre of planning and pathways developed that support access to the right care, in the right place at the right time.

A regional implementation approach should be developed, supported by a national clinical lead. As part of this, providers of vascular services should review the vascular requirements to determine the level of vascular service able to be provided in their hospitals. This should be considered in a regional context so that:

12 Outcomes Recommendations acute and elective service pathways are clearly defined within the Region formalised arrangements are agreed to provide services during both normal and after hours.

Process and access indicators are reviewed as new national data collections mature to include additional indicators to monitor access to vascular services.

Referral pathways for a random selection of vascular procedures should be reviewed. Findings from the review should inform service and quality improvement activities.

Pathway audit should be repeated periodically to assess the effectiveness of the changes.

With the introduction of the new electronic health record, further work should be considered by the Vascular Society, in conjunction with the Ministry of Health, to identify opportunities for introducing national reporting of vascular quality and clinical outcome measures.

Strategy 3: Enhance the intervention pathway Outcomes Recommendations

Acute and elective Recommendation 5: (Part 2, page 37) care pathways ensure patients Pathways for patients presenting with acute vascular conditions or receive timely trauma should be agreed within each region in collaboration with a intervention in the national clinical lead. most appropriate The pathways should reflect the vascular capability of the hospitals setting within the region, and should be developed in conjunction with Improved patient ambulance providers, the Major Trauma Clinical Network (for vascular journey through trauma), and vascular providers within each region. developing a Recommendation 6: (Part 2, page 38) standard information pack to Elective pathways should be agreed within the region, to facilitate support elective equitable access to a vascular care, as close to home as is clinically surgery decision appropriate. making, and improved relative An agreed set of prioritisation criteria for FSA and elective equity of access to surgical/endovascular treatment should be developed to support

13 Outcomes Recommendations elective care consistent and equitable access to elective care.

Strategy 4: Integrate services effectively Outcomes Recommendations

Patients are able to Recommendation 7: (Part 2, page 38) access appropriate imaging, allied health A formal agreed national process for conducting vascular MDM and social services should be documented and implemented within each region. The process should include the following components: Effective linkages with other service terms of reference providers supports protocols for establishment and administration patients membership coordination referral and case presentation process, including criteria for inclusion of a case in a MDM documentation communication of MDM outcome audit and review.

As part of implementing the model of care for vascular services, it is recommended that there is a local assessment of each region’s work force and technology needs. Local or regional business cases will be required to address identified gaps.

14 c. PART 1: Case for Change

1. Background

In May 2015, following a request from the Vascular Society of New Zealand to the Director General of Health, it was agreed that work would commence on the development of a Tier Two Service Specification for Vascular Services.

Development of the specification was endorsed by the National Network of GMs P&F. The rationale for the specification was that provision of vascular services was materially different to general surgery, and that it was important to describe the minimum requirements for a DHB intending to deliver vascular services.

As part of the development of the specification, it was necessary to describe a model of care for vascular services. The model of care will guide the types and locations of services, ensuring patients access the right level of care in a seamless and timely manner to improve quality of care and patient outcomes.

2. Process

To develop the Service Specification, and associated model of care, a Vascular Services Advisory Group was convened.

Chief operating officers were approached and asked to nominate people from the multi- disciplinary team involved in providing vascular services. An independent chair of the group was appointed by the Ministry of Health (the Ministry).

Upon receipt of nominees, the Ministry, Chair and President of the Vascular Society reviewed nominees to ensure an appropriate level and range of expertise, and input from rural, large provincial, metropolitan and tertiary providers. Membership is provided in Appendix 1.

Secretariat support for the Vascular Services Advisory Group was provided by the Ministry.

3. Vascular services

Vascular services encompass specialist management of conditions relating to the vascular system, including diseases of arteries, veins and lymphatic vessels which may present a risk to life or which adversely affect quality of life. Adults may receive access to vascular services in a range of centres, while specialised vascular care for children is generally provided in Auckland, at Starship Children’s Hospital.

15 The Service provides assessment and management of:

symptoms or signs, either chronic or acute, suggestive of vascular disease or dysfunction, (eg, intermittent claudication, varicose veins, lymphatic disorders, diabetic vessel disease, carotid artery stenosis) as well as some asymptomatic conditions such as abdominal aortic aneurysm provision of access to vascular circulation, eg, for haemodialysis, chronic administration of antibiotics or cancer chemotherapy.

Assessment and management may require multi-disciplinary input and clarity of responsibility for care co-ordination. Surgery (including endovascular intervention) plays a variable role, depending on the specific needs of the patient. The core activities of the service include:

open surgical or endovascular treatment of arterial aneurysms or dissections to prevent complications such as limb loss, organ ischaemia or death from rupture open surgical or endovascular treatment of carotid artery stenosis to prevent disabling stroke or death open surgical or endovascular restoration of arterial supply to the limbs for symptom relief and/or prevention of amputation limb amputation when restoration of blood supply is either not possible or would be futile open surgical, endovenous or conservative management of chronic venous insufficiency to relieve symptoms and/or prevent or treat complications such as venous ulceration open surgical, endovenous or conservative management of selected cases of venous thrombosis or occlusion to relieve symptoms and/or prevent or treat complications open surgical or endovascular treatment of acute vascular trauma or haemorrhage (eg, gastrointestinal tract haemorrhage, massive haemoptysis, or post-partum haemorrhage) and the provision of assistance to colleagues in management of surgical trauma to vessels and/or haemorrhage assisting colleagues from other specialties with the control of major blood vessels to facilitate dissection (in cancer surgery for example) providing and maintaining vascular access (for patients requiring haemodialysis, cancer chemotherapy, or chronic administration of antibiotics for example) providing renal transplant surgery promoting cardiovascular health and management of vascular risk factors.

4. Service providers

Vascular services are provided by a multi-disciplinary team, with input from a range of specialties and disciplines that includes:

vascular surgeons general surgeons, including those with a vascular sub-specialty interventional radiologists

16 vascular sonographers vascular nurses and nurse specialists vascular operating theatre and medical radiology nurses and medical radiation technologists.

Interventional radiology plays an important role in delivering vascular services. Interventional radiologists are a core provider of vascular services in partnership with other specialist vascular practitioners. Vascular sonography (ultrasound) is a subspecialty within general ultrasound services, with training under the Australasian Society for Ultrasound Medicine (ASUM).

Vascular sonographers are often based in radiology departments, where they may also perform non-vascular ultrasound studies, but they may also be part of dedicated vascular laboratories under the direct supervision of vascular surgeons with vascular ultrasound training.

5. Support services

Vascular services should be well integrated with other primary health, general and specialist health services to support effective consultation, liaison and referral between services, follow up and discharge processes.

Vascular services should have effective links and working arrangements with a range of other service providers, including:

community or district nurses (including specialists in wound care) other specialist medical disciplines, including nephrologists, diabetologists, oncologists, infectious diseases and stroke physicians clinical support services, including laboratory and pathology, pharmaceutical, diagnostic and interventional imaging allied health support services, including podiatry, orthotics, occupational therapy, physiotherapy, rehabilitation services social services, counselling, home help, community services, new migrant community health workers disability support services and providers aged residential care facilities limb centres consumer support groups.

6. Geographical flows

Patients access secondary care according to historical geographical flows and regional arrangements. Within each region there are at least two DHBs providing some degree of vascular surgery. Regional flows in 2016/17 are depicted in Figure 1.

Figure 1: Current Referral flows

17 Notes: Prior to 1 July 2016, Nelson Marlborough DHB referred to Capital & Coast DHB. Southern DHB refers only transplant and thoracic surgery and refers to three tertiary centres. Whanganui DHB refers some low complexity vascular to MidCentral DHB, with more complex vascular referred to Capital & Coast DHB

Figure 2, below, shows the volume of vascular activity delivered at each of the providers over a three-year period (where reported using vascular purchase units). The National Minimum Data Set (NMDS) shows that Auckland provides the largest volume of vascular surgery, with Waikato, Capital and Coast, Canterbury and Southern DHBs also providing large volume of activity over the three-year period.

18 A higher proportion of vascular surgery is provided electively - 53 percent, compared to 46 percent elective in other surgical specialties. Of the main vascular providers, only Southern DHB is providing more acute than elective surgery. Data also shows that since 2013/14, 62 percent of vascular surgery is provided to patients aged 65 and over, compared to 32 percent in other surgical specialties.

Figure 2: Acute Elective split of vascular surgical discharges 2013/14 – 2015/16

Source: NMDS extracted August 2016. Data is extracted for the purchase unit: S75001 – Vascular Surgery – Inpatient Services (DRG) by provider DHB.

7. Access to Vascular services

Vascular services are provided across the continuum of primary and secondary care, but only secondary care activity is reported in national collections. Table 1, below, shows activity reported as vascular surgery through the vascular surgery purchase unit, based on the DHB of patient domicile (ie, where someone lives as opposed to where the service was provided). This does not include all vascular surgery (see Appendix 2 for a list of vascular procedures defined by International Classification of Diseases (ICD) codes).

Based on activity reported to the NMDS between 2009/10 and 2015/16 vascular inpatient surgery makes up two percent of hospital surgical discharges, but accounts for a relatively high level of patient complexity, having four percent of hospital case weighted discharges.

There has been marked growth in reported delivery of vascular surgical services since 2009/10, with 2473 extra people receiving treatment in 2015/16 (up 60% over 2009/10), and the majority of this increase (1400, or 71%) being elective. Some of the growth (acute and elective) relates to a reporting change with some DHBs, eg, in 2012/13 Southern changed reporting from general surgery to vascular. Even discounting the growth in Southern and Nelson Marlborough DHBs (attributed in the main to a reporting change) there has still been positive growth of 38 percent since 2009/10.

19 20 Table 1: Vascular surgical discharges (acute and elective) – 2009/10 to 2015/16 DHB of domicile Population 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015 /16 Auckland 477,182 507 444 485 524 648 622 704 Bay of Plenty 218,427 229 377 367 358 351 352 327 Canterbury 515,717 472 610 594 730 891 841 973 Capital and Coast 303,081 465 489 490 494 553 533 509 Counties Manukau 527,033 26 27 28 34 30 54 48 Hawkes Bay 157,521 97 92 111 144 184 392 354 Hutt Valley 145,819 265 313 313 356 319 274 260 Lakes 103,096 91 107 103 108 101 97 94 MidCentral 171,408 73 50 67 81 67 78 70 Nelson Marlborough 143,161 14 90 131 147 153 194 197 Northland 160,773 165 201 221 253 260 223 226 South Canterbury 57,140 21 24 39 42 49 43 56 Southern 311,292 18 4 9 429 657 686 751 Tairawhiti 46,579 34 40 44 37 47 48 53 Taranaki 111,001 33 10 36 38 89 121 148 Waikato 377,930 987 1,122 1,038 1,049 1,046 1,032 996 Wairarapa 40,786 67 73 91 70 93 93 70 Waitemata 576,843 527 518 554 547 637 599 628 West Coast 33,263 22 34 42 57 60 58 78 Whanganui 62,637 24 30 46 46 59 49 53 National 4,540,689 4,137 4,655 4,809 5,544 6,294 6,389 6,595 Source: NMDS, extracted August 2016. Data is extracted for the purchase unit: S75001 – Vascular Surgery – Inpatient Services (DRG) by DHB of patient domicile. Any vascular surgery reported as general surgery will not be included in Table 1. Counties Manukau DHB provides vascular surgery for its population, and reports it as S00001 – General Surgery – Inpatient Services (DRG), which accounts for their low volume. Southern DHB reported vascular surgery as S00001 – General Surgery – Inpatient Services (DRG) prior to 2012/13.

