British Cardiac Society. Clinical and laboratory cardiac facilities required in the UK

Transcription

1 Page 1 of 15 British Cardiac Society Clinical and laboratory cardiac facilities required in the UK David Hackett Professional Standards & Peer Review Committee December 2004 Summary: Clinical cardiac facilities required Clinical requirements Current Per million population requirements Per million population CCU beds 9356 admissions Other inpatient beds General outpatient consulting rooms Specific consulting rooms (Eg post-mi, post-pci, etc, but excluding RACPC) Exercise ECG laboratories Echocardiography laboratories Myocardial perfusion imaging laboratories Diagnostic coronary angiography laboratories Percutaneous Coronary Intervention (PCI) labs Pacemaker implant laboratories Other device implant laboratories Cardiac electrophysiology laboratories Current Future Current Future Future requirements Per million population Future Current Future Current 1500 Future Current 450 Future 900 Current 100 ICD Future 700 ICD ICD-CRT Current Future

2 Page 2 of 15 Introduction In this document, the requirements for clinical laboratory facilities for cardiology practice in the UK have been estimated from the bottom up, based on population or cardiac network needs. It is difficult to forecast the recommended cardiac laboratory requirements of the future when there are so many rapid cardiac advances currently being introduced. More cardiac advances are expected and are likely to be introduced into clinical practice within the time frame of our estimated workforce requirements. Finally, clinical advances that are as yet clinically unknown are likely to be introduced into cardiac practice within the time frame addressed in this document. It is difficult to specify a precise future timescale for the need for cardiac clinical and laboratory facilities. But the recommended requirements estimated in this document can be used for future strategic planning over the next tenyear timescale. In this way, cardiac networks can estimate their clinical and laboratory requirements, rather than base their needs on individual institutions, or on the competency need for single institutions. For example in some areas, large secondary care hospitals may provide all secondary and some tertiary care cardiac services. On the other hand, in other regions, small secondary care hospitals may provide little specialist secondary or tertiary care cardiology, and these services might be provided by tertiary care hospitals for the local cardiac network. The cardiac laboratory requirements are for an average population need. Many of the estimates used here have been derived from the analyses used in the document Cardiac workforce requirements in the UK published by the British Cardiac Society in May 2004; please refer to this document for specific details of the methods of analyses used. These requirements should be adjusted for the local burden of cardiac disease. Where the local incidence or prevalence of cardiac illness is high, for example in Scotland and in Northern Ireland, then the cardiac laboratory requirements should be adjusted accordingly. However, where the local incidence or prevalence of cardiac illness is lower than average, for example in prosperous parts of England, it is highly debateable whether the cardiac laboratory requirements should be adjusted down accordingly. Demographic trends will, in fact, result in an increased need for cardiac procedures, and thus an increased need for clinical and laboratory cardiac requirements, in the future. The reduction in mortality of coronary heart disease leads to an increase (not a decrease) in the prevalence of cardiac morbidity and in the numbers of patients with cardiac problems. An increased ageing of the population, and the improved management of patients with cardiovascular diseases, results in a higher prevalence of cardiac disease. The prevalence of cardiac diseases will grow faster than the population grows. The cardiac laboratory requirements recommended in this document are for the provision of all cardiac services for populations or cardiac networks. Where there is substantial independent provision, from the private sector for example, then the National Health Service requirements could be reduced accordingly. With more formal training programs and competency-based assessments, more of the trainer s time will be required to train the trainees in the future. In fact, the needs of trainers in training the trainees is likely to require additional training time over and above the estimated requirements for delivering the service workload by trained, substantive clinicians. Allowances will need to be made for increased procedure times when training the trainees, and thus there will be an increase in cardiac laboratory requirements for training. If 40% of clinics or procedures involve trainees being trained, and clinic or procedure times increase by 25% as a consequence, then an overall increase in the capacity of clinic and laboratory cardiac requirements of 10% would be necessary. If routine laboratory procedures are regularly undertaken outside of regular working hours, for example in the evenings or during weekends, then the requirements for the numbers of cardiac laboratories estimated here would be reduced accordingly. If clinical laboratories were staffed with shift workers instead of a 9-5 working pattern, or a 7-day rather than 5-day working pattern, or both, and achieved more patient throughput during any 24-hour period, then the requirements for cardiac laboratories would need to be reduced accordingly.

