NHS GRAMPIAN, NHS ORKNEY & NHS SHETLAND …Introduction This is the first Annual Report of the Grampian, Orkney and Shetland Collaborative Abdominal Aortic Aneurysm (AAA) Screening

NHS GRAMPIAN, NHS ORKNEY & NHS

SHETLAND COLLABORATIVE

ABDOMINAL AORTIC ANEURYSM (AAA)

SCREENING PROGRAMME

ANNUAL REPORT OCTOBER 2012

TO OCTOBER 2013

Prepared by:

Mrs Alison Mundie

AAA Screening Programme Manager, Aberdeen Royal Infirmary

NHS Grampian

THE GRAMPIAN COLLABORATIVE AAA SCREENING PROGRAMME ANNUAL REPORT 2012/2013 Final Version – 27 March 2015 Page 2 of 12

Executive Summary A national ‘Abdominal Aortic Aneurysm (AAA) Screening Programme’ was launched in Scotland in 2012. In the northeast of Scotland AAA-screening involves collaboration across NHS Grampian, NHS Orkney and NHS Shetland. Rollout within the collaborative commenced as a phased process across 11 sites in October 2012, with NHS Grampian being the third Health Board to begin screening in Scotland. Across the Collaborative AAA-screening is undertaken in urban, rural and island communities. The screening sites include the major mainland hospitals, community hospitals and island hospitals. AAA screening is undertaken by trained NHS nurses in Grampian/Orkney and by a Trainee Sonographer/Radiographer and Advanced Practitioner (Reporting Sonographer) in Shetland. Within the AAA-screening programme all men aged 65 are invited by postal invitation for an abdominal ultrasound scan to identify the presence of an AAA. Men with a normal abdominal aortic diameter (<3.0 cms) are discharged from the programme; men with a diameter between 3.0 to 5.4 cms are offered surveillance within the programme: and men with a diameter >= 5.5 cms are referred to the Vascular Surgery Unit at Aberdeen Royal Infirmary (ARI) for assessment (with a view to undergoing open repair or endovascular aneurysm repair, EVAR). Men over the age of 65 years, who have not previously been screened, are also able to self-refer themselves for AAA-screening. During the first year of AAA-screening across the Grampian-Orkney-Shetland Collaborative 6,021 men were offered screening and 87 men with AAA were identified (prevalence 1.4 per 1,000 men screened). Failure to measure aortic diameter was uncommon (1.3 per 1,000 men at first assessment). No adverse clinical incidents occurred during the first year of AAA-screening. Across the collaborative uptake among invited men was 88% (Grampian 89%; Orkney 82% and Shetland 84%). Only 218 self-referring men (aged > 65 years) were screened and these comprised 3.6% (218/6,021) of all men offered screening. In Grampian uptake was highest (91%) in the most affluent quintile and lowest (84%) in the most deprived quintile based on the Scottish Index of Multiple Deprivation (SIMD). Uptake of AAA-screening was highest among men living in small towns and rural areas; and lowest in men living in urban areas. Overall 78 men entered surveillance and 9 men were referred to vascular surgery at ARI. Of the 9 men referred to ARI, 8 (89%) were considered suitable for surgery. All 8 men survived surgery (4 open repair and 4 EVAR) and there were no deaths in the 30-days following surgery. Among these referrals 6/9 (67%) men received specialist assessment within 10 working days and 6/8 (75%) of those suitable for surgery were operated on within 40 working days. The ‘NHS Grampian-Orkney-Shetland’ Collaborative AAA-screening has achieved a high level of uptake (88%) during its first year of operation. The prevalence of AAA in the community (1.4%) is lower than anticipated (this has also been observed elsewhere and attributed to the sustained decline in the prevalence of smoking among men). In the next 12-months an assessment of the repeatability of aortic diameter measurements is being undertaken and a participant survey piloted. In order to offer participants a choice of suitable locations for AAA-screening the collaborative continues to monitor attendance and uptake rates across the multiple screening sites Data describing the ‘influence of rurality, deprivation and distance‐from‐clinic on the uptake by men of

abdominal aortic aneurysm screening in Grampian’ was presented at the Scottish Faculty of Public Health Conference in Dunblane, Scotland (7 November 2013): http://www.fphscotconf.co.uk/uploads/FPH%202014%20Session%20D/alison_mundie.pdf

http://www.fphscotconf.co.uk/uploads/FPH%202014%20Session%20D/alison_mundie.pdf


Programme Contacts

NHS Grampian Collaborative Programme Manager: Mrs Alison Mundie Room 4.34, Ashgrove House Aberdeen Royal Infirmary Foresterhill Aberdeen Tel: 01224 553905 or 550825 Email: [email protected]