Equity of access

An important part of improving health outcomes is to reduce inequalities in access to health services. A basic assessment of equity for high risk populations may be to look at the level of access to surgery compared to the population make up for that ethnic group. While this will not take into account the prevalence of disease within the populations, it does highlight that in most specialties areas Māori are receiving lower rates of surgery than Pasifika or non-Māori.

Table 2: Access to surgery by ethnicity – 2015/16 Māori Pacific Other New Zealand population 16% 6% 78% Vascular 11% 4% 85% Cardiothoracic 12% 7% 81% ENT 18% 9% 74% General surgery 14% 6% 80% Gynaecology 16% 9% 76% Ophthalmology 10% 11% 79% Orthopaedics 13% 6% 81% Plastics 13% 8% 78% Urology 9% 4% 87% Source: NMDS – extracted March 2017. Population data from Statistics New Zealand, 2016/17 projections from 2013 Census

21 8. Elective surgical access

Assessing a DHB populations’ relative access to elective vascular surgery cannot be achieved through activity reported against the vascular purchase unit, as some DHBs report vascular surgery under the general surgery purchase unit.

Not only is a consistent method of reporting required, but population demographics need to be standardised to account for variation in age, gender, ethnicity and social deprivation. Standardised intervention rates (SIRs) use Vascular Diagnostic Related Group (DRG) codes rather than purchase units presented in Table 1, above, and assess access to elective surgery only by DHB of patient domicile. The DHB and regional rates (raw and standardised) for 2014/15 are identified below. The SIRs standardise for ethnicity, and a DHB with a high proportion of Māori or Pacific people will need to deliver a higher standardised rate of elective vascular surgery to demonstrate equitable access.

Improving equity of access for patients requiring elective vascular services is a key requirement for the model of care. Patients should have relatively similar access to both acute and elective care, regardless of where they live.

Figure 3: Standardised intervention rates – 2014/15

S ource: NMDS extracted September 2015. Data is extracted by Diagnostic Related Group, and presented by DHB or Region of patient domicile. DRGs included within the SIR report are in Appendix 2.

The data on access to vascular surgery shows variation in the way activity is coded in national collections. Greater consistency is required to give more reliable interpretation of access. The Common Counting Standards 2013/14 (Common Counting Standards Technical Advisory Group , 2015) outline how health activity should be defined measured and counted to support the planning of health and disability services. These state that:

22 allocation of Health Specialty Codes (HSC) for both inpatient and outpatient events is dependent on the specialty for which the treating clinician is employed to perform those events allocation of Purchase Unit Code (PUC) for inpatient events is based on the Health Speciality Code allocated for Outpatients the PUC is usually allocated on the clinic code which could be different to the Health Speciality Code.

Recommendation 1:

Inpatient vascular services, provided by a surgeon employed within the vascular specialty, should be reported using PUC S750001 – Vascular Surgery – Inpatient Services (DRG).

Outpatient vascular services should be reported using one of the following valid purchase units:

S75002 - Vascular Surgery Outpatient - 1st attendance S75003 - Vascular Surgery Outpatient - Subsequent attendance S00008 - Minor Operations S00011 - Surgical non-contact First Specialist Assessment - Any health specialty S00012 - Surgical non-contact Follow Up - Any health specialty MS01001 - Nurse Led Clinic.

Vascular services (inpatient and outpatient) should be reported using HSC S75 – Vascular Surgery, particularly when reporting against a non-vascular purchase unit (eg, S00008).

23 d. PART 2: Model of care

9. The strategic approach

The model of care for adult vascular services aims to improve patient outcomes and quality of care, in accordance with the New Zealand Triple Aim, which is a national commitment to simultaneously achieve three outcomes in the delivery of health services:

1.improving the quality, safety and experience of patient care through improving the timeliness of access to specialist advice 2.improving health and equity for all populations through reducing current disparities in access 3.getting the best value from the resources made available to the public health system through implementing evidence based improvements referral pathways.

The model of care for vascular services also complements the five themes of the New Zealand Health Strategy 2016 (Minister of Health, 2016):

Figure 4: Five themes of the New Zealand Health Strategy

10. Service continuum and model of care

Patients requiring hospital services should access these as close to home as possible. Where services are provided will be determined by the patient’s clinical needs and the location of the appropriate vascular skills and infrastructure.

The model of care has four high level strategies to improve quality of care for patients within the vascular service and are across the continuum.

24 Figure 5: Strategies to improve quality of care

Recommendation 2:

A Vascular services implementation plan is developed that supports achievement of the strategies to improve the quality of vascular care, specifically:

optimise prevention and detection reduce clinical variation enhance the intervention pathway integrate services effectively.

The New Zealand Role Delineation Model outlines vascular services within a framework of specialist resources and support services. Requirements to determine the level of vascular services within a hospital or facility are detailed in Appendix 6.

RDL Level 1 and 2 Services: Vascular services delivered within a primary or community setting. RDL Level 3 and 4 Services: Vascular services delivered within a secondary care setting. May be provided by general surgeons, including those with training in vascular surgery, vascular surgeons, interventional radiologists, nursing and allied health staff. RDL Level 5 and 6 Services: Vascular services provided within a tertiary care setting. May be provided by vascular surgeons, interventional radiologists, vascular sonographers, specialist vascular nursing and allied health staff. The specific services provided in tertiary care centres depend upon the available resources, staff expertise and sub-specialist interest, and the role the centre plays in delivery of a regional service.

Figure 6: Vascular services by RDL Level

Continuum of Vascular care

Level Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

Hospital level Hospital level Hospital level Community (general Hospital level Vascular care provided by Complex Vascular care Highly complex Vascular Description Primary services and convalescent) Vascular care provided by Vascular and/or General provided by Vascular care provided by services General Surgery Surgery surgeons Vascular surgeons Prevention and health Community and district Non-intervention Multi-disciplinary team to Multi-disciplinary team Full interdisciplinary Services promotion nursing management , including manage patient to manage patient assessment Detection and Allied health, e.g. dietary or lifestyle advice assessment & diagnosis. assessment & diagnosis Development & diagnosis physiotherapy Specialist nursing services Access to (vascular Specialist imaging execution of individual Early intervention Social services, e.g. Non specialist ultrasound ultrasound, CT and MRI Follow up & treatment management plans Surveillance home help, social and CT imaging Visiting Vascular Service , of patients within scope Resident vascular and Referral workers Visiting Vascular SMO on site General Surgeon Resident vascular and interventional radiology Post intervention care Post intervention Emergency and elective with Vascular training interventional radiology service, 24 hour acute recovery assessment & diagnosis service, 24 hour acute service Stabilising and transfer of service Fully integrated regional complex patients provider Non specialist ultrasound and CT imaging

25 11. Strategy 1: Optimising prevention and detection

Optimising prevention, detection, and self-management of disease features clearly in the New Zealand Health Strategy, and is a driver of improved quality and patient outcomes.

The Health Strategy’s road map of actions includes a number of action areas that will contribute to prevention and detection of vascular disease, including increasing health literacy, supporting lifestyle changes and advice, and cardiovascular risk assessment, as well as creating a “one team” approach to health in New Zealand.

Behavioural and biological risk factors are the major cause of cardiovascular disability. Biological factors include obesity, elevated serum cholesterol and hypertension. Behavioural factors include lack of exercise, smoking and poor nutrition. Māori are more likely to experience biological and behavioural risk factors than non-Māori. For example, smoking is a leading cause of stroke and heart disease in people aged under 65 years, and Māori are 2-3 times more likely to be current smokers than non-Māori (Ministry of Helth, 2016).

Primary care plays an important role in caring for patients with vascular disease, particularly in optimising and prevention. Strengthening primary care, and providing appropriate access to diagnostic services will have a positive impact on patient outcomes, particularly for Māori and Pasifika, who are 3.3 and 2.9 times, respectively, more likely to have unmet need for a GP compared to other population groups (Ministry of Helth, 2016).

Some specific areas of opportunity to improve the prevention and/or detection of vascular disease are identified below. While not a comprehensive range of strategies for prevention and detection of vascular disease, these are some areas where it is felt there is opportunity to improve equity and patient outcomes.

Abdominal Aortic Aneurysm screening

The National Health Committee (NHC), commenced a Tier Two report on models of care for Abdominal Aortic Aneurysm (AAA) (National Health Committee, 2016). With the disestablishment of the NHC, the NASC will be making recommendations for screening for AAA. These recommendations will need to be considered in conjunction with the implementation of the vascular model of care.

According to the NHC report, Māori have higher AAA prevalence rates than New Zealand Europeans, present to hospital with AAA approximately 8.3 years younger than people of other ethnicities, have higher AAA-related mortality, lower relative survival and are less likely to have an elective repair. Incidence of AAA and related mortality were found more often in Māori women, with speculation this was linked to high rates of smoking (National Health Committee, 2016).

Improving the detection of AAA will be an important factor in improving equity for Māori. However, screening alone will not improve cardiovascular disease outcomes for Māori. Other

26 strategies will be required, including improved vascular disease assessment and management in primary care, and increased health literacy for Māori.

Cardiovascular risk assessment

The prevention and detection of cardiovascular disease has been one of six health targets until 2015/16, and is Action 8 of the Health Strategy road map.

The factors involved in the development of cardiovascular disease contribute equally to vascular conditions, including stroke and peripheral vascular disease, affecting similar high risk populations. Cardiovascular risk assessment is important in the prevention and detection of these vascular conditions and improving equity for Māori who are disproportionately represented in cardiovascular disease, with stroke still a leading cause of adult disability for people aged 65 and over (Ministry of Helth, 2016).

While stroke rates are declining, Māori and Pasifika stroke rates are declining more slowly than those of the general population, and Māori and Pasifika experience stroke at a younger age (mean age of 60-62 years) compared with New Zealand Europeans (mean age of 75 years) (Ministry of Helth, 2016).

As with cardiovascular disease, measures to prevent and detect peripheral vascular disease are most appropriately implemented in primary care. People accessing cardiovascular risk assessments receive education on disease and risk factors, as well as lifestyle advice and treatment (where necessary) that will reduce the potential risk and impact of a range of vascular conditions, including carotid stenosis and diabetes related peripheral vascular disease.

While cardiovascular risk assessment will no longer be reported as a health target, the Ministry will continue to encourage DHBs to regard this work as a priority for their population. The Ministry’s work on obesity, stroke prevention and diabetes includes opportunities to influence prevention and detection of vascular disease.

In the context of prevention and detection it is therefore recommended that cardiovascular and peripheral vascular disease are considered together. To support and facilitate this, it is recommended that the next review of the Primary Care Handbook includes advice on peripheral vascular disease, developed with input from the Vascular Society.

Increasing health literacy

The New Zealand Health Strategy recognises the importance of increasing health literacy and self-management in improving outcomes. The first action in the road map is to inform people about public and personal health services so they can be “health smart” and have greater control over their health and wellbeing.

Research has found that people with poor health literacy are less likely to use prevention services such as screening, are less likely to manage long-term or chronic conditions, and are more likely to use emergency services (Ministry of Health, 2006). The survey found that on

27 average New Zealanders have poor health literacy skills, but that among New Zealanders Māori tended to have the poorest health literacy across rural, income and workforce groups.