3 Page 3 of 15 The agreed terms and conditions in the Agenda For Change policy for those non-medical staff who work in the NHS in England will result in standard rates and bands of pay, as well as standard hours of work and leave allowances. We understand that not all professional groups have agreed to the Agenda for Change policy, however. But for planning purposes, we have assumed that all nonmedical NHS staff will be working according to the Agenda for Change terms and conditions. These indicate a standard working week of 37.5 hours excluding meal breaks, and thus that each session of work would be 3.75 hours in duration. The 2003 consultant contract in England indicates that each programmed activity (PA) of consultant work time during standard working hours is 4.0 hours in duration. Thus for planning purposes, we assume that each session of clinical or laboratory activity will be 3.75 hours; but for specific consultant cardiologist activity (such as a consultant cardiologist outpatient clinic), we assume each programmed activity will be 4.0 hours. The agreed terms and conditions in the Agenda For Change policy in England indicate that for nonmedical clinicians there will be standard annual leave arrangements of days, as well as 8 days of public holidays. Standard annual leave for consultant cardiologists in the new consultant contract will be days, as well as 8 days of public holidays. Internal trust clinical governance requirements, as well as external study and professional leave, will be in addition to this. For planning purposes, we assume that non-medical clinicians will be available for weeks each year, and consultant cardiologists for weeks per year. We assume that clinical facilities will be available for use within routine working hours and days during 50 weeks per year. In this document we have not assessed the need for cardiac laboratory facilities for resting ECG recording, or for ambulatory investigations such as ambulatory ECG or blood pressure recording. We expect many of these investigations will be available and will be performed within primary care; thus it is difficult to estimate the required facilities for these needs, and these requirements are not directly relevant to the need for secondary or tertiary cardiac care facilities.

4 Page 4 of 15 CCU beds required Incidence of myocardial infarction is 4678 pmp; if it is assumed that there are twice these number of myocardial infarctions, to allow for NSTEMI / troponin positive acute coronary syndromes and arrhythmias, and other cases requiring CCU care. These numbers will include those who die before reaching hospital (perhaps 25%?), so that these totals already allow for peaks and troughs in demand. It is assumed that there is an average length of stay in CCU of 2.0 days. More beds would be required for acute chest pain observation units for the initial diagnosis of those people presenting with suspected but unproven acute coronary syndromes. CCU beds 9356 pmp x 2.0 days 51 beds pmp Cardiac inpatient beds required now Current cardiac pmp x 6.4 days Less CCU beds 9356 pmp x 2.0 days Inpatient beds required Allow 15% extra capacity for peaks & troughs 207 beds pmp -51 beds pmp 156 beds pmp 179 beds pmp Cardiology admission rates are higher in the USA (by 11-45%), but the length of stay is shorter (42-62% of that in the NHS); and thus the number of bed-days varies from 53% fewer to 13% more. It would be expected that, in the NHS in future, there will be more cardiology admissions (increased morbidity) but with shorter lengths of stay (more efficiency). If it is assumed in the future that there will be 11-45% more admissions, with 42-62% shorter length of stay: Cardiac inpatient beds required in future Future cardiac pmp x days Less CCU beds 9356 pmp x 2.0 days Inpatient beds required Allow 15% extra capacity for peaks & troughs beds pmp -51 beds pmp beds pmp beds pmp There is a current requirement for about 179 inpatient cardiac beds and 51 CCU beds per million population. In future, the range of possible numbers of inpatient beds required will be much wider than now depending on the nature of inpatient care. If there are more consultants and with the resources available to provide the most efficient 24h/7d/52w care for all inpatient cardiology, including all necessary investigations and treatments (not just for emergencies), it would be expected that the number of inpatient cardiac beds required would be at the lower end of the forecast range. It is very doubtful, however, whether the required workforce numbers and laboratory facilities will be available to provide 24h/7d/52w care so as to achieve such reductions in the length of in-patient stay and beds. On the other hand, if routine inpatient cardiology care is provided on a less-efficient 9-5 basis for 5 working days a week, then it would be expected that the number of inpatient cardiac beds required would be at the higher end of the forecast range and greater than the present requirement.

