Diagnostic Testing Procedures in Cardiology - the Royal Cornwall ...

Diagnostic Testing Procedures in Cardiology
V1.0
10 September 2012
Diagnostic Testing Procedures in Cardiology
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Table of Contents
1. Introduction ................................................................................................................... 3
2. Purpose of this Policy/Procedure .................................................................................. 3
3. Scope ........................................................................................................................... 3
4. Definitions / Glossary .................................................................................................... 3
5. Ownership and Responsibilities .................................................................................... 3
5.2. Role of the Managers ............................................................................................ 3
5.3. Role of the Medicine & ED Divisional Governance Management Board ............... 4
5.5. Role of Individual Staff ........................................................................................... 4
5.11. Role of Governance Leads ................................................................................ 4
6. Standards and Practice ................................................................................................ 4
6.1. Diagnostic tests provided by the service ............................................................... 4
6.3. Risk assessment of diagnostic tests ...................................................................... 4
6.7. Requesting diagnostic tests ................................................................................... 5
6.9. Patient preparation ................................................................................................ 5
6.11. Informed consent ............................................................................................... 5
6.16. How the diagnostic test is requested ................................................................. 5
6.24. How the person requesting the test is informed of test results ........................... 6
6.29. How the patient is informed of test results ......................................................... 6
6.33. Actions to be taken by a person receiving test results ....................................... 7
6.39. How the minimum requirements are recorded ................................................... 7
6.54. How the organisation monitors compliance........................................................ 8
7. Dissemination and Implementation ............................................................................... 8
8. Monitoring compliance and effectiveness ..................................................................... 8
9. Updating and Review .................................................................................................... 9
10. Equality and Diversity ................................................................................................ 9
10.2. Equality Impact Assessment .............................................................................. 9
Appendix 1. Diagnostic tests undertaken by the Cardiology Department ......................... 10
Appendix 2. Governance Information ................................................................................ 11
Appendix 3.Initial Equality Impact Assessment Screening Form ....................................... 13
Diagnostic Testing Procedures in Cardiology
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1. Introduction
1.1. This policy describes the testing procedures undertaken by the Department of
Cardiology and sets out the procedures governing their procurement, performance
and reporting.
1.2. This version supersedes any previous versions of this document.
2. Purpose of this Policy/Procedure
2.1. The purpose of this policy is to prevent avoidable harm to patients who need
cardiology tests, arising:
2.1.1. directly from the tests performed, or
2.1.2. from delays in tests being undertaken, or
2.1.3. from delays in reporting the results of tests, or
2.1.4. from delays in acting upon the results.
3. Scope
3.1. This policy applies to all those who request cardiology diagnostic tests, those
who perform them and those who receive, process or need to act on the results.
4. Definitions / Glossary
GP: General Practitioner
CVIS: Cardiovascular Imaging and Information System
PAS: Patient Administration System
RCHT: Royal Cornwall Hospitals NHS Trust
5. Ownership and Responsibilities
5.1. The strategic and operational roles responsible for the development,
management and implementation of the policy are shown below.
5.2. Role of the Managers
Line managers are responsible for:
• conducting stringent recruitment checks to ensure that only appropriately
qualified and registered staff undertake tests and authorise test results;
• checking professional registration in line with renewal requirements;
• checking staff training and competence to perform tests;
• ensuring that staff follow established processes and procedures, as described
below.
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5.3. Role of the Medicine & ED Divisional Governance Management
Board
5.4. The Medicine & ED Divisional Governance Management Board is responsible
for the development, approval and communication of this policy and monitoring
compliance with it.
5.5. Role of Individual Staff
5.6. The diagnostic pathway begins when a request is generated; it progresses via
the diagnostic testing process and ends when a report is received by the requestor
and acted upon. Various healthcare staff are involved in this pathway including
Doctors, Nurses, Healthcare Assistants/Support workers and Professions Allied to
Medicine.
5.7. Ward based administrative staff have an important role in ensuring that, for
paper based reporting systems, all results are communicated to the clinical staff in
charge of the patient.
5.8. Administrative staff in the Outpatient Booking Office also have a role to play in
ensuring diagnostic appointments are booked and appropriate preparation instigated
in accordance with agreed operating policies.