Opportunities to increase literacy and self-management of vascular conditions, particularly for Māori, exist predominantly in primary care. Some of the actions already being developed include:

using social media to support healthy living by providing clear, authoritative, information to support people making healthy food and activity choices, and information on diabetes prevention and early stage management continuing to strengthen the National Telehealth Service by providing more support for people to manage their own health conditions creating partnerships for better health services by giving everyone involved in a person’s care, including the person, access to the same information a framework for health literacy, and reference material such as “Rauemi Atawhai: a guide to developing health education resources in New Zealand” (Ministry of Health, 2012).

A “one team” approach can be adopted through vascular service providers working more closely with primary care to develop health pathways. This will not only enhance relationships, but will also increase the visibility of vascular conditions within primary care, contributing to more opportunity for patient involvement in managing their condition.

Imaging and screening

Improving access to screening will be closely linked to strategies to improve health literacy and to improving access to primary care.

In respect to peripheral vascular disease ultrasound has an important role in confirmation of the diagnosis and defining the severity of the pathology. Consideration should be given to ways whereby this assessment modality can be made more readily accessible in primary care, either through inclusion in referral pathways (eg, Health Pathways or Map of Medicine) or through direct access to radiology programmes within DHBs. Health pathways will be an important tool to support primary care in determining the most appropriate tests and accessing these.

In 2015, the Ministry published National Criteria for Access to Community Radiology, including ultrasound. The premise for the criteria was that radiological investigation is a basic component of primary health care. Improving primary care practitioners’ ability to diagnose and manage conditions and to make more appropriate and timely referrals to secondary health care should lead to better patient outcomes.

The criteria, which include nationally recommended minimum levels of access, are intended to assist primary care practitioners to manage patients in the community by ensuring they get appropriate access to diagnostics. While the criteria are not mandatory, DHBs may use them to develop or update their own criteria. Where DHBs do not already have criteria to improve primary care access to vascular ultrasound it is recommended they consider implementing the national criteria with endorsed vascular referral pathways to ensure appropriate use of this

28 scarce resource. Pathway development should be a collaborative process with relevant stakeholders involved, including the Vascular Society, RANZCR, and primary care practitioners.

The criteria include recommendations for minimum access to ultrasound for:

clinically or radiologically suspected AAA follow-up of AAA as per local guideline carotid Doppler ultrasound for a history of transient ischaemic attack or stroke with minor deficit where presentation meets local pathway criteria, or where no local pathway is in place and a relevant specialist has recommended a carotid Doppler ultrasound where there is a pulsatile mass for investigation suspected deep vein thrombosis in accordance with local pathways proximal superficial thrombophlebitis in the thigh.

The criteria explicitly exclude screening for AAA, which has been referred to the NASC for consideration, following a NHC assessment. Following consideration, any recommendations for screening of AAA should be incorporated into the National Criteria for Access to Community Radiology.

Recommendation 3:

To increase opportunities to improve prevention and early detection of vascular disease, it is recommended that cardiovascular and peripheral vascular disease (arterial and venous) are considered together. To support and facilitate this, it is recommended that:

the next review of the Primary Care Handbook includes advice on peripheral vascular disease, developed with input from the Vascular Society and other relevant Colleges, eg, the Royal Australian and New Zealand College of Radiologists vascular service providers work more closely with primary care to develop health pathways which will enhance relationships, increase the visibility of vascular conditions within primary care, and contribute to greater opportunity for patient involvement in managing their condition where not already in place, DHBs consider opportunities to improve primary care access to vascular ultrasound, in line with the national criteria, and referral pathways. Recommendations for screening of AAA that are endorsed by the NASC should be incorporated into the National Criteria for Access to Community Radiology.

12. Levels of Vascular service provision

The following table describes the six levels of service provision for adult vascular services, as defined by the New Zealand RDL model. Definitions and classifications are included in Appendix 5. The RDL provides a framework for describing the current capacity of centres to provide vascular services, but is not intended to be a rigidly applied mechanism. The model should be

29 used to identify gaps and where appropriate support investment to ensure adequately resourced, high quality, services. It is expected that centres will change their described capacity level in response to changing demographics and resource availability.

Further work is required to stratify hospital facilities to a vascular provider level, and vascular conditions according to complexity, including the role of interventional radiology in service provision. This work should be considered as part of implementation of the model of care. The classifications would represent local and regional agreements based on current situations and would need to be reviewed or revised as circumstances, populations or technology changes.

As regions agree on the level of facilities within the region, acute and elective pathways should be aligned so that patients receive care in a facility with appropriate expertise and support services. National clinical leadership will be important to support a collaborative and patient outcome focused approach.

Under the model, there are some complex conditions that are currently managed through an MDM approach between Level 6 providers, with patients referred to and managed by the most clinically appropriate centre. Other conditions may be managed in some, but not all, Level 6 centres, and it is not expected that these pathways would change.

As part of implementing the model, regional pathways will provide guidance about specific conditions and relationships with other specialties, such as cardiothoracic, orthopaedics, gynaecology, or general surgery.

Table 3: Levels of vascular service

RDL Level Descriptor Vascular requirements

Patient Characteristics: Level 1  Stable, pre and post intervention  Acute presentation of variable complexity Primary Services Clinician Characteristics:  Services provided by general practitioners, supported by nurses, allied health, and aged care providers Hours of access:  Normal hours, with afterhours arrangements through accident and medical centres Inter-specialty relationships:  May interface with secondary and tertiary services providing both pre and post intervention care Key procedures or treatments:  Prevention of vascular disease or disorder through lifestyle advice and cardiovascular disease risk assessment  Health promotion and patient education to improve health literacy and involvement in care and health planning  Detection of vascular disease through history, physical examination, and the use of limited diagnostic investigations  Early intervention through blood pressure and cholesterol control, support for modification of lifestyle, eg, smoking, diet and exercise  Referral for secondary or tertiary care when appropriate, eg, in acute

30 RDL Level Descriptor Vascular requirements

situations  Surveillance and monitoring of patient condition  Pre and post intervention care, including wound management, and palliative support.

Patient Characteristics: Level 2  Stable, pre and post intervention Clinician Characteristics: Community (general  Services by general practitioners and/or medical officers, nurse and convalescent) practitioners, nurses, allied health, and aged care providers within services community hospitals, including integrated family care facilities Hours of access:  Normal hours, with some extended or after hours care Inter-specialty relationships:  Will interface with primary care, and with hospital services providing both pre and post intervention care Key procedures or treatments:  Wound care, including (in some cases, depending upon local nursing expertise) advanced wound care nursing and compression therapy for chronic venous insufficiency.  Supervised exercise therapy for intermittent claudication  Convalescent services Acute services limited to triage and referral.

RDL Level Descriptor Vascular requirements Patient Characteristics: Level 3  Non-complex vascular surgery with low anaesthetic risk patients Clinician Characteristics: Hospital level vascular  Services by general surgery specialist medical officers (SMO), care provided by including those with vascular expertise, supported by medical officers General Surgery or registered medical officers (RMO) and Level 5 or 6 vascular (NZRDL) providers Hours of access:  General surgery SMOs on site normal hours, and rostered on call after hours  Formal arrangement with Level 5-6 provider for support both in normal hours and after hours  Medical officer or RMO on site 24 hours Inter-specialty relationships:  Provides core specialist services, including access to operating theatres, ICU/HDU, diagnostic imaging, pathology and CCU and access to interventional radiology  Supports some access to visiting vascular outpatient services from

31 Level 4-6 providers  Supported by nurse practitioners, nurses, allied health, and aged care providers Key procedures or treatments:  Outpatient care provided by local general surgeons, including those with vascular expertise, and/or visiting vascular surgeons.  Supports primary and community care providers in managing patients with low complexity vascular conditions  Provides limited range of diagnostic investigations including portable vascular ultrasound and ankle/brachial pressure indices.  Develops a written plan of care including management of vascular risk factors, eg,: . dietary and lifestyle advice and pharmacotherapy . non-surgical management strategies including surveillance of small AAA, or exercise therapy for intermittent claudication  Provides some outpatient procedures, eg, endovenous ablation of varicose veins and non-complex, low anaesthetic risk surgery.  Provides follow up, treatment, surveillance and rehabilitation in line with visiting specialist plan of care  Provides access to specialist wound care and compression bandaging services, internally and through community service providers  Prioritises elective vascular referrals and facilitates access to visiting vascular SMO or redirects to a Level 5 or 6 vascular service  Provides emergency stabilisation services and facilitates acute transfer to in-patient vascular interventions and/or endovascular interventions  Supports visiting outpatient vascular specialists as part of a locally delivered regional service . Referral for consultation and clinical assessment . Provides follow up and treatment in line with visiting specialist plan of care.

32 Vascular requirements RDL Level Descriptor Patient Characteristics: Level 4  Low and moderate complexity surgery, with low and medium anaesthetic risk patients Hospital level vascular Clinician Characteristics: care provided by  Services by vascular and/or general surgery SMOs with vascular Vascular and/or expertise and/or interventional radiologists, supported by: General Surgery . medical officers or RMOs and/or interventional . Level 5 or 6 vascular SMOs radiology, and Hours of access: outpatient  Vascular and/or general surgery SMOs on site normal hours, and consultations by rostered on call after hours vascular surgeon  Medical officer or RMO on site 24 hours during normal working  Formal arrangement with Level 5-6 provider for support both in hours (NZRDL) normal hours and after hours Inter-specialty relationships:  Provides Level 4 core specialist services (acute 24 hour services in range of specialties), including access to interventional radiology, operating theatres, ICU/HDU, diagnostic imaging, pathology and CCU  Supported by nurse practitioners, nurses, allied health, and aged care providers  supports regular/frequent access to visiting Vascular specialists for surgery and/or outpatient services Key procedures or treatments:  Outpatient care provided by vascular and/or general surgery SMOs with vascular expertise, nurse practitioners and supported by visiting Level 5 or 6 vascular SMOs.  Supports primary and community care providers in managing patients with low complexity vascular conditions  Develops a written plan of care including management of vascular risk factors  Participates in Level 5 and 6 multi-disciplinary meetings and vascular audit, and individually or collectively manages patient follow up, treatment, surveillance and rehabilitation  Provides access to specialist wound care and compression bandaging services, internally and through community service providers  Provides surgery and/or endovascular procedures of moderate complexity in patients that are of low or medium anaesthetic risk.  Prioritises elective vascular referrals and facilitates access to visiting vascular SMO or redirects to a Level 5 or 6 Vascular service  Provides vascular ultrasound and other diagnostic imaging (including CT) and interventional procedures on site, with an interventional SMO available normal hours (may be visiting )with formal arrangements in place for after hours  Acute vascular surgery may be provided by a general surgery SMO with vascular expertise or a resident vascular surgeon, with formal arrangements in place for Level 5-6 provider support both in normal hours and after hours  Provides emergency stabilisation services and facilitates acute transfer for patients requiring acute open or endovascular arterial surgery, where not able to be provided locally.