5 Page 5 of 15 General cardiac outpatient consulting rooms required now Current 75 th centile of new-patient appointments (20-30min each) Current 75 th centile of follow-up appointments (15min each) Current total outpatient requirements: Current outpatient requirements: Current outpatient requirements: If clinics undertaken for 10 sessions per week, 50 weeks per year patients pmp pa patients pmp pa patients pmp pa hours pmp pa PAs clinic rooms From , there was a 5.0% per year increase in cardiology outpatient attendances. In future, it is expected that estimated overall outpatient requirements for cardiology will increase. If these current trends continue, it is estimated that there will be a cumulative increase of at least 100% in cardiology outpatient attendances by 2010, and it would be appropriate to plan for increases of 100% 150% over this time. On the other hand, general outpatient requirements should be reduced for those patients attending at specific (non-consultant) clinics, eg: RACPC, routine post MI follow-up, patient pre-assessment before cardiac angiography and PCI, routine post PCI follow-up, RAHFC, and heart failure follow-up, etc. For planning purposes it is assumed that between one-third and two-thirds of these patients attending specific clinics would not require consultant outpatient visits. General cardiac outpatient consulting rooms required in future Future new-patient appointments Future follow-up appointments Current total outpatient requirements: Reduce by specific clinics (see below): Future outpatient requirements: Future outpatient requirements: Future outpatient requirements: If clinics undertaken for 10 sessions per week, 50 weeks per year patients pmp pa patients pmp pa patients pmp pa Less patients pmp patients pmp pa hours pmp pa PAs pmp pa clinic rooms There is a current requirement for about 5-7 general cardiac outpatient consulting rooms per million population. In future, the range of possible numbers of general cardiac outpatient consulting rooms required will be much wider than now depending on the nature of outpatient care: general versus specific clinics. Rapid Access Chest pain Clinics (RACPC) (and exercise ECG laboratories) Incidence of pmp pa* Referrals for chest pain = 2x incidence Laboratory time each referral (including Exercise ECG testing) Allow 15% extra capacity to allow for peaks & troughs & for inefficiency** If each laboratory If RACPC 10 sessions per week & used 50 weeks per year 5700 patients pmp pa patients pmp pa hours pmp pa hours pmp pa sessions pmp pa 5 7 laboratories pmp * **It is not possible to do a partial number of cases in each session (eg 3.5 cases in 3.5 hours); only whole numbers of cases can be seen and investigated.

6 Page 6 of 15 There is a requirement for 5-7 RACPC laboratories per million population. Fewer laboratories would be required: If people unable to undertake an exercise ECG were screened out before referral and were not seen in the RACPC If the first line investigation used for people with suspected angina is not exercise ECG testing, but other investigations such as stress echocardiography or stress perfusion imaging. There are additional requirements for exercise ECG laboratories; other indications for exercise ECG testing include: Functional assessment of coronary stenoses; Post PCI follow-up for restenosis; Assessment of exercise associated palpitations and arrhythmias, and chronotropic incompetence; Assessment of cardio-respiratory function (assessment of maximum aerobic capacity, heart failure, etc). These additional indications might require one additional cardio-respiratory exercise ECG laboratory per million population? There is a requirement for 5-7 RACPC laboratories per million population in the UK, a total of 6-8 exercise ECG laboratories per million population. Specific cardiology outpatient clinic rooms: Post-MI follow-up: Incidence of MI 4678 patients pmp per year 50% discharged alive 2339 patients pmp per year Clinic time 30 min 1170 hours pmp per year Allow 15% extra capacity to allow for peaks & troughs 1346 hours pmp per year If each clinic 359 sessions pmp per year If clinics 10 sessions per week, 50 weeks per year 0.7 clinic rooms Pre-assessment of patients before elective angiography and PCI Current volume of angiography (see below) Of which perhaps?50% is elective angiography Planned future volume of PCI Of which perhaps?50% will be elective PCI Total elective angiography and PCI If each If each clinic If clinics 10 sessions per week, 50 weeks per year patients pmp pa patients pmp pa patients pmp pa patients pmp pa patients pmp pa hours pmp pa sessions pmp clinic rooms Post-PCI follow-up