NHS Grampian Collaborative Clerical Assistant: Miss Mhairi King Room 4.35, Ashgrove House Aberdeen Royal Infirmary Foresterhill Aberdeen Tel: 01224 553905

Key Personnel

NHS Grampian Programme Co-ordinator: Dr Mike Crilly Senior Lecturer in Clinical Epidemiology University of Aberdeen Medical School

NHS Grampian Collaborative Clinical Lead: Mr Paul Bachoo Vascular Clinical Lead and Consultant Vascular Surgeon Aberdeen Royal Infirmary

NHS Shetland Programme Co-ordinator: Dr Susan Laidlaw Consultant in Public Health Medicine Gilbert Bain Hospital, Lerwick

NHS Orkney Programme Co-ordinator: Dr Kenneth Black Consultant in Public Health Medicine Balfour Hospital, Kirkwall

NHS Grampian & NHS Orkney Lead Sonographer: Mrs Linda Sleigh Vascular Scientist Aberdeen Royal Infirmary

NHS Grampian & NHS Orkney Screening Nurses Mrs Penny Bruce Mrs Fiona Colvin Ms Wendy Geddes Miss Hazel Smart All based at Aberdeen Royal Infirmary

NHS Shetland Lead Sonographer: Lucy Wilson Radiographer/Sonographer Gilbert Bain Hospital, Lerwick

NHS Shetland Sonographers: Lucy Wilson Inga Tulloch Both based at Gilbert Bain Hospital, Lerwick

Introduction This is the first Annual Report of the Grampian, Orkney and Shetland Collaborative Abdominal Aortic Aneurysm (AAA) Screening Programme which includes the 2012/13 screening population cohort. It should be noted that the Key Performance Indicators (KPI’s) referred to throughout this report are not officially in operation although we have benchmarked our figures against the anticipated KPI’s. The Grampian, Orkney and Shetland Collaborative were the third Board to launch the Programme in Scotland, on 25 October 2012. Using a phased approach the Grampian, Orkney and Shetland Collaborative completed the roll out of the Programme in May 2013. The National AAA Screening Programme commenced roll-out across Scotland in June 2012 and reached full national roll out in August 2013. The aim of the programme is to detect AAA’s early and monitor or treat them. This greatly reduces the chance of an aneurysm rupturing and causing serious problems. AAA (aortic diameter > 3 cm) is a relatively unknown condition across the general population. Aneurysms are commonest in men, and are associated with smoking, high cholesterol and high blood

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pressure. AAA’s are often asymptomatic and the first sign of any problem will be when they rupture, which is often fatal. An invitation to attend for screening is sent to all men aged 65 and men aged 66 and over can self-refer. A scan will be taken using a portable ultrasound machine to measure the diameter of the aorta, the results of which are available to the participant at the point of testing. Depending on the result will dictate the pathway to be followed.

Screening Outcomes

Based on the results of the participants abdominal ultrasound scan they follow the appropriate pathway:

Normal - Men with an AAA < 2.9 cm A normal result means that the aorta is not enlarged and there is no aneurysm. Men with a normal result are discharged from the Programme with no further recall as no treatment or monitoring is required. No further invites will be sent to the participant. The GP is not informed of the result.

Small Aneurysm - Men with a small AAA > 3.0 cm - < 4.4 cm If a small aneurysm is found participants are monitored by the Programme and invited to return for a yearly surveillance scan.

Medium Aneurysm - Men with a medium AAA > 4.5 cm to < 5.4 cm If a medium aneurysm is found participants are monitored by the Programme and invited to return for a quarterly surveillance scan.