Patient Characteristics: Level 5  Surgery of most levels of complexity, and for all levels of anaesthetic risk Hospital level vascular Clinician Characteristics: service, with vascular  Services by vocationally trained vascular surgeons and/or surgeons and/or interventional radiologists, supported by: interventional . medical officers or vascular RMO radiology and Hours of access: registrars  Vascular SMOs on site normal hours, and rostered on call after hours  Vascular registrars or equivalent on site 24 hours Complex diagnostic  Interventional radiology on site normal hours and rostered on call and treatment on all after hours risk patients, including Inter-specialty relationships: acute AAA service  Provides Level 5 core specialist services (acute 24 hour services in range of specialties), including operating theatres, ICU/HDU, diagnostic imaging, pathology and CCU  Level 5 interventional radiology services, which includes registered nurses or technical staff, and on-site service normal hours  Supported by nurse practitioners, nurses, allied health, and aged care providers Key procedures or treatments:  Outpatient care provided by vascular SMOs, nurse practitioners and nurse specialists.  Supports primary and community care providers in managing patients with low complexity vascular conditions  Provides specialist wound care and compression bandaging services, internally and through community service providers  Provides extended range of vascular and endovascular surgery for patients of all anaesthetic risk  Acute vascular service provided by vocationally trained vascular surgeons, with SMO on site during normal hours and on call after hours to provide stabilisation of all patients and definitive treatment for most vascular conditions  Refers or transfers patients to Level 6 vascular services where required, eg, organ transplantation and some complex endovascular thoracic procedures.  Provides comprehensive vascular diagnostic (including specialised vascular ultrasound, CT and MRI) and interventional procedures on site, with an interventional SMO on site normal hours and rostered on call after hours  Coordinates multi-disciplinary meetings and vascular audit, and individually or collectively manages patient follow up, treatment, surveillance and rehabilitation, and participates in Level 6 MDMs  Supports other surgical specialties with acute and elective cases to prevent or manage iatrogenic vascular trauma  May provide outreach and visiting vascular services to Level 3 and 4 DHBs

Patient Characteristics: Level 6  Surgery of all levels of complexity, and for all levels of anaesthetic risk Clinician Characteristics: Vascular and  Services by vocationally trained vascular SMOs (including endovascular service subspecialist surgeons providing highly complex procedures for other regions) and/or interventional radiologists, supported by: Provides highly . RMOs that are part of vascular service roster (basic or complex diagnostic advanced trainees) and treatment Hours of access: procedures for  Vascular SMOs on site normal hours, and rostered on call after hours vascular medicine in  Vascular registrars or equivalent on site 24 hours association with other  Interventional radiology SMO on site normal hours and rostered on specialties. call after hours Inter-specialty relationships: Has on site Level 6  Provides Level 6 core specialist services (acute 24 hour services in Emergency Medicine extended range of specialties), including operating theatres, ICU/HDU, diagnostic imaging, pathology and CCU  Interventional radiology immediately available 24 hours and provides emergency procedures  Supported by nurse practitioners, nurses, allied health, and aged care providers Key procedures or treatments:  Outpatient care provided by vascular SMOs, nurse practitioners and nurse specialists.  Supports primary and community care providers in managing patients with low complexity vascular conditions, and supports Level 3-5 services in providing follow up, treatment, surveillance and rehabilitation  Provides specialist wound care and compression bandaging services, internally and through community service providers  Develops and executes individual vascular/endovascular management plans for patients referred to the service  Provides acute and elective complex vascular surgery for patients with high anaesthetic risk using a combined vascular/endovascular approach, including potential use of specialised (hybrid) operating theatres  Acute vascular service provided by vocationally trained vascular/endovascular surgeons, with SMO on site during normal hours and on call after hours to provide stabilisation and definitive treatment of all patients, including transplant and thoracic procedures  Supports Level 3-5 hospitals and liaises with emergency services to facilitate timely and appropriate transfer of acute patients  Provides comprehensive vascular diagnostic (including specialised vascular ultrasound, CT and MRI) and interventional procedures immediately available at all times  Coordinates a multi-disciplinary team approach to the management of patients, including Level 4 and 5 vascular providers in the development and implementation of plans of care for complex patients  Supports other surgical specialties with acute and elective cases to: . Prevent or manage iatrogenic vascular trauma . Control major blood vessels to facilitate dissection (eg, in

35 cancer surgery) . Manage vascular complications of conditions such as renal disease, diabetes, complex wounds or leg ulcers . Provide vascular access for renal patients requiring haemodialysis . Provide outreach and visiting vascular services to other DHBs . Provide renal transplantation surgery . Support cardiothoracic surgery

13. The Model of Care – Vascular Services

The model of care for vascular services is through a regional hub and spoke model. The service will be delivered through one or more hubs per region, depending on the resources and expertise available within each region’s hospitals. The goal of the model is to ensure patients access quality care seamlessly to optimise outcomes.

The service will be based around Level 6 vascular centres (providing a comprehensive range of treatments), supporting:

Level 5 centres, Level 4 centres a vascular service which might include general surgeons with a vascular interest services providing some, but not all treatment for patients with vascular disorders Level 3 centres, where services are provided by general surgeons, with some visiting vascular services.

The vascular hub and spoke model will be supported by a range of support services, including investigative and interventional radiology services, primary care practitioners, nursing and allied health staff with close cooperation to ensure patients have equitable access to comprehensive care, in their locality where possible.

Figure 7 shows the current hub and spoke configuration, with referral pathways. Referrals to vascular centres should provide equitable and consistent access to services, in line with agreed clinical standards and referral pathways, and based on agreed inter district flows.

As the model of care is implemented existing referral pathways should be reviewed and either confirmed or adjusted as clinically appropriate within the region to support a safe and sustainable Vascular service. A clinical leader will be appointed to work with regions to promote a nationally consistent approach, within local and regional requirements.

The model should strengthen relationships within the region to foster closer collaboration so that patient needs are at the centre of planning and pathways developed that support access to the right care, in the right place at the right time.

Figure 7: Current Vascular Hubs

36 Recommendation 4:

A regional hub and spoke model of care is recommended for vascular services, based on six levels of vascular service provide – two primary/community and four providing acute and elective hospital care.

A regional implementation approach should be developed, supported by a national clinical lead. As part of this, providers of vascular services should review the vascular requirements identified in Table 2 to determine the level of vascular service able to be provided in their hospitals.

This should be considered in a regional context so that:

acute and elective referral pathways are clearly defined within the region formalised arrangements are agreed to provide services during both normal and after hours.

14. Care pathways

Pre hospital

Acute care pathways will generally, but not always, begin in primary care. Many acute vascular conditions are a life or limb threatening emergency. Early intervention by an appropriately qualified vascular specialist is essential.

The NHC (National Health Committee, 2016), in its draft tier two report on models of care for AAA, identified that over a 10 year period 76 percent (2490) of people experiencing ruptured AAA died from the condition. This was despite approximately 60 percent (2029) of people with a ruptured AAA being admitted to hospital. Only half of the patients who reached hospital received emergency surgery. The survival rate for those who received surgery was 65 percent (796). Early surgical intervention is considered a contributor to better outcomes for patients with AAA, and ensuring the patient reaches a hospital with vascular specialists on site and on call/available is important.

In conjunction with clinical pathways, pre-hospital pathways may be useful to facilitate the patient’s transfer to the definitive care provider as rapidly as possible. As pathways need to be followed by paramedics assessing patients in emergency settings, the pathway needs to provide clarity for the assessor, and clearly define when it is safer for the patient to by-pass a local facility.

37 Figure 8: Pre-Hospital Pathway – an example

Hospital acute pathways

Once the patient has presented in an emergency department, the following process depicts the expected management of diagnosis, referral, transfer and management.

Pro forma pathways for specific acute vascular conditions are included in Appendix 3. These pathways should be reviewed and localised, based on the functional level of vascular services of the hospitals within the region. Once pathways have been defined, regional discussion will be required to support consistent application to ensure patients are transferred to the facility able to provide optimal clinical care as quickly as possible. Pathways should include clinically appropriate repatriation or transfer of care if the vascular provider is not the patient’s local DHB.

Recommendation 5:

Pathways for patients presenting with acute vascular conditions or trauma should be agreed within each region, in collaboration with a national clinical lead.

The pathways should reflect the vascular capability of the hospitals within the region, and should be developed in conjunction with ambulance providers, the Major Trauma Clinical Network (for vascular trauma), and vascular providers within each region.

Elective pathways

Elective pathways depend to some extent on the source of the referral. In a resource constrained environment, access to FSA and elective surgery is on the basis of clinical priority relative to that of other patients, and the DHB’s capacity to provide assessment within four months.

It is important to support and strengthen primary care, and care provided in Level 3 centres to maximise local care. Health pathways guiding diagnostic work up and referral are being used in a number of regions. Where these are not in place, support to disseminate and localise pathways will be important to ensure patients are appropriately worked up prior to referral to a Vascular centre.

Underpinning the model of care for vascular services is the promotion of equity of access, and in particular, the reduction of inequalities of access for high risk populations such as Māori and Pacific people.

Where a patient’s initial assessment occurs in a private setting, it may be more appropriate use of resource to consider the patient’s priority for direct access to the treatment list, provided the patient is prioritised using the same criteria as DHB referrals, and the patient’s assessed priority is within the DHB’s agreed threshold.

38 Referrals for FSA that meet the regional referral pathway, and access threshold would be accepted for FSA. Subsequent decisions on whether treatment is the best option also require a determination of the patient’s priority in comparison to the agreed access threshold. Elective pathways are described in Appendix 4. As with acute pathways, these may require regional localising and agreement.

Recommendation 6:

Elective pathways should be agreed within the region, to facilitate equitable access to vascular care, as close to home as is clinically appropriate.

An agreed set of prioritisation criteria for first specialist assessment and elective surgical/ endovascular treatment should be developed to support consistent and equitable access to elective care.

15. Multi-disciplinary meetings MDMs

An MDM involves a range of health professionals, from one or more organisations, coming together to deliver comprehensive patient care.

MDMs are structured, regular meetings either face-to-face or via videoconference at which health professionals with expertise in a range of different specialities discuss the options for patients’ treatment and care prospectively. Prospective treatment and care planning involves making recommendations, with an initial focus on the patient’s primary treatment. MDMs facilitate a holistic approach to the treatment and care of the patient.

Effective MDMs have positive outcomes for patients receiving the care. They are an important support for the clinicians involved in treatment planning for the provision of optimum patient care. Health professionals within this forum considering all therapeutic options achieve improved continuity of care with less duplication and better quality of outcomes. The coordination is improved with better communication between care providers and clear lines of responsibility leading to better use of time and resources.

Vascular MDMs should be implemented in all Level 5 and 6 vascular centres to support decision making and optimisation of care. MDMs should be implemented at a regional level, with participation from those involved in the patient’s care. The MDM process should be formalised to meet quality and safety requirements. In accordance with the Guidance for Implementing High Quality Multi-Disciplinary Meetings (Ministry of Health, 2012), core team members should be present for the discussion of all cases where their input is needed. The recommendation is that core members include at least four clinicians from the following disciplines: vascular surgeon, general surgeon with vascular interest, interventional radiologist and/or nurse practitioner. In addition to core team members, vascular MDMs should also include participation by vascular nurses or nurse specialists, vascular sonographers, interventional

39 MRTs, anaesthesiology and ICU where appropriate. Administrative support and coordination should also be provided.

The recommended structure and process for MDMs is described in Appendix 5.

Recommendation 7:

A formal agreed national process for conducting Vascular MDM should be documented and implemented within each Region. The process should include the following components:

terms of reference protocols for establishment and administration membership coordination referral and case presentation process, including criteria for inclusion of a case in a MDM documentation communication of MDM outcome audit and review.

16. Priorities for service development

Workforce

The vascular workforce is diverse, and involves a range of disciplines. Key areas of risk for vascular services are summarised below. HWNZ models and monitors the status of some specialist workforces, and can provide advice on current and future needs. Where there is a known or anticipated workforce vulnerability, HWNZ may be able to provide some national support for workforce planning or development by identifying the ideal number of training positions to meet future demand.