7 Page 7 of 15 Future incidence of PCI Less 50% of discharged MIs who had PCI & attend post MI clinic Patient follow-ups (one visit only) Clinic time 30 min Allow 15% extra capacity to allow for peaks & troughs If each clinic If clinics 10 sessions per week, 50 weeks per year pmp per year pmp per year pmp per year hours pmp per year hours pmp per year sessions pmp clinic rooms RAHFC: diagnosis of heart failure Incidence of heart failure Referrals with symptoms = 2x incidence Clinic mins excluding echo Allow 15% extra capacity to allow for peaks & troughs If each clinic If clinics 10 sessions per week, 50 weeks per year 1080 patients pmp per year 2160 patients pmp per year 1080 hours pmp per year 1242 hours pmp per year 331 sessions pmp per year 0.6 clinic rooms Heart failure follow-up in specific outpatient clinic Prevalence of heart failure patients pmp per year Clinic time required 6 min each 7484 hours pmp per year Allow 15% extra capacity to allow for peaks & troughs 8607 hours pmp per year If each clinic 2295 sessions pmp per year If clinics 10 sessions per week, 50 weeks per year 4.6 clinic rooms * At least 6 monthly : Heart failure: echocardiography laboratories required Incidence of heart failure Referrals with symptoms = 2x incidence Echo lab mins Prevalence of heart failure Echo lab time annual min Total echo lab time Allow 15% extra capacity to allow for peaks & troughs If each clinic If echo labs used for 10 sessions per week, 50 weeks per year# 1080 pmp per year 2160 pmp per year 1080 hours pmp per year pmp per year 7484 hours pmp per year 8564 hours pmp per year 9849 hours pmp per year 2626 sessions pmp per year 5 echo labs pmp Summary: Cardiology outpatient clinic rooms:* Specific clinic Post MI follow-up Assessment of patients before elective angiography and PCI Post PCI follow-up RAHFC Clinic rooms required 0.7 clinic rooms pmp clinic rooms pmp clinic rooms pmp 0.6 clinic rooms pmp

8 Page 8 of 15 Monitoring heart failure Total specific cardiology clinic rooms required General outpatient cardiology consultant clinic rooms Total all cardiology outpatient clinic rooms 4.6 clinic rooms pmp clinic rooms pmp rooms clinic rooms pmp RACPC laboratories** Total exercise ECG laboratories Echo laboratories for diagnosing & monitoring heart failure 5 7 RACPC laboratories pmp** 6 8 exercise ECG laboratories pmp 5 echo laboratories pmp *Assume clinic rooms are used 50 weeks per year; **assumes RACPC are undertaken in exercise ECG laboratories and not in separate clinic rooms. It can be seen that there is a requirement for outpatient clinic rooms per million population. If there is no further increase in the current growth of outpatient referrals to cardiology, and only onethird of those patients seen in specific clinics such as RACPCs are subsequently seen by consultants, then the need for outpatient rooms will be at the lower end of this range. On the other hand if there is a further increase in the current growth of outpatient referrals to cardiology, and two-thirds (but not all) of those patients seen in specific clinics such as RACPCs are subsequently seen by consultants, then the need for outpatient rooms will be at the higher end of this range. Finally, these estimations assume that consulting rooms will be used with extremely high efficiency, for 10 sessions each week and for 50 weeks of the year. Echocardiography laboratories The British Society of Echocardiography has estimated the need for echocardiography studies in their submission* to the British Cardiac Society Workforce Working Group in 2004: Transthoracic echo requirements: frequency* Total trans-thoracic: studies pmp min each** Less ~5000 studies performed on portable machines = studies pmp min each** Less out-of-hours use: assume one case performed per day outof-hours = 45 min per day = 5.3h per week = 1.5 sessions per week hours pa hours pa sessions pa 74 sessions pmp pa out-ofhours = sessions within working hours laboratories pmp *See evidence submitted by British Society for Echocardiography to Cardiac Workforce Working Group (2004). ** Weighted average: out-patient trans-thoracic echocardiography study = 30min, in-patient or teaching trans-thoracic echocardiography study = 45min. Refer to * for more details. Trans-oesophageal echo requirements: frequency* Trans-oesophageal: 2000 studies pmp 1.0h each Less out-of-hours use: assume one case performed per week out-ofhours = 1.0h per week = 0.3 sessions per week 2000 hours pmp pa 533 sessions pmp pa 14 sessions pmp pa out-ofhours = 519 sessions within working hours 1 laboratory pmp Stress echocardiography requirements: frequency* Stress echocardiography: 3800 studies pmp 1.5h each 5700 hours pmp pa 1520 sessions pmp pa 3 laboratories pmp