Large Aneurysm - Men with a large AAA > 5.5 cm If a large aneurysm is found participants are referred to Vascular Services for rapid surgical assessment and discussion of treatment options at Aberdeen Royal Infirmary. Detected early a large aneurysm may be repaired by elective surgery with lower associated mortality.

Screening Locations The sites within Grampian used by the Programme during the year 2012/13 included:

Hospitals: Aberdeen Royal Infirmary, Woodend (Aberdeen) and Dr Gray’s (Elgin)

Community Hospitals: Aboyne, Chalmers (Banff), Jubilee (Huntly), Leanchoil (Forres), Kincardine (Stonehaven), Peterhead


Programme Performance Activity/Uptake

1. Invitation and Attendance

National Screening Programme Key Performance Indicators for Invitation and Attendance

Patient Journey

Topic Quality Measure Essential and Desirable Criteria

1. Invitation and Attendance

CORE Completeness of offer Acceptance of Offer Core Uptake

1.1 % of eligible population who are sent an initial offer to screening

90% E 100% D

1.2 % of subjects offered screening who are tested. Statistics to be broken down by Scottish Index of Multiple Deprivation (SIMD).

1.3 % of subjects offered screening who are tested 70% E 85% D

1.4 % of subjects who attend for surveillance (quarterly and yearly data)

90% E 100% D

Core Completeness of Offer – 1.1

NHS Board Initial Allocation

Eligible Participants added since “go live”

Total Allocation

Self Referrals

Total Offered Screening

Overall Percentage Offered

Collaborative (all 3 Boards)

4222 4441 8663 218 6021 69.5% (6021/8663)

Grampian 3853 4064 7917 199 5645 71.3% (5645/7917)

Orkney 186 178 364 14 205 56.3% (205/364)

Shetland 183 199 382 5 171 44.8% (171/382)

Due to the large number of eligible participants within the initial allocation all three Boards within the collaborative found that demand exceeded their available capacity. This continues to be a challenge for all Boards but will be monitored closely. We would envisage that this KPI will be met for the next Annual Report (2013/14) of the Collaboratives second year of screening.

Acceptance of Offer – 1.2 (NHS Grampian – Uptake by Deprivation)

We took all the Grampian men invited for screening and analysed uptake by their SIMD (Scottish Index of Multiple Deprivation) scores into 5 quintiles with the 1

st quintile being the most

affluent and the 5th quintile being the

most deprived. The chart indicates that our most deprived areas have the lowest uptake (84%), with the two most affluent quintiles showing very similar uptakes (91%).

Core Uptake (Initial) – 1.3

NHS Board Total Offered Screening

Acceptance of Offer Overall Percentage Uptake

Collaborative (all 3 Boards) 6021 5315 88.3% (5315/6021)

Grampian 5645 5002 88.6% (5002/5645)

Orkney 205 169 82.4% (169/205)

Shetland 171 144 84.2% (144/17)


Number of NHS Grampian Participants Invited/Number of Participants Screened Per Screening Location

Number of NHS Orkney and Shetland Participants Invited/Number of Participants Screened

Uptake in relation to residence in urban/rural areas and the distance from the screening clinic

What is surprising with this chart is that it demonstrates that for the first year of the Programme, Aberdeen, which is our largest urban area, with our participants having the least amount of travelling to do (2 to 2.9 miles), has the lowest uptake rates.

NHS Grampian Data – no data available for Orkney and Shetland

No. Invited

Screened after

invite % Uptake

Aberdeen 2115 1847 87%

Jubilee Hospital 812 738 91%

Chalmers Hospital 704 648 92%

Peterhead Hospital 694 601 87%

Leanchoil Hospital 528 454 86%

Aboyne Hospital 329 283 86%

Kincardine Hospital 307 295 96%

Dr Grays 156 136 87%

5645 5002 89%

0

50

100

150

200

250

Orkney Shetland

Orkney & Shetland

No. Invited Screened after invite

No. Invited

Screened after

invite

Did Not

Attend % uptake

Orkney 205 169 36 82.40%

Shetland 171 144 27 84.20%

80%

85%

90%

95%

100%

< 1 mile 1.0 to 1.9 2.0 to 4.9 5.0 to 9.9 10.0 to 14.9 ≥ 15 miles

Up

tak

e o

f A

AA

sc

ree

nin

g (

%)

Distance from home to screening clinic in miles

Small Town

Rural

Urban


Core Uptake (Surveillance) – 1.4

NHS Board Total Offered Surveillance Screening

Acceptance of Offer Overall Percentage Uptake

Collaborative (all 3 Boards) 3 3 100% (3/3)

Grampian 3 3 100% (3/3)

Orkney 0 0 100% (0/0)

Shetland 0 0 100% (0/0

1 Participant from Grampian moved out with Scotland during the year so unable to offer surveillance screening appointment.