Vascular specialists

Training for general surgeons does not include vascular sub specialty training. As older generation general surgeons retire, vascular experience in regional hospitals may reduce, resulting in increased dependence upon Level 4-6 vascular centres

Interventional radiology

Historically there has been a national shortage of interventional radiologists. While this has resolved recently vigilance may be required in future

Vascular sonography

Health Workforce New Zealand (HWNZ) has reported on a critical shortage of sonographers in New Zealand (Ministry of Health, 2016). To help address this, they have included sonographers

40 in the Voluntary Bonding Scheme, administered by HWNZ. This scheme incentivises medical, nursing and midwifery graduates to work in hard-to-staff specialties or communities for three to five post graduate years.

DHB Shared Services is supporting a national Sonographer Workforce Development Programme. The programme focuses on the overall sonographer workforce, rather than individual specialty areas, such as vascular. The programme approach is to improve the overall workforce, which will then assist with improving specialised sonography services.

The Australasian Society for Ultrasound in Medicine (ASUM) has engaged with the University of Otago to promote further development within all fields of ultrasound, including Masters and PhD level qualifications.

Nursing

There is potential for a specialised integrated nursing workforce across vascular and related sub-specialties. Nursing workforce development should include nurses with vascular special interests as well as advanced clinicians such as nurse specialists and nurse practitioners

Investing in a well-resourced vascular nursing workforce improves patient access, patient flow, and enables other members of the vascular team to focus on their core expertise.

Vascular nursing services may include complex wound management, intermittent claudication clinics, coordination of multi-disciplinary diabetic foot clinics, pre-admission work-up, inpatient complex case management, post discharge follow-up, aneurysm surveillance, virtual clinics, and cardiovascular risk factor management.

Vascular nurses also contribute to service development by participating in clinical reviews, guideline development, developing patient education resources, auditing and research projects.

Diagnostic imaging

Vascular imaging is a fundamental requirement to visualise the vascular system. Access to some vascular imaging modalities can be constrained, either because of capacity/staffing or because of high demand.

Vascular sonography

Vascular sonography should be provided within either the Radiology department or within a Vascular Diagnostic Laboratory. To optimise standards the preference is that vascular ultrasound examination should be provided by a trained vascular sonography workforce. Investing in a well-supported sonography workforce will improve patient access and service, particularly in smaller centres.

Magnetic Resonance Angiography (MRA)

41 MRA is a type of Magnetic Resonance Image (MRI) scan that looks specifically at the body’s blood vessels. MRA requires specific technology and expertise, which is currently limited in New Zealand. Unlike the more traditional angiogram, MRA is less invasive, and the time required for post scan processing of data is very small.

Recommendation 8:

As part of implementing the model of care for vascular services, it is recommended that there is a local assessment of each region’s work force and technology needs. Local or regional business cases may be required to address identified gaps.

17. Reporting and monitoring of quality

Reporting and monitoring of performance and/or quality indicators is important to reduce clinical variation, and ensure quality of care is optimised. Quality indicators fall into two categories:

process and access indicators – these indicate whether services are provided in a timely and equitable manner, and whether services are patient centred outcome measures – which are a measure of health improvement or deterioration attributable to medical care (Adamson Consulting Services, 2014).

Criteria for good indicators and indicator sets should be considered in setting the national metrics. These criteria include relevance, balance, validity, data timeliness and reliability, meaning and implications.

For quality indicators to result in change, it is important that unit level results are considered by influencers of change, including the Vascular Society of New Zealand, DHB senior executives and the Ministry of Health.

Process and access indicators

In the absence of a national clinical outcomes registry for vascular services, national process and access indicators are proposed, based on activity recorded in national collections. The focus should be on quality improvement rather than performance management.

Process and access indicators are organised in two groups – existing national indicators that are currently measured or monitored (Table 3) and potential metrics that may be introduced as the new National Patient Flow (NPF) collection matures (Table 4).

Table 4: Existing process and access indicators

Impact area Indicator Data source

Timely Patients accepted for vascular first specialist assessment waiting longer NBRS

42 Impact area Indicator Data source

than four months (ESPI¹ 2) Patients accepted for vascular treatment waiting longer than four NBRS months (ESPI 5) Equitable Standardised intervention rates for vascular FSA² NNPAC Standardised intervention rates for elective vascular treatment³ NMDS Prioritisation of referrals for elective vascular surgery on a national, or NBRS nationally recognised prioritisation tool (ESPI 8) Patients waiting without a commitment of surgery whose priority is NBRS above the actual treatment threshold (ESPI 3) Patient centred Patients notified of outcome of prioritisation for FSA within 15 days or NBRS less from the date referral received (ESPI 1) Note: 1 Elective Services Patient Flow Indicators (ESPIs) are national measures of whether DHBs are meeting the required performance standard at various points of the elective patient pathway. These indicators are reported through the National Booking Reporting System (NBRS). 2 The standardised intervention rate for vascular FSA is reported against the purchase unit of S75002, and are published quarterly on the Electives restricted website Quickr. 3 The standardised intervention rate for vascular elective treatment is for a prescribed range of Vascular DRGs, and are published quarterly on the Electives restricted website Quickr. Table 5: Potential or future process and access indicators

Impact area Indicator Data source

Timely Waiting time for vascular first specialist assessment in accordance with NPF prioritised urgency (requires prioritisation tool with urgency criteria) Waiting time for vascular treatment in accordance with prioritised NPF urgency (requires prioritisation tool with urgency criteria) Time from admission to operating theatre treatment for acute vascular NMDS/NPF procedures (requires capture of time of admission and time of admission to theatre/administration of anaesthesia) Equitable Proportion of referrals for first specialist NPF on a new national prioritisation tool consistent within service and across DHBs Prioritisation of referrals for elective surgery is: NBRS/ NPF on a new national prioritisation tool consistent within service and across DHBs Patients accepted for treatment in accordance with: NPF  assigned priority  agreed access thresholds Patients accepted for FSA in accordance with: NPF  assigned priority  agreed access thresholds Patient centred Cancelled surgery (pre or post admission) NPF  number of cancellations/rebookings  within 72 hours of planned surgery Rescheduled outpatient appointments NPF  number of cancellations/rebookings  within 72 hours of planned surgery Patients notified of outcome of prioritisation for treatment within 15 days NPF

43 Impact area Indicator Data source

or less Effective Varicose vein patients treated as day case NMDS / NPF Average length of stay for inpatient vascular (acute and elective) NMDS Patients waiting for elective care who receive it acutely NBRS / NPF The number of repeat referrals for varicose veins where a referral was NPF declined Outcome indicators

Capture of consistent national clinical outcome data in New Zealand is not widespread. In areas that do focus on clinical outcome metrics it is generally acknowledged that this results in better outcomes, fewer futile interventions and lower costs.

While some other jurisdictions (eg, the United Kingdom and the United States) have some reporting on vascular service quality and outcomes, there does not appear to be a comprehensive quality/outcome package that could be adopted.

Developing a clinical outcomes package requires considerable thought, expertise and effort for meaningful results, and this needs to be undertaken within the context of the data that is currently or potentially available through the new national electronic health record or clinical data repositories.

It is recommended that the Vascular Society work with the Ministry’s Technical and Digital Services Directorate to identify opportunities for introducing national reporting of vascular quality and clinical outcome measures.

Review of vascular referral pathways

In addition to monitoring of quality through process and access indicators, or clinical outcomes, it will be important to understand the extent to which referral pathways are adopted and adhered to.

The referral pathways describe where and who should be providing vascular care in specific situations or circumstances. The intent of these pathways is to improve clinical care for patients, through reduced variation.

As part of the implementation of these pathways, understanding the current referral pathway, and how this varies to the desired pathway will inform the degree of change impact. Review of a random sample of referrals pre and post implementation will provide good insight into their effectiveness.

Recommendation 9:

Process and access indicators are reviewed as new national data collections mature to include additional indicators to monitor access to vascular services.

44 Referral pathways for a random selection of vascular procedures should be reviewed. Findings from the review should inform service and quality improvement activities.

Pathway audit should be repeated periodically to assess the effectiveness of any changes.

With the introduction of the new electronic health record, further work should be considered by the Vascular Society, in conjunction with the Ministry of Health, to identify opportunities for introducing national reporting of vascular quality and clinical outcome measures.

45 e. PART 3: Implementation Plan

18. Approach

To support the health system implementing the model of care for vascular services, the following approach is recommended. This has been broken down into three phases, each of which overlaps the others.

Planning – this step includes all aspects of project management that relate to implementation – it is proposed that the Ministry of Health will work with Regional Shared Service Agencies to develop an implementation plan for the model of care within each region. The Ministry of Health will provide some funding to support the implementation, including funding for a national clinical lead. Assessing current conditions – analysis of change readiness, and impact of introducing the change at a local level. Assessment should be a circular process, with feedback provided before, during and following implementation of the new model – the proposed accountability and governance for overseeing the implementation requires confirmation, but should include a Vascular clinical lead, and representation from GMs P&F, DHB chief operating officers, and the Ministry of Health. Introducing the change – The aim of this phase is to change current practice to follow the defined model – it is proposed that DHBs would be supported to implement the change by the regional shared service agencies, which support DHBs within their regions with work across the region.

During the change process, a number of key roles have been identified.

Champions – the people who want and strongly believe in the change. They have a valuable role engaging their peers and colleagues in understanding the reasons for the development of the new model. In addition to a national clinical lead, each region should identify a clinical champion, to work with the Regional Shared Service Agency. Agents – appointed to implement the change – the Ministry of Health is providing some funding to each Region to support assignment of a project lead Sponsor – the individual with high level responsibility and accountability for the success of a project, including implementation – it is proposed the project sponsor be nominated by the GMs P&F Targets – the people required to change, whether it be behaviour, emotional, knowledge or perceptions

The proposed implementation approach for the vascular model of care is outlined in more detail below.

46 Figure 9: Implementation approach

Source: New South Wales Agency for Clinical Innovation: Understanding the process to implement a Model of Care (Agency for Clinical Innovation, 2013)

Prior to implementation, the model of care needs to be endorsed through wider consultation. The initial step for endorsement is to present the document to the National Services Governance Group and General Managers, Planning and Funding. Once endorsed, feedback from key stakeholders should be sought, and the Model finalised and approved for implementation.

19. Implementation plan

To support the health system implementing the model of care for vascular services, the following approach is recommended. This has been broken down into three phases, each of which overlaps the others.

Planning – this step includes all aspects of project management that relate to implementation. The Ministry of Health will work with the National Clinical Lead, and with regional shared service agencies to confirm an implementation plan for the model of care within each region.

Each region would need to appoint the following:

A change agent or project manager to implement the change (estimated 0.2-0.4 FTE, with funding of $20,ooo per region to be allocated from Quality Improvement funding to support this role) A change champion or clinical lead for the project (estimated 0.1 FTE) A project sponsor or senior manager with accountability for the success of the implementation Additional resources may include business analytical or administrative support.

Assessing current conditions – analysis of change readiness, and impact of introducing the change at a local level. Assessment should be a circular process, with feedback provided before, during and following implementation of the new model.

Introducing the change – the aim of this phase is to change current practice to follow the defined model –DHBs will be supported to implement the change by the regional shared service agencies, which support DHBs within their regions with work across the region.

Process evaluation - a process evaluation to assess the extent to which the model of care has been implemented should occur one year after implementation. The Action Plan should be re- evaluated at that time to determine if any changes are warranted.

Summative evaluation - a summative evaluation of the model of care should be considered within five years, to see if the stated outcomes, particularly quality improvements, have been achieved.