9 Page 9 of 15 Fewer echocardiography laboratories would be required: If bedside handheld echocardiography substantially replaces traditional echocardiography performed in echocardiography laboratories; If portable echocardiography machines are used in outpatient clinic consulting/examination rooms, and this practice substantially replaces traditional echocardiography performed in echocardiography laboratories. It is difficult to predict how the expected growth in demand and need for echocardiography will translate into the demand and need for formal echocardiography laboratories, as compared with the demand and need for echocardiography machines. Some of the trends might include: Screening studies on portable systems for heart failure and for heart murmurs performed in primary care settings; Screening studies performed in hospitals for murmurs arising out of preadmission clinics, and for suspected left ventricular dysfunction before major non-cardiac surgery or chemotherapy; Ultrasonic stethoscopes used in cardiac clinics; Focused studies for patient follow-up in, for example, aortic regurgitation, Marfan s syndrome, septal width in hypertension; Screening studies to assess the suitability of patients with left ventricular dysfunction & wide QRS complexes for cardiac resynchronisation treatment. Fewer stress echocardiography laboratories would be required: If myocardial stress perfusion nuclear imaging rather than stress echocardiography is used locally as the primary investigation for stress imaging studies (about 3 fewer laboratories pmp). Total echocardiography laboratory requirements* Transthoracic laboratories Trans-oesophageal laboratories Stress echocardiography laboratories Total echocardiography laboratories *Assumes laboratories are used 50 weeks per year laboratories pmp 1.0 laboratory pmp 3.0 laboratories pmp laboratories pmp Nuclear cardiology: A. Myocardial perfusion imaging laboratories NICE recommendation for myocardial perfusion scintigraphy (stress + rest) Time min each Allow for 20% inefficiency** and for peaks & troughs 4000 studies pmp pa* 3000 hours pa 3600 hours pa 960 sessions pa 2 laboratories pmp * ** It is not possible to do a partial number of cases in each programmed activity (eg 5.3 cases in 4.0 hours); only whole Fewer myocardial stress nuclear perfusion imaging laboratories would be required: If stress echocardiography rather than myocardial stress perfusion nuclear imaging is used locally as the primary investigation for stress imaging studies.