5.9. Cardiology Department staff must ensure that any paper reports are
despatched in a timely manner.
5.10. All staff members are responsible for:
• being aware of this policy and any documents referred to within it pertaining to
their part in the diagnostic pathway.
• adhering to any requirements described within this policy and documents
described in the standards and practice section pertaining to their role in the
diagnostic pathway.
5.11. Role of Governance Leads
5.12. It is the responsibility of Governance Leads to ensure that processes are in
place within specialties which ensure that every cardiology test result is acted upon.
6. Standards and Practice
6.1. Diagnostic tests provided by the service
6.2. A list of tests provided by the Cardiology Service may be found at Appendix 1.
6.3. Risk assessment of diagnostic tests
6.4. Diagnostic tests are evaluated prior to introduction (e.g. to check that they are
‘fit for purpose’, that they are within the competence of the staff who will perform
them, etc.).
6.5. As new guidelines are developed or equipment introduced, the level of risk is
reassessed.
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6.6. Responsibility for ensuring that these tasks are undertaken by suitably qualified
personnel rests with the Specialty Lead for Cardiology at the time.
6.7. Requesting diagnostic tests
6.8. Test requests fall into 4 categories:
• those ordered by consultant cardiologists or their teams (including cardiology
nurses) in respect of patients referred directly to them by General Practitioners;
• those ordered by consultant cardiologists or their teams (including cardiology
nurses) in respect of patients referred to them by other Trust clinicians;
• those ordered directly by non-cardiology Trust clinicians;
• those ordered directly by General Practitioners to inform their decisions in
primary care.
6.9. Patient preparation
6.10. Where any specific measure is required (e.g. fasting, cessation of medication),
it will be indicated in user guides/requesting information or specific information
provided for patients.
6.11. Informed consent
6.12. Patient consent is required for all cardiology testing procedures but, in most
instances, it need only be oral consent. Where the testing procedure carries a known
risk of harm to the patient, however, written consent is required. The list of tests at
Appendix 1 shows the type of consent required for each one.
6.13. In all cases, the person obtaining consent must be satisfied that the patient is
giving informed consent, i.e. that the patient has been given and understood all
relevant information about the proposed procedure.
6.14. Informed consent for a diagnostic test must either be obtained or checked by
the person performing the test.
6.15. Further information may be found in the RCHT consent policy.
6.16. How the diagnostic test is requested
6.17.Format
6.18. Tests may be requested by completion of a pre-printed form or by letter. A daily
check of all sources is made from Monday to Friday and paper copies of all referrals
are date stamped.
6.19. In the case of letters dictated following attendances at cardiology outpatient
clinics, it is recognised that avoidance of delay is contingent upon prompt
transcription. Until order communications for cardiology is in place, cardiology
clinicians are responsible for taking all necessary steps to ensure that urgent
requests are placed without delay.
6.20.Process
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6.21. For outpatient procedures, requests are e-mailed to the Cardiology Outpatient
Booking Office generic e-mail address cardiology.outpatient@rcht.cornwall.nhs.uk.
Urgent requests are coloured red to distinguish them.
6.22. For outpatient 24 hour tapes, BP monitors, event monitors, letters are copied by
e-mail to the Cardiac Physiology Department and paper copies are taken to the
Department daily. Urgent requests may be e-mailed to
mandie.leggatt@rcht.cornwall.nhs.uk.
6.23. For inpatient/daycase procedures, requests are e-mailed to the Cardiology
Inpatient Booking Office generic e-mail address
cardiology.elective@rcht.cornwall.nhs.uk. Urgent requests are coloured red to
distinguish them.
6.24. How the person requesting the test is informed of test results
6.25. In respect of tests requested by consultant cardiologists or members of their
teams, it is acknowledged that this part of the diagnostic process requires revision to
ensure that every result is communicated to the person who requests the test without
delay and in a format that flags the availability of the result and records any delay in
expert review of the result. Currently, various methodologies are employed within the
different consultant firms to facilitate timely review.
6.26. For echocardiographs ordered direct by GPs, the Cardiac Technicians send
results directly to them.