Detected Aneurysms

Size

NHS Board Number of Aneurysms Detected

Detection Rate

Large Medium Small Referred to Vascular (%)


87 1.64% (87/5315)

9 3 75 10.4% (9/87)

Grampian 82 1.7% (82/5002)

8 3 71 9.8% (8/82)

Orkney 2 1.2% (2/169) 1 0 1 50% (1/2)

Shetland 3 2.1% (3/144) 0 0 3 0% (0/3)

NHS Grampian Detected Aneurysms by Screening Location

NHS Grampian Detected Aneurysms by Eligible Cohort/Self Referral

Screened

after invite

AAA's

Detected

Aberdeen 1847 44

Jubilee Hospital 738 10

Chalmers Hospital 648 7

Peterhead Hospital 601 6

Leanchoil Hospital 454 5

Aboyne Hospital 283 4

Kincardine Hospital 295 3

Dr Grays 136 3

5002 82

Aberdeen, 44

Jubilee Hospital, 10

Chalmers Hospital, 7

Peterhead Hospital, 6

Leanchoil Hospital, 5

Aboyne Hospital, 4

Kincardine Hospital, 3 Dr Grays, 3

AAA's Detected

67

3

5

4

3

0 10 20 30 40 50 60 70 80

Surveillance 12 months

Surveillance 3 months

Referred to Vascular

Eligible Cohort Self Referrals

Eligible

Cohort

Self

Referrals

Surveillance 12 months 67 4

Surveillance 3 months 3 0

Referred to Vascular 5 3

75 7


Clinical Governance

2. Minimising Harm - Quality of Scan/Images

National Screening Programme Key Performance Indicators for Minimising Harm

Patient

Journey

Topic Quality Measure Essential and

Desirable Criteria

2. Minimising

Harm

Quality of

scan/images/samples/testing

technique

2.1 % of screening encounters where

aorta could not be visualised

<3% E

< 1% D

2.2 % accurate calliper placement,

determined by review of static image

<96% E

<99% D

% of screening encounters where aorta could not be visualised) – 2.1

Number of participants screened (Grampian, Orkney &

Shetland)

Non visualisation at

first scan

% Performance Non visualisation at

return scan

% Performance

5315 7 0.13% (7/5315) 0 0% (0/5315)

Results - % calliper placement, determined by review of static image – 2.2 Total

QA’d Total

Failures QA

Anatomy QA

Angle QA

Calliper QA

Image Quality

% Failures that are Calliper


509 62 2 45 2 13 2.55% (13/509)

Grampian 460 62 2 45 2 13 3.23% (13/460)

Orkney 30 0 0 0 0 0 0.00

Shetland 19 0 0 0 0 0 0.00

The AAA screening programme went live at the end of October 2012 with 4 Screening Nurses being recruited for ultrasound training. As trained nurses they already had ample skills which would be utilised as AAA Screening Nurses.

Prior to commencing clinics in the community the 4 nurse screeners attended the Vascular Lab at Aberdeen Royal Infirmary for training. During the first few weeks the Lead Sonographer and a Clinical Vascular Scientist attended the Clinics with the Screening nurses and gradually by January 2013 the nurses were able to carry out these clinics without assistance from the Sonographers. The Screening Nurses use each other for support alongside the Lead Sonographer and the Clinical Vascular Scientist.

During the year all 4 Screening Nurses attended the “Focused Ultrasound Course in AAA Screening - University based component of the AAA Programme” at Glasgow Caledonian University and over the year the Screening Nurses gathered their evidence of 100 images for their portfolio requirements as part of the accreditation process. The Screening Nurses were also required to be assessed on their knowledge and practical abilities. This involved both practical appraisals and discussions on theory by the Lead Sonographer during clinics. Assessments in the workplace took place which had to reach a required standard in order to move to the next assessment. Reflective pieces from the Screening Nurses and the Lead Sonographer were written up and discussed. All four Screening Nurses are working towards their accreditation.