47 20. Project governance

Project governance will be established to oversee the implementation of the vascular model of care. Governance will include the national clinical lead, a Ministry of Health official, and a representative of the National Network of General Managers Planning and Funding. Each region will be represented with the designated sponsor and the regional clinical champion.

Immediate priorities for implementing the service are:

confirm project funding for the national clinical lead and regional shared service agencies for project support engage a clinical leader contracting with the regional shared service agencies for project support establish governance and project teams assessing current conditions to develop a regional action plan

21. Action plan

A regional hub and spoke model has been identified for vascular services. The model is based on six levels of vascular service provider – two primary/community and four providing acute and elective hospital care.

The following action plan is based on regional teams, supported by a national clinical lead and a Ministry of Health facilitator to achieve the identified strategic objectives.

Figure 10: Strategic objectives of the model of care

Establishing the project teams

Actions Lead Timeline

The finalised model of care is endorsed for implementation by MoH June 2017 GMs Planning & Funding for implementation.

A project lead is appointed to develop a vascular services MoH July 2017 implementation plan that supports achievement of the strategies to improve the quality of vascular care

A national clinical lead is engaged MoH July 2017

48 Actions Lead Timeline

Project governance is agreed with terms of reference. The MoH Aug 2017 project governance should include:

The clinical lead Ministry of Health official Representative of the national Network of GMs P&F

From each region implementing in Phase 1:

the designated sponsor (senior DHB manager) the regional clinical champion

Contracts are in place with the Phase 1 regional shared service MoH Aug 2017 agencies

Within each Phase 1 region the individuals to fill the following Regions/ Sept 2017 roles are identified: GMs P&F Clinical champion – a vascular surgeon to lead the implementation within the region Change agent – the regional shared service agency should identify a project manager to work with their regional and national counterparts Sponsor – a senior DHB manager, nominated by the GMs P&F from the region Target/s – a vascular service provider and/or consumer from within the region

Regional action plans are developed to implement the endorsed Regions TBD actions to achieve the four strategies of the model of care.

Action plans should consider:

milestones and deliverables to achieve actions communication requirements and plan risks and issues change readiness within the region o the gap between the current state and the future requirements o any infrastructure and equipment needs o workforce shortages o technology needs

49 Actions Lead Timeline

A framework to monitor and evaluate the progress of regional Project TBD teams is established governance

50 Strategy 1: Optimise prevention and detection

Outcomes Action areas

1. Increased health literacy 2. Lifestyle advice and changes Update the vascular content of the Primary Care 3. Cardiovascular risk assessment Handbook 4. Access to diagnostics Progress development of health pathways to include vascular conditions

Consider opportunities to improve primary care access to diagnostic ultrasound and AAA screening (in line with a future national screening programme)

Actions Lead

The next review of the Primary Care Handbook includes advice on peripheral vascular disease, developed with input from the Ministry of Vascular Society and other relevant Colleges, eg, the RANZCR Health Vascular Society

Timing/priority Long term

Actions Lead

Vascular service providers work more closely with primary care to Regional develop health pathways which will enhance relationships, increase the Project Teams visibility of vascular conditions within primary care, and contribute to greater opportunity for patient involvement in managing their condition

Timing/priority During 2017/18

51 Actions Lead

Where not already in place, DHBs consider opportunities to improve Regional primary care access to vascular ultrasound, in line with the national Project Teams criteria and referral pathways Timing/priority During 2017/18

Actions Lead

Recommendations for screening of AAA that are endorsed by the NASC Ministry of should be incorporated into the National Criteria for Access to Health Community Radiology

Strategy Two: Reduce clinical variation

1. Standardised processes to improve quality and outcomes Achieve greater consistency in reporting of 2. Enhanced management through Vascular activity within National Collections best practice guidelines Regional vascular service configuration is 3. Whole of system protocols that agreed, including defined acute and elective define roles and accountabilities pathways

Process and access indicators are agreed at a national level and monitored within regions along with regular audit of pathways and outcomes

Actions Lead

Work with providers of Vascular care to amend National Collection Ministry of reporting so that:

52 Actions Lead

Inpatient vascular services, particularly where provided by a surgeon Health employed within the vascular specialty, are reported using purchase unit code S750001 – Vascular Surgery – Inpatient Services (DRG). Regional Project Teams Outpatient vascular services should be reported using one of the following valid purchase unit codes:

S75002 - Vascular Surgery Outpatient - 1st attendance S75003 - Vascular Surgery Outpatient - Subsequent attendance S00008 - Minor Operations S00011 - Surgical non-contact First Specialist Assessment - Any health specialty S00012 - Surgical non-contact Follow Up - Any health specialty MS01001 - Nurse Led Clinic

Vascular services (inpatient and outpatient) should be reported using HSC S75 – Vascular Surgery, particularly when reporting against a non- vascular purchase unit (eg, S00008).

Actions Lead

Within regions, providers of vascular services should review the Regional Project vascular requirements to determine the level of vascular service able Teams to be provided in their hospitals.

This should be considered in a regional context so that:

acute and elective service pathways are clearly defined within the Region formalised arrangements are agreed to provide services during both normal and after hours. Timing/priority During 2017/18

53 Actions Lead

Process and access indicators are reviewed as new national data Vascular Society collections mature to include additional indicators to monitor access to vascular services.

Actions Lead

Referral pathways for a random selection of vascular procedures Regional Project should be reviewed. Findings from the review should inform service Teams and quality improvement activities.

Actions Lead

Pathway audit should be repeated periodically to assess the Regional Project effectiveness of the changes. Teams

Baseline Vascular Society Ongoing Timing/priority Long term

Actions Lead

With the introduction of the new electronic health record, further Vascular Society work should be considered by the Vascular Society, in conjunction with the Ministry of Health, to identify opportunities for introducing national reporting of vascular quality and clinical outcome measures.

54 Strategy 3: Enhance the intervention pathway

1. Acute and elective care pathways ensure patients receive timely Acute and elective pathways are agreed within intervention in the most appropriate each region setting A national prioritisation tool is developed to 2. Improved patient journey through support nationally consistent access developing a standard information pack to support elective surgery decision making, and improved relative equity of access to elective care

Actions Lead

Pathways for patients presenting with acute vascular conditions or Regional Project trauma should be agreed within each region in collaboration with a Teams national clinical lead.

The pathways should reflect the vascular capability of the hospitals within the region, and should be developed in conjunction with ambulance providers, the Major Trauma Clinical Network (for vascular trauma), and vascular providers within each region.

Actions Lead

Elective pathways should be agreed within the region, to facilitate Regional Project equitable access to a vascular care, as close to home as is clinically Teams appropriate.

55 Actions Lead

An agreed set of prioritisation criteria for FSA and elective Ministry of surgical/endovascular treatment should be developed to support Health consistent and equitable access to elective care. Vascular Society

Strategy 4: Integrate services effectively

1. Patients are able to access appropriate imaging, allied health and social An MDM process is established services Workforce and technology shortages are 2. Effective linkages with other service identified so that local solutions can be providers supports patients developed

Actions Lead

A formal agreed national process for conducting vascular MDM should Regional Project be documented and implemented within each region. The process Teams should include the following components:

terms of reference protocols for establishment and administration membership coordination referral and case presentation process, including criteria for inclusion of a case in a MDM documentation communication of MDM outcome audit and review.

56 Actions Lead

As part of implementing the model of care for vascular services, it is Regional Project recommended that there is a local assessment of each region’s work Teams force and technology needs. Local or regional business cases will be required to address identified gaps.

57 f. Measuring success

The goal of the model of care for vascular services relate to improve health outcomes for people with vascular disease through improved access to well integrated, high quality services.

The effectiveness of implementation will be assessed through a process evaluation during 2018/19 related to the short term actions.

Five questions have been identified to evaluate the extent to which the recommendations for the model of care have been adopted.

1. To what extent has the model of care been implemented? 2. Which components been delivered and what is still to be achieved? 3. Is the model of care achieving the stated improvement objectives, namely does the service model: a. Optimise prevention and detection b. Reduce clinical variation c. Enhance the intervention pathway d. Integrate services effectively. 4. Can the model of care be fine-tuned to improve efficiency and effectiveness? 5. Are staff, referrers, and family and whānau satisfied with the vascular services provided? Summative evaluation

Longer term evaluation should be considered at least five years post implementation to see if the longer term actions have progressed, and whether stated outcomes, particularly quality improvements, have been achieved.

58 Appendices

Appendix 1 - Advisory group membership

Name Organisation Role

Allan Panting RACS Chair Andrew Holden Auckland DHB Interventional Radiologist Patrisio Capasso MidCentral DHB Interventional Radiologist Fiona Unac Hawke's Bay DHB Nurse Practitioner Acute Care – Radiology & Vascular Services Gerry Hill Southern DHB Vascular sonographer J S (Kes) Wickremesekera Capital & Coast Vascular Surgeon James Letts Southern DHB Interventional Radiologist Janice Donaldson South Island Alliance GM Planning & Funding delegate Justin Roake Canterbury DHB Vascular Surgeon Keith Todd Canterbury DHB Vascular Service Manager Phil Thwaite Bay of Plenty General Surgeon (with Vascular sub specialty) Rene van den Bosch South Canterbury General Surgeon (with Vascular sub specialty) Samantha Titchener Auckland Vascular Service Manager Sue Perrin (retired) Auckland Vascular Clinical Nurse Specialist Thodur Vasudevan Waikato Vascular Surgeon Tim Norman (retired) Waikato Vascular Service Manager

Supported by the Ministry of Health:

Name Role Area

Jacqui Milina Secretariat Electives & National Services Jane Potiki Facilitation Electives & National Services Anika de Mul Subject matter expertise DHB Accountability Jane Craven Subject matter expertise DHB Accountability

59 Appendix 2 – ICD10 block codes and Standardised Intervention Rate Vascular DRGs ICD10 AM Eighth Edition block codes used in Vascular

Bloc Block code description Block Block code description k code code 81 Surgical sympathectomy 761 Repair of arteriovenous fistula of abdomen 85 Reoperation for previous sympathectomy 762 Other repair procedures on vascular sites 642 Myocardial preservation 763 Reoperation procedures on other vascular sites 684 Repair of ascending thoracic aorta 764 Procedures for external arteriovenous shunt 685 Repair of aortic arch and ascending thoracic aorta 765 Procedures for surgically created arteriovenous fistula 686 Repair of descending thoracic aorta 766 Vascular access device 687 Replacement of ascending thoracic aorta 768 Transcatheter embolisation of blood vessels 688 Replacement of aortic arch and ascending thoracic 777 Other procedures on arteries and veins aorta 689 Replacement of descending thoracic aorta 812 Other procedures on lymphatic structures 693 Repair procedures on aorta 985 Laparotomy 694 Arterial catheterisation 987 Other incision procedures on abdomen, peritoneum or omentum 695 Exploration of artery 990 Repair of inguinal hernia 696 Other incision procedures on artery 992 Repair of umbilical, epigastric or linea alba hernia 697 Interruption of artery 993 Repair of incisional hernia 698 Other destruction procedures on artery 996 Repair of other abdominal wall hernia 699 Biopsy of peripheral artery 1000 Other repair procedures on abdomen, peritoneum or omentum 700 Endarterectomy 1049 Complete nephrectomy 701 Endarterectomy to prepare site for anastomosis 1050 Complete nephrectomy for transplantation 702 Arterial embolectomy or thrombectomy 1051 Complete nephrectomy for removal of transplanted kidney 703 Embolectomy or thrombectomy of an arterial 1058 Kidney transplantation bypass graft 704 Arterial atherectomy 1062 Procedures for establishment or maintenance of peritoneal dialysis 705 Resection of lesion of carotid artery 1374 Incision procedures on neck or thorax 706 Resection of recurrent lesion of carotid artery 1375 Ostectomy of rib 707 Patch graft of artery 1399 Amputation of shoulder 708 Direct closure of artery 1412 Other excision procedures on humerus or elbow 709 Repair of artery by anastomosis 1423 Incision of fascia of forearm 710 Repair of artery by interposition graft 1426 Excision procedures on forearm 711 Arterial bypass graft using vein 1440 Incision procedures on muscle, tendon or fascia of hand 712 Arterial bypass graft using synthetic material 1448 Amputation of wrist, hand or digit 713 Arterial bypass graft using composite, sequential or 1471 Revision procedures on hand or finger crossover graft 714 Repair of aneurysm of neck, intra-abdominal area or 1484 Amputation of pelvis or hip extremities 715 Replacement of aneurysm with graft 1497 Decompression fasciotomy of calf 716 Repair of aorto-enteric fistula 1505 Other excision procedures on knee or leg 718 Other repair procedures on arteries 1533 Amputation of ankle or foot