10 Page 10 of 15 B. Cardiac PET The future clinical role for cardiac PET is unclear; it could be used in future as the gold-standard for assessment of cardiac viability. It is currently difficult to predict or quantify the future routine clinical requirement for cardiac PET facilities. Diagnostic coronary angiography laboratories Current laboratory requirements for diagnostic coronary angiography: Diagnostic coronary angiography* procedures pmp pa Time 40 min each hours pmp pa Allow for 20% inefficiency** and for peaks & troughs hours pmp pa sessions pmp pa laboratories pmp *For details of how the estimated requirements for diagnostic coronary angiography have been derived, please refer to: and ** It is not possible to do a partial number of cases in each programmed activity (eg 6.4 cases in 4 hours); only whole Future trends: Current developments in multi- (64- or 128-) slice, simultaneous, fast acquisition, cardiac CT imaging with sufficient resolution might replace diagnostic (epicardial) coronary angiography within the next few years. As a result, there may be fewer isolated diagnostic coronary angiography cases required in the medium and long-term future. Until this technology becomes available, it is very difficult to quantify how many current patients undergoing diagnostic coronary angiography might have similar useful diagnostic information provided by future cardiac CT imaging. It is expected that in future there will be proportionately more diagnostic coronary angiography cases proceeding directly to percutaneous intervention (PCI) at the same time; and therefore fewer sole diagnostic coronary angiography cases. Future requirements for diagnostic coronary angiography laboratories It is very difficult to quantify with confidence or precision how many fewer sole diagnostic coronary angiograms might be required in the medium and longer-term future. The following estimates must be treated with considerable caution. But if it is assumed that: Either 50% of current sole diagnostic coronary angiography procedures become combined angiography and consideration of directly proceeding to percutaneous intervention (PCI) at the same time, = fewer sole diagnostic angiography cases pmp; Or alternatively, if most patients with acute myocardial infarction or acute coronary syndromes have urgent in-hospital angiography and consideration of directly proceeding to PCI: with a total of 4678 pmp myocardial infarctions, say 50% (= 2339 pmp) initially survive and are admitted to hospital, and say 75% of these might actually have urgent angiography and consideration of PCI (= 1750 pmp) fewer diagnostic angiography cases pmp; a very similar estimation to that above. Because of the considerable uncertainty of the future need for sole diagnostic coronary angiographic laboratories, it has been assumed that the future requirement might range from the possible future reduction indicated above to the current predicted need. Possible future laboratory requirements for diagnostic coronary angiography:

11 Page 11 of 15 Diagnostic coronary angiography* Less diagnostic cases pmp pa Time 40 min each Allow for 20% inefficiency** and for peaks & troughs procedures pmp pa procedures pmp pa hours pmp pa hours pmp pa sessions pmp pa laboratories pmp Percutaneous Coronary Interventional laboratories: current requirements In submissions to the to the British Cardiac Society Workforce Working Group in 2004, BCIS has recommended that planning for a current volume of 1500 PCI procedures pmp is now appropriate. Current laboratory requirements for percutaneous coronary intervention (PCI): Percutaneous coronary intervention 1500 cases pmp pa Time min each 2250 hours pmp pa 2700 hours pmp pa 720 sessions pmp pa Less out-of-hours use: assume one case performed per day out-of-hours 156 sessions pmp pa outof-hours = 90 min per day = 10.5h per week = 3 sessions per week = 564 sessions within working hours 1.1 laboratories pmp * It is not possible to do a partial number of cases in each programmed activity (eg 2.7 cases in 4 hours); only whole numbers of cases can have procedures performed. Other (non-device, non-electrical) cardiac interventions: Examples of these include percutaneous closure of PFO/ASD, percutaneous carotid intervention, percutaneous mitral valvuloplasties, and percutaneous septal ablation in hypertrophic cardiomyopathy, etc. If it is assumed that one extra day (equivalent to two extra sessions) per week per million population would be required for these miscellaneous procedures: Current laboratory requirements for percutaneous cardiac intervention (PCI): PCI requirements (within working hours) 564 sessions pmp pa 2 extra sessions per week pmp for miscellaneous procedures 96 sessions pmp pa Total laboratory sessions 660 sessions pmp pa 1.3 laboratories pmp Percutaneous Coronary Interventional laboratories: future requirements Best estimates for current planning for longer-term future PCI requirements in the UK should be within a range of procedures per million population (see BCS Cardiac Workforce s in the UK 2004 for derivation of the estimated numbers required).