Quality Assurance is carried out by the Lead Sonographer. All QA images are assessed and checked for various aspects of their measurements. The images can be passed or failed and a recommendation placed for further scanning. Incidental findings are also sent to the Lead Sonographer. These are discussed with Mr Paul Bachoo, Clinical Lead.


Results

3. Timely availability of results

National Screening Programme Key Performance Indicators for Results

Patient Journey


3. Results Timely availability of results

3.1 % results communicated on the same day 97% E 99% D

All results are given verbally to participants at the time of their appointment with a written letter being sent to them within a couple of days of their appointment. Consequently timely availability of results is 100% across the Collaborative.

Referrals to Vascular Services - Outcomes

There were 9 aneurysms >5.5 cm found across the Grampian, Orkney and Shetland Collaborative (8 from Grampian and 1 from Orkney) during the first year of the Programme which resulted in a referral to Vascular Services at Aberdeen Royal Infirmary.

Grampian Collaborative Detected Large Aneurysms by Screening Location

Screening Location Number of Aneurysms Detected

Balfour Hospital, Orkney 1

Chalmers Hospital, Banff 1

Jubilee Hospital, Huntly 1

Leanchoil Hospital, Forres 1

Peterhead Community Hospital, Peterhead 1

Woodend Hospital, Aberdeen 4

4. Referral for assessment/treatment

National Screening Programme Key Performance Indicators for Referral to Vascular Services Patient Journey


4. Referral for assessment/ treatment

CORE Timely treatment/intervention by specialist, measures from first positive scan/referral

4.1 % of subjects with AAA > 5.5cm seen by vascular specialist within ten working days of referral

75% E 95% D

4.2 %of subjects with AAA > 5.5cm deemed appropriate for intervention/operated on by vascular specialist within forty working days of referral

60% E 80% D

% seen by vascular specialist within 10 days – 4.1 Total %

Yes 66.6% (6/9)

No 33.3% (3/9)

Grand total 100% (9/9)

Of the 6(66.6%) men who were seen within 10 working days, 2(22.2%) were admitted on the same day/next day to Vascular Services, one man was already known to Vascular Services, 2(22.2%) were seen at an Out Patient Clinic by a Vascular Consultant and one had their tests carried out prior to being seen by a Consultant.

Of the 3(33.3%) men who were not seen within 10 working days, 2 were seen at an Out Patient Clinic by a Vascular Consultant at 15 days and 45 days after date of referral. One commenced their tests 16 days after date of referral, prior to being seen by a Vascular Consultant.


Intervention/operated on within 40 working days of referral – 4.2 Total %

Yes 75% (6/8)

No 25% (2/8)

Not appropriate for surgery 1

Grand total – appropriate for surgery 8

Nine ‘large’ aneurysms were detected in the first year of screening, although one man was already known by vascular surgery to have an aneurysm that was unsuitable for surgery. Of the remaining eight men, 5/8 (63%) was sent at the Out Patient Department for assessment within 10 days and 6/8 (75%) underwent surgery within 40 days.

Six of the eight men (75%) appropriate for surgery were operated on within 40 days. Of the two men (who were deemed appropriate for surgery) who were not operated on within 40 days of referral, one was operated on within 57 days and the other was operated on within 58 days

Time to assessment/surgery among the eight men suitable for surgery was correlated with the size of the aneurysm and some ~40% of the variability in the time to assessment/surgery was attributable to aortic size (the major factor which predicts the risk of future rupture). In relation to time to surgery, a 1cm increase higher aortic diameter was on average associated with a 9 day reduction in the time to surgery.

The progress of men through the local referral pathway has been reviewed to ensure smooth transition from detection to assessment/surgery. We continue to monitor the time to assessment/surgery of men with a detected AAA and have reviewed the local referral pathway to ensure that inappropriate delays are avoided.