60 Bloc Block code description Block Block code description k code code 720 Other procedures on arteries 1554 Other application, insertion or removal procedures on other musculoskeletal sites 721 Application of external stent to vein 1558 Incision of fascia of other musculoskeletal sites 722 Injection of varicose veins 1559 Incision procedures on other musculoskeletal sites 723 Other application, insertion or removal procedures 1566 Excision procedures on other musculoskeletal sites on veins 724 Exploration of vein 1604 Other application, insertion or removal procedures on skin and subcutaneous tissue 726 Interruption of vein 1606 Incision and drainage of skin and subcutaneous tissue 727 Interruption of sapheno-femoral or sapheno- 1642 Other split skin graft to granulating area popliteal junction varicose veins 728 Other destruction procedures on veins 1693 Excision of arteriovenous malformation [AVM] 729 Venous thrombectomy 1694 Microsurgical repair for restoration of continuity of blood vessel of distal extremity or digit 730 Procurement of vein 1695 Microsurgical anastomosis of blood vessel 731 Patch graft of vein 1696 Microsurgical graft of blood vessel 732 Direct closure of vein 1850 Vascular pressure monitoring 733 Repair of vein by anastomosis 1851 Examination and recording of wave forms of intracranial arterial circulation 734 Repair of vein by interposition graft 1852 Examination and recording of wave forms of peripheral vessels 735 Venous bypass graft using vein or synthetic material 1886 Perfusion 736 Other repair procedures on veins 1944 Duplex ultrasound of cranial, carotid or vertebral vessels 737 Reoperation procedures on veins 1945 Duplex ultrasound of intrathoracic or intra-abdominal vessels 738 Venous catheterisation 1946 Duplex ultrasound of limb 739 Other procedures on veins 1947 Duplex ultrasound of artery or cavernosal tissue of penis 740 Examination procedures on other vascular sites 1948 Duplex ultrasound of other vessels 741 Surgical peripheral arterial or venous 1966 Spiral angiography by computerised tomography catheterisation 742 Other application, insertion or removal procedures 1989 Arteriography on other vascular sites 743 Destruction of vascular lesions 1990 Other angiography 745 Interruption of feeding vessels of arteriovenous 1991 Magnetic resonance angiography fistula 746 Other destruction procedures on vascular sites 1992 Digital subtraction angiography of head or neck 748 Excision of vascular anomaly 1993 Digital subtraction angiography of thorax 750 Excision of arteriovenous fistula of neck 1994 Digital subtraction angiography of abdomen 751 Excision of arteriovenous fistula of limb 1995 Digital subtraction angiography of upper limb 752 Excision of arteriovenous fistula of abdomen 1996 Digital subtraction angiography of lower limb 753 Other excision procedures on vascular sites 1997 Digital subtraction angiography of aorta and lower limb 754 Transluminal balloon angioplasty 1998 Other digital subtraction angiography 758 Peripheral laser angioplasty 1999 Fluoroscopy 759 Repair of arteriovenous fistula of neck 2005 Other circulatory system nuclear medicine imaging study 760 Repair of arteriovenous fistula of extremity 2015 Magnetic resonance imaging

Vascular DRG codes used in SIR reports

DRG_NZ DRG_NZ

61 B04A Extracranial Vascular Procedures W Catastrophic or Severe CC B04B Extracranial Vascular Procedures W/O Catastrophic or Severe CC F08A Major Reconstruct Vascular Procedures W/O CPB Pump W Catastrophic CC F08B Major Reconstruct Vascular Procedures W/O CPB Pump W/O Catastrophic CC F11A Amputation for Circ System Except Upper Limb and Toe W Catastrophic CC F11B Amputation for Circ System Except Upper Limb and Toe W/O Catastrophic CC F14A Vascular Procs Except Major Reconstruction W/O CPB Pump W Cat CC F14B Vascular Procs Except Major Reconstruction W/O CPB Pump W Sev CC F14C Vascular Procs Except Major Reconstruction W/O CPB Pump W/O Cat or Sev CC F20Z Vein Ligation and Stripping F65A Peripheral Vascular Disorders W Catastrophic or Severe CC F65B Peripheral Vascular Disorders W/O Catastrophic or Severe CC

62 Appendix 3 – Acute clinical referral pathways

63 64 65 Appendix 4 – Elective clinical referral pathways

Note: Subspecialist Centres provide care for organ transplantation and some complex endovascular thoracic procedures.

66 67 68 Appendix 5 – Multi-disciplinary meetings MDM Structure

There should be agreed terms of reference established to govern the MDMs. Written protocols should ideally describe the organisation and content of the meeting. The chair is appointed in line with the terms of reference for the MDMs. The chair ensures that:

members adhere to the clinical protocols and guidelines all issues relevant to each patient’s future management are presented and discussed all members participate in the meeting as appropriate to their speciality.

Other responsibilities of the chair are to summarise the discussion and formulate an agreed recommendation. MDMs should have access to a database or pro forma templates so that recommendations can be documented by the MDM coordinator during the meeting. The MDM coordinator is a core member of the MDM where there is a dedicated clerical MDM coordinator role.

A patient’s general practitioner can attend the MDM where their participation is agreed and provided for in the MDM terms of reference. Core members are present for the discussion of all cases where their input is needed.

The chair decides whether there is adequate representation at a single meeting to make sound recommendations about any or all patients. The chair will decide on the necessary action if there is inadequate representation at a single meeting. A record of who attends each MDM is kept.

A regular meeting time is set, preferably in a dedicated room that is of an appropriate size and layout. The room should be easy to for all participants to access as significant travel is a deterrent to attending MDMs.

The MDM should be supported by teleconferencing technology for hosting or participating in regional and supra-regional MDMs when required. Audio visual and videoconferencing equipment should be available to help specialist MDMs function effectively and efficiently. In this way close links can be forged between vascular providers.

MDM Coordination

A single point of coordination for MDMs to support the clinicians participating in them is recommended. It improves communication, maintains MDM standards and ensures MDMs are timely. In larger metropolitan hospitals, an MDM coordination team may be required. The MDM coordinator:

receives referrals and ensures they are complete ensures all clinical information required is documented on the proforma and/or is available for discussion

69 ensures prior radiology and pathology information is available prepares the clinical MDM agenda in advance and makes it available at the meeting records the outcomes of the MDM discussions and informs the treating clinician and/or the patient’s general practitioner enters the data set into the MDM database for clinical audit and reporting. MDM Referral and Case Presentation

Locally agreed referral pathways are established with clear information as to who can refer, how to refer and the timeframes within which referrals are expected (including locally agreed processes for late referrals). Locally agreed referral pathways are aligned with any nationally agreed referral pathways.

Each MDM has agreed criteria for the patients that should be discussed. If the MDM terms of reference allow for referring, but not formally presenting some patients, there are clear criteria for such cases. These patients are still registered via the MDM process so that relevant data are captured.

No case is discussed in the absence of the lead clinician for that case, or their delegate (who is briefed). The needs and views of patients are presented as part of the multi-disciplinary discussion where practical.

The standard treatment protocols used will align with current evidence-based care and/or best practice. Supportive care and palliative care needs are also discussed. MDM attendees confirm concordance between the clinical, imaging, and other information for each case.

The treatment recommendations agreed by the MDM participants are documented during the MDM and recorded in each patient’s electronic and/or hard copy medical record.

The meeting recommendations are not prescriptive. Each patient, in consultation with members of the treating team, will be involved in the final decisions about the treatment and care plan.

MDM Communication of Outcome

Patients are informed about the recommendations from the MDM. In consultation with members of the treating team, they make final decisions about their treatment and care plan. This consultation can be performed on outpatient basis.

The confidentiality of information that identifies the patient is respected.

Processes are in place to communicate recommendations to patients, general practitioners and clinical teams within locally agreed timeframes. The lead clinical team member who will discuss the meeting’s recommendations with the patient is identified.

MDM Audit and Review

Data sets are consistently and routinely captured so that they can be used in clinical audit and pathway monitoring for ongoing quality improvement. This activity reflects the level of clinical

70 involvement in MDM decision-making. Where data collected locally also contributes to national data sets or reporting, they are aligned with the nationally mandated data definitions and codes.

MDMs are reviewed annually for their effectiveness and performance.

71 Appendix 6 – The New Zealand Role Delineation Model (RDL) RDL Level Descriptors RDL Level Descriptor Description 1 Primary services Community based services provided by primary practitioners. May be in a rural, provincial or urban setting. 2 Community (general and General and convalescent services, sometimes in rural convalescent) services communities, providing sub-acute care and access to acute services. 3 Acute and elective specialist Specialist services providing acute and elective care to services communities. 4 More specialised services Large services with some subspecialisation. 5 Major specialised services Large services with multiple subspecialties & subspecialty support. 6 Supra specialist and definitive Most complex service of any subspecialty. Will be a provider of care services definitive care (does not transfer to another centre).

Key Determinants Hours of access The hours a service is available to receive patients is a marker of capability. The hours range from normal working hours to after hours and includes on- site & on-call cover. Clinician characteristics The model focuses primarily on the medical hierarchy. This is driven by the medical model being easily verified and having a significant correlation with complexity. Inter-specialty relationships Co-location with other specialties in addition to support services strengthens their ability to respond to increased patient complexity. Patient characteristics The characteristics of the patient, best described by neonates and gestational age. Key procedures or treatments Procedure Complexity eg, AAA. Limited use and most likely at the most complex levels to differentiate definitive care providers.

Detailed key determinants

Determinant Definition Description

Normal working hours: Monday to Hours of Access The hours a service is Friday during business hours. Not available to receive patients is a marker of capability. The required to be full time. Is often able to hours range from normal be visiting, where stated. working hours to after hours Extended: normal working hours plus and includes on-site & on-call evening and weekend cover. This may cover (Haggerty, 2008). be having cover until 10 pm weekdays and Saturday mornings. After hours: usually 10pm to 8am and weekend cover.

72 Determinant Definition Description

On-site or On-call: On-site means there is an on-site SMO or medical officer. On-call means there are rostered on-call SMO or medical officers. Rostered: means that there is a roster that designates an SMO available to provide the service. Where a roster is for a subspecialty such as neurology the form will identify where that roster must all be specialists in that area of practice, and not a generalist with a subspecialty interest It is not possible above Level 5 for a generalist roster to cover a subspecialty, eg, for general medicine to be covering cardiology A consultant or specialist must be Clinician The model focuses primarily recognised by an appropriate College for Characteristics on the medical hierarchy. This is driven by the medical that area of practice. model being easily verified The model specifies where a recognised and having a significant specialist in that specialty is required correlation with complexity. and not a generalist with a subspecialty interest. Where a “medical officer” is stated, any level of medical officer including house officer, registrar, medical officer or senior medical officers.