12 Page 12 of 15 Future laboratory requirements for percutaneous coronary intervention (PCI) Percutaneous coronary intervention cases pmp pa Time min each hours pmp pa hours pmp pa sessions pmp pa Less out-of-hours use: assume = two cases performed per day outof-hours 291 sessions pmp pa out-of- = 3h per day = 21h per week = 5.6 sessions per week hours = sessions within working hours laboratories pmp Other (non-device, non-electrical) cardiac interventions: If it is assumed that one or two extra days (equivalent to two to four extra sessions) per week per million population would be required for these miscellaneous procedures: Future laboratory requirements for cardiac intervention PCI requirements (within working hours) sessions pmp pa 2-4 extra sessions per week pmp for miscellaneous procedures sessions pmp pa Total laboratory sessions sessions pmp pa laboratories pmp Summary: Current and future laboratory requirements for cardiac angiography and PCI Service Current laboratory need Future laboratory need Diagnostic angiography laboratories pmp laboratories pmp PCI + other intervention 1.3 laboratories pmp laboratories pmp Total laboratories pmp laboratories pmp Pacemaker & device implant laboratories Current planning for pacemaker implants should be for 450 new systems per million population per year (evidence submitted by British Pacing and Electrophysiology Group) Current requirements for pacemaker implant laboratories Pacemakers: 360 pmp (80%) dual 720 hours pmp pa Pacemakers: 90 pmp (20%) single 135 hours pmp pa 4% (18 cases pmp) reoperation 27 hours pmp pa 20% (90 cases pmp) generator changes 90 hours pmp pa Pacemaker 188 hours pmp pa Total pacemaker implant time 1160 hours pmp pa 1392 hours pmp pa 371 sessions pmp pa 0.7 laboratories pmp * It is not possible to do a partial number of cases in each programmed activity (eg 2.6 pacemakers in 4 hours); only whole

13 Page 13 of 15 Current requirements for ICD implant laboratories ICD implants: hours pmp pa 4% (2 cases pmp) 4 hours pmp pa 20% (10 cases pmp) generator changes 15 hours pmp pa Total ICD implant time 119 hours pmp pa 143 hours pmp pa 38 sessions pmp pa 0.1 laboratories pmp * It is not possible to do a partial number of cases in each programmed activity (eg 2.6 ICDs in 4 hours); only whole Current cardiac laboratory requirements for electro-physiology studies and ablations In 1996 in the United States of America, there were cardiac electrophysiology studies and ablations performed per million population. It would seem a sensible starting point for the estimated requirements for the current planning need for cardiac electrophysiology studies and ablations in the UK. Diagnostic & therapeutic invasive cardiac electro-physiology studies: each hours pmp pa hours pmp pa sessions pmp pa laboratories pmp * It is not possible to do a partial number of cases in each programmed activity (eg 2.6 studies in 3.5 hours); only whole Future requirements for pacemaker implant laboratories The Arrhythmia Alliance* has estimated that future planning for pacemaker implants should be for 900 devices pmp, as is currently being achieved in some countries in western Europe: Pacemakers: 720 pmp (80%) dual 1440 hours pmp pa Pacemakers: 180 pmp (20%) single 270 hours pmp pa 4% (36 cases pmp) reoperation 54 hours pmp pa 30% (270 cases pmp) generator changes 270 hours pmp pa Pacemaker 375 hours pmp pa Total pacemaker implant time 2409 hours pmp pa 2891 hours pmp pa 771 sessions pmp pa 1.5 laboratories pmp * * It is not possible to do a partial number of cases in each programmed activity (eg 2.6 pacemakers in 4 hours); only whole

14 Page 14 of 15 Future requirements for ICD implant laboratories The Arrhythmia Alliance* has estimated that future planning (for 2013) for ICD implants should be for 800 devices pmp; but 100 of these are expected to be combined ICD-CRT devices (see below): ICD implants: hours pmp pa 4% (28 cases pmp) 56 hours pmp pa 20% (140 cases pmp) generator changes 210 hours pmp pa Total ICD implant time 1666 hours pmp pa 2000 hours pmp pa If each laboratory session is 3.5 hours 571 sessions pmp pa 1.1 laboratories pmp * * It is not possible to do a partial number of cases in each programmed activity (eg 2.6 ICDs in 4 hours); only whole numbers of cases can have procedures performed. Future requirements for cardiac resynchronisation device implant laboratories Note: there is considerable uncertainty with regard to the likely future need for cardiac resynchronisation devices (biventricular pacemakers). The estimated requirements for these devices used here are approximately 10% of the incidence of heart failure. It is also uncertain how those patients that are likely to obtain the most benefit from cardiac resynchronisation treatment are predicted and identified before implantation. It is assumed that all those patients who have biventricular pacemakers implanted will also have an ICD implanted, so the future numbers of ICD implants estimated above have been reduced accordingly. Heart failure: incidence 