Time (in days) from referral to Vascular Assessment and time (in days) from referral to surgery correlated with the size of the aortic size

5. Outcome

National Screening Programme Key Performance Indicators for Outcomes

Patient Journey


5. Outcome CORE Post-operative mortality (assessed annually over most recent 100 cases submitted by vascular network)

5.1 30-day mortality rate following open elective AAA surgery

<5% E < 3.5% D

5.2 30-day mortality rate following EVAR intervention

<4% E <2% D


Of the eight men undergoing surgery 4(50%) had open surgery and 4(50%) Endovascular Aneurysm Repair (EVAR). There were no deaths.

30 day mortality rate following open elective AAA surgery – 5.1 Total %

Survived more than 30 days post surgery 100% (4/4)

Did not survive more than 30 days post surgery 0% (0/4)

30 day mortality rate (open surgery) 0% (4/0)

30 day mortality rate following EVAR elective AAA surgery – 5.2

Total

Survived more than 30 days post surgery 100% (4/4)

Did not survive more than 30 days post surgery 0% (0/4)

30 day mortality rate (EVAR surgery) 0% (4/0)

Incidents

All incidents are reported using the electronic data base DATIX system and then investigated. Lessons learned are shared with the Team, with relevant changes being made to improve practice.

During our first year there were no clinical incidents reported. Only a small number of non clinical minor incidents were reported, with the exception of the incident involving another Board accidentally populating an active clinic within NHS Grampian. Nine participants were affected by this and were contacted by NHS Grampian. The majority of other incidents reported were due to equipment/IT failure which is being monitored and reported to the National Programme when appropriate.

Type of Incident Details Number Reported

Total Reported

Clinical 0 0

Non Clinical 12

Equipment Failure Ultrasound failure 4

System Failure (admin) Appointment letters were not sent from central office 2

IT Failure Failure to transfer from ultrasound to scanner 3

Incidents affecting participants Participant scanned under the wrong details 1

Participant attended his appt but nurses could not find him, possibly sitting in wrong waiting area

1

Other Board thought they were working in the Training Module but were in active system, populated what they thought was an imaginary Clinic for NHS Grampian but was, in fact, an active Clinic, resulting in us having to contact participants to advise that their appointment details were inaccurate.

1

Grand Total 12

Future Developments The Grampian, Orkney and Shetland Collaborative is at the early development stages and in the coming year (2013/14) the objectives for the Programme include:

o Continued regular meetings with the Programme Manager, Programme Co-ordinator, Lead Sonographer and Clinical Lead to monitor and discuss programme performance using National Key Performance Indicators as a bench marking tool.

o Monitor capacity/demand of the eligible participants to meet KPI’s.


o Continued monitoring of the screening locations attendance rates. o Undertaking a “Repeatability study” to assess/confirm that the nurses are obtaining comparable

AA diameter measurements. o Developing a “Participant Questionnaire” to assess participant’s experiences with the AAA

Screening Programme. o Continue to offer participants a choice of suitable locations for screening to maintain high uptake. o The Programme is at the initial stages of developing Nurse Led Out Patient Clinics for our

surveillance participants (“enhanced surveillance clinics”)

o Ensure the competencies of the screening nurses are in accordance with National standards through a programme of mentoring and continuing professional development.

o Present initial findings for Programme at National Public Health Faculty Conference in November

2013, CPD Meeting for NHS Grampian’s Public Health Department in February 2014 and Scottish Vascular Group Meeting in March 2014.

Acknowledgements A special thank you must be made to all those who have worked so hard to set up the Programme to ensure that the objective of screening its initial allocation of eligible participants has been achieved. In particular Linda Sleigh, Lead Sonographer, Anna Colledge, Clinical Vascular Scientist, the Screening Nurses and Sonographers in Shetland who have all played a key role in successfully implementing the Screening Programme throughout the collaborative. In addition thanks to Dr Mike Crilly, AAA Co-ordinator, Paul Bachoo, Clinical Lead and Fred Nimmo, Statistical Information Officer, all NHS Grampian, for their contributions to the development of this report.

Documents

NHS GRAMPIAN, NHS ORKNEY & NHS SHETLAND …Introduction This is the first Annual Report of the Grampian, Orkney and Shetland Collaborative Abdominal Aortic Aneurysm (AAA) Screening