Inter Specialty Clinical Networks and The following information is supplied: Relationships Telemedicine: The model describes what happens where a Clinical Network is required it is within a facility and within a specified DHB. It accommodates where another provider is responsible service provision and support from a network or for a regional network the model also telemedicine service where enables that to be recognised appropriate for the capability the model specifies where a visiting, level. telemedicine or regional network is able to be recognised Co-location with other specialties in addition to telephone support from a specialist in support services strengthens another DHB or hospital is not able to be their ability to respond to recognised unless it is part of a formal increased patient complexity network or telemedicine service.

73 Determinant Definition Description

The model requires a service to have an appropriate mix of subspecialties to achieve higher levels of complexity. Where subspecialties are only available on an elective basis, the impact on increasing the level is less than if those specialties are required to have acute access

Facility assessment Facility Acute (on-call 24 hours) Elective level Level 3 L3 General Surgery, Orthopaedic, Gynaecology Level 4 L4 General Surgery, L3 Orthopaedic, Gynaecology Ophthalmology, ENT/ORL, Urology Level 5 L5 General Surgery, L4 Neurosurgery, Orthopaedic, Gynaecology Maxillofacial L4 Ophthalmology, ENT/ORL, L3 Vascular Urology Level 6 L6 General Surgery, L5 Cardiothoracic Orthopaedic, Gynaecology L5 Ophthalmology, ENT/ORL, Urology, Neurosurgery, Plastics, Vascular, Maxillofacial

Surgical complexity Surgical anaesthetic risk Low Medium High Minor Level 2 Level 2 Level 2 Intermediate Level 2 Level 3 Level 4 Complex Level 3 Level 4 Level 5

Patient complexity is determined by surgery (minor, Patient The characteristics of the intermediate, complex) and anaesthetics (low, medium, Characteristics patient, best described by high). neonates and gestational age. New Zealand has adopted the Queensland Health “Clinical Services Capability Framework v3.1) 2013. Anaesthetic and Surgical Complexity Matrix

74 DHB Assessment Tool – Vascular F.11 Vascular Surgery

Minimum Level of Support An Th Int IC CC Pa Ph Di Level Description ae ea er U/ U th ar ag s tre Ra H m Im d D ag U 1  No Planned Service ------

2  No planned Service ------ Provided by General Surgical Service Level 3. 3 3 3 - 3 3 3 3 3  Has levels of support service to at least that indicated in the ‘Minimum levels of support’ column Level 3 plus:  Outpatient consultations by vascular surgeon during normal 4 working hours. May be visiting. 4 4 4 4 4 4 4 4  Has levels of support to at least that indicated in the ‘Minimum levels of support’ column As level 4 plus:  Complex diagnostic and treatment procedures on all risk patients including an acute aortic aneurism service. 5  Vascular Surgeons rostered normal hours and on-call after hours. 5 5 5 5 5 5 4 5  Vascular Registrars or equivalent on site 24 hours.  Has levels of support service to at least that indicated in the ‘Minimum levels of support’ column. As level 4 plus:  Provides highly complex diagnostic and treatment procedures for vascular medicine in association with other specialties. 6 5 5 6 6 5 6 5 5  On site level 6 Emergency Medicine Service.  Has levels of support service to at least that indicated in the ‘Minimum levels of support’ column.

75 Appendix 7 – The New Zealand RDLs – Vascular Levels

1 Primary Services No planned hospital level Vascular services Community based services provided by primary practitioners. May be in a rural, provincial or urban setting 2 Community (General and convalescent) No planned hospital level Vascular services General and convalescent services, sometimes in rural communities, providing sub-acute care and access to acute Services services Have triage facilities & may have limited hospital facilities sufficient for minor day stay surgery

RDL Vascu Anaesthetics Theatres Interventional radiology ICU/HDU CCU Pathology Pharmacy Diagnostic imaging lar descri ption

3 Vascul Level 3: Level 3: No service Level 3: Level 3: Level 3: Level 3: Level 3: ar Supports Supports Immediate Immediate resuscitative blood and Pharmaceuticals Designated xray servic ------intermediate intermediate resuscitative management of the diagnostic supplied on facility with e surgery on surgery on management of the critically ill collecting individual bucky table provid medium risk medium risk unexpectedly prescription ed by patients, and patients and critically ill - Provides ionotropic - Appropriate - Plain xray and Pharmacy- Gener complex surgery complex surgery support trained - film processing on low risk on low risk - Identified facility in collection controlled drug capacity or al Designated area with patients patients the hospital with - staff distribution to teleradiology Surger clear admission and bedside monitoring – inpatients y - Specialist - Has a separate discharge policy may be combined with - Pathologist - General Servic anaesthetist on recovery area and ICU/HDU available - Sterile dispensing ultrasound site during a minimum of - Provides normal hours, and IV admixture service e, SMO with interest in normal hours, two operating mechanical - on site, or service available level 3 Radiographer and on-call roster theatres ventilation and coronary care rostered part of a - normal hours - Provides a specialist service available - G after hours simple invasive network of - Service provided cardiovascular laboratory outpatient extended hours e normal working monitoring and services with dispensing service n On-call hours with ionotropic support a Level 5 or - er Clinical pharmacy theatre staff for less than 24 greater hub - radiographer for al rostered on-call hours service service includes xray and su after hours drug information, ultrasound rg - SMO with interest - Range of drug monitoring, service 24 hours e in intensive care urgent tests utilisation review o rostered normal available and adverse drug n hours, or SMO during reaction supporting ro cover for individual normal hours Registered st patients by other (FBC, - er rostered specialty electrolytes, pharmacist on-site e glucose, cross normal hours d matching, o basic n coagulation,

76 RDL Vascu Anaesthetics Theatres Interventional radiology ICU/HDU CCU Pathology Pharmacy Diagnostic imaging lar descri ption

si pregnancy te testing, urine n microscopy or and gram m staining al w - Blood storage or facilities ki available on n site with g controlled h stock of 0- o negative ur blood, and s with 24 hour a on call access n d ro st er e d o n- ca ll af te r h o ur s - M e di ca l O ffi ce r or R M O o n si te

2 4 h o ur s - U p to in te r m e di at e su rg er y o n m e di u m ri sk p at ie nt s, or so m e co m pl ex su rg er y o n lo w

ri sk p at ie nt s

79 Level Level 4: Level 4: Level 4: Level 4: Level 4: Level 4: Level 4: Level 4: 3, Level 3, plus: Level 3, plus: Level 3, plus: Level 3, plus: Level 3, plus: Level 3, plus: Level 3, plus: 4 Vascular plus: - - Supports - Supports diagnostic and - Provides - Designated coronary - Range of - Non sterile - CT scanning - O surgery of all surgery for all interventional complex multi- care area tests manufacturing service, u patients except patients except procedures system life performed service normal Provides cardiology t those having those having available on site support for - on site will working hours Pharmacist on- p complex complex several days diagnostics on site also include - - Interventional Mobile image at surgery with a surgery with a and available during fine needle site normal hours - SMO Designated ICU ie high level of high level of - extended hours. Will aspirations, and on-call 24 intensifier to (radiologist/ n risk risk which excludes include stress testing, frozen hours support cardiologist) t HDU patients holter monitoring and sections theatre, CCU, Provides acute One acute available normal c - - ultrasound and bone ICU hours (may be - SMO with o pain operating marrows, visiting) interest in - Specialist cardiologist - Ultrasound n management theatre liver intensive care on site normal hours service (all s service immediately function rostered in modalities) ul available 24 tests, - Rostered normal hours supported by ta hours with on- cardiac anaesthetist sonographers ti site theatre enzymes, available on- o staff calcium, site extended - Specialist n magnesium hours and - Has on-site radiologists on s and rostered on- access to a site normal b phosphate call after hours Level 4 or hours y greater On site v - - On call after intensive care laboratory a hours may be unit services s teleradiology c operating ul extended a hours with r 24 hour on s call access u r g e o n d u ri n g n o r m al w o r ki n g h o u r

80 s ( m a y b e vi si ti n g)

Level Level 5: Level 5: Level 5: Level 5: Level 5: Level 5: Level 4: Level 5: 5 4, Level 4, plus: Level 4, plus: Level 4, plus: Level 4, plus: Level 4, plus: Level 3, plus: As above Level 4, plus: plus: - Supports surgery - Supports - Has registered - Service provides - Invasive cardiac - Range of tests - Ct scan, MRI and - C of all complexity surgery of all nurses and/or complex multi- monitoring available performed on full ultrasound o on patients with complexity on technical staff to system life support site will also service, available Has on site access to m all levels of patients with support more for an indefinite - include fine 24 hours on site pl anaesthetic risk all levels of complex patients period angiography, angioplasty, needle Access to digital ex anaesthetic risk and procedures and permanent aspirations, - Does not transfer May be sub- di - - pacemaker services frozen subtraction Has on-site Service is available ag patients for - - specialised, eg, during normal hours sections and angiography anaesthetic risk access to a level on site normal cardiovascular ICU, bone locally with a n - Specialist cardiologist os 5 or greater hours paediatric ICU marrows, formal - Anaesthetic rostered on call after ti intensive care liver function arrangement registrar or SMO - Level 4 - Specialist hours c unit tests, cardiac on site 24 hours a anaesthetics, ICU, intensivists rostered - Specialist a enzymes, day - Two acute CCU and operating normal hours and radiologists on n calcium, operating suite services on rostered on call site normal d magnesium theatres site after hours hours and on call tr and immediately 24 hours ea phosphate available 24 - Supports t hours radiological - On site m interventions where e laboratory an interventional services nt therapeutic pr operating procedure is likely extended oc to result from a e hours with 24 diagnostic hour on call d assessment ur access es o n al l ri sk p at ie nt s, in cl

81 u di n g ac ut e A A A se rv ic e - V as c ul ar su rg eo ns ro st er e d n or m al h o ur s a n d o n ca ll af te r h o ur s - V as c ul ar re

82 gi st ra rs (o r e q ui va le nt ) o n si te 2 4 h o ur s

83 Level Level 5: Level 5: Level 5, plus: Level 5, plus: Level 5: Level 5, plus: Level 5: Level 5: 5, As above As above As above. Level 4, plus: As above 6 Service is Provides Will plus: - - - immediately complex life perform - Has developed - P available 24 support which testing of a subspecialty r hours and includes services complex pharmacy o provides such as Extra technical support for a vi emergency Corporeal nature in major d procedures Membrane fields such hospital/DHB Oxygenation as providing Level 5 e - Specialist s (ECMO) and molecular or Level 6 medical staff in h mechanical diagnostics, services radiology, and ig cardiac support electron or/cardiology Sterile h microscopy - are rostered on ly , flow manufacturing site normal c cytometry and IV admixture hours and o and service including rostered on call m specialised cytotoxic drugs if after hours. pl inorganic clinical unit e chemical present in x analysis hospital d - All tests - Pharmacist on- ia able to be site extended g provided hours and on-call n urgently 24 hours o st ic a n d tr e at m e n t p r o c e d u r e s f o r v a s c u la r

84 m e d ic i n e i n a s s o ci at io n w it h o t h e r s p e ci al ti e s - O n si te le v el 6 E m e r g e n c y M e d ic i n e

85 s e r vi c e

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