6.27. For patients referred to the Rapid Access Chest Pain Clinic, clinic nurses send
letters to GPs on the day of attendance.
6.28. In all cases, results requiring urgent action are drawn to the attention of the
requestor or, if the requestor is unavailable, to the Cardiologist of the Week.
6.29. How the patient is informed of test results
6.30. Patients must be made aware of the reason for tests being requested and the
approximate timescale and communication method for availability of the results so
that they may request an update on results as necessary. Results which have
significant implications for the patient must be discussed with them in the appropriate
timescale.
6.31. There is an expectation that patients are informed of results by the requesting
clinician in a timely fashion. It is the responsibility of the requestor to consider how,
when and what to tell the patient.
6.32. The mechanisms and timescales for informing patients of results are the
responsibility of the requesting clinician but may include, according to the nature of
the test, availability of result and the significance of the result:
• telling patients (face to face or, with the consent of the patient, by telephone);
• writing to patients;
• discussing with patients at outpatient or pre-operative assessment clinics;
• writing to the patient’s GP;
• adding to a discharge summary letter.
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6.33. Actions to be taken by a person receiving test results
6.34. The person receiving the results should ensure the results are brought to the
attention (urgently if necessary) of the clinical team currently caring for the patient.
Results should be reviewed by a person with clinical responsibility for the patient who
is able to interpret the results and ensure a management plan is recorded as
required.
6.35. A requesting consultant will take responsibility for ALL investigations requested
personally or in her/his name, but responsibility for signing off a result can be
appropriately delegated.
6.36. Requesting clinicians are responsible for reviewing urgent results requested
during their shift, and passing the responsibility on if they finish their shift. For those
tests that are requested but the patient has moved on to another area when the test
is done or the result is available, responsibility for the results passes to the clinician
responsible for the patient in that area.
6.37. It is incumbent on the responsible clinician to ensure that he or she personally
checks the reporting systems on a regular basis for the investigation results and then
acts on the information within the report with the necessary degree of urgency. If they
are unable to do this they must hand the responsibility over to a colleague. Failure to
do this may put patients at risk.
6.38. ‘Safety net’ procedures must be established by requestors, to ensure high risk
diagnoses and results are not inadvertently missed. The procedure must take
account of patients moving from area to area within a hospital and being discharged
before results are received.
6.39. How the minimum requirements are recorded
6.40.Requesting
6.41. Outpatient tests are recorded as outpatient appointments on the PAS system.
6.42. Elective day case or in-patient diagnostics to be performed in a Cardiac
Catheter Laboratory or other appropriate setting are recorded on the CVIS system
and PAS upon receipt.
6.43.Informing the clinician
6.44. At present there is no record of clinicians being informed of results other than
the printing of reports and those which are telephoned. Practices vary as to what is
recorded by the requestor and where.
6.45. Communication of test results between clinical staff who have received results
and other healthcare staff or patients must be recorded in the notes.
6.46. Informing the patient
6.47. Records are kept of any discussion or correspondence with patients or their GP
in the casenotes.
6.48.Actions taken
6.49. Actions taken are documented in the casenotes.
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6.50. When recording results within the patient’s casenotes, the minimum information
which must be included is:
• forename and surname
• NHS/Hospital number
• for unknown patients a coded identifier may be used
• test or procedure
• date and time test was performed
6.51. Interpretive comments made or conclusion reached may also be recorded.
6.52. The method of communication of the actions must be recorded, i.e. face to face
contact, phone call, letter, email, fax, etc.
6.53. Hospital discharge summaries should record confirmed diagnosis and any
outstanding investigations.
6.54. How the organisation monitors compliance
6.55.The lack of an integrated cardiology information system is not compatible
with effective, sustainable compliance monitoring. Urgent consideration is
currently being given to the development of suitable technologies and processes
to address this requirement.
7. Dissemination and Implementation
7.1. This document will be placed on the Cornwall & Isles of Scilly Health
Community Documents Library with notification to all users via email.
8. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Patients progressing through RTT pathways
Service Lead
Tool Booking Tool to be used to monitor diagnostic and Phase 2
patients
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
Booking Tool is reviewed on a weekly basis to ensure diagnostics
booked within required booking window and Phase 2 patients are
monitored on a weekly basis to ensure pathways progressing
Reported through local Performance Meeting and RTT Meeting
RTT Committee
Through local Performance Meeting and Cardiology
Specialty/Governance Meeting
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9. Updating and Review
9.1. This policy will be reviewed every two years or sooner if circumstances suggest
this may be necessary.
10. Equality and Diversity
10.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.
10.2. Equality Impact Assessment
10.3. The Initial Equality Impact Assessment Screening Form is at Appendix 2.
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Appendix 1. Diagnostic tests undertaken by the Cardiology
Department
TEST
TYPE OF CONSENT
Echocardiography (Echo)
- Transthoracic (TTE) Oral
- Transoesophageal (TOE) Written
Electrophysiology studies (EPS)
Written
Electrocardiogram (ECG) and blood pressure recording
- Standard & 12 lead ECGs Oral
- Ambulatory ECG Monitoring Oral
- Ambulatory Blood Pressure Monitoring Oral
Exercise Tolerance Testing
Tilt Testing
Implantation of ECG Recorder
Cardiac Catheterisation
Oral
Oral
Written
Written
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Appendix 2. Governance Information
Document Title
Diagnostic Testing Procedures in Cardiology
Date Issued/Approved: 18 September 2012
Date Valid From: 18 September 2012
Date Valid To: 18 September 2014
Directorate / Department responsible
(author/owner):
Sandy Webster, Performance and
Operational Manager, Division of Medicine
Contact details: 01872 253142
Brief summary of contents
Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:
Date revised:
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Name and Post Title of additional
signatories
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
Document Library Folder/Sub Folder
Links to key external standards
Related Documents:
This policy sets out an approved
documented process whereby the risks
associated with diagnostic testing
procedures in Cardiology are managed.
Diagnostic results, diagnostic reporting,
management of results
RCHT PCT CFT
Medical Director
New Document
New Document
Cardiology Governance Lead
Rowena Green
Trevor Johnston, Consultant Cardiologist &
Specialty Lead
{Original Copy Signed}
Internet & Intranet
Intranet Only
Clinical / Cardiology
NHSLA Standard 5 – Criterion 7: Diagnostic
Testing Procedures
Safer Practice Notice 16, February 2007
An Organisation-wide Policy for the
Diagnostic Testing Procedures in Cardiology
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Training Need Identified
Management of Diagnostic Testing
Procedures
No
Version Control Table
Date
10 Sept
2012
Version
No
V1.0 Initial Issue
Summary of Changes
Changes Made by
(Name and Job Title)
Helen Williams,
Service Lead,
Medicine
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
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Appendix 3.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Diagnostic Testing Procedures
Directorate and service area: Medicine & Is this a new or existing Procedure New
ED, Medicine & ED, Cardiology
Name of individual completing
Telephone:01872 253205
assessment: Helen Williams, Service
Lead
1. Policy Aim* Sets out an approved documented process whereby the
risks associated with diagnostic testing procedures are
managed through the provision of local policies which
are implemented and monitored.
2. Policy Objectives* The risks associated with diagnostic testing procedures
are minimised; compliance with Diagnostic Testing
Procedures is achieved.
3. Policy – intended To ensure that the diagnostic process contributes the
Outcomes*
maximum benefit to the treatment of patients.
4. How will you measure
the outcome
5. Who is intended to
benefit from the Policy
6a. Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around this
policy
As described in Section in the ‘Monitoring Compliance’
section of this policy.
All patients.
No.
b. If yes, have these
groups been consulted
c. Please list any groups
who have been consulted
about this procedure.
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EA guidance notes
for areas of possible impact and also the Glossary if needed.
• Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
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• Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
• Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
Negative
Impact
No
Impact
X
Reasons for decision
Disability
X
Religion or
belief
X
Gender
X
Transgender
X
Pregnancy/
Maternity
Race
X
X
Sexual
Orientation
X
Marriage / Civil
Partnership
X
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
• A negative impact and
• No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities
or improved relations - could it be
adapted so that it does How
Full statement of commitment to policy of
equal opportunities is included in the policy
Please sign and date this form.
Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean
House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trust’s web site.
Signed ________________________________________
Date _________________________________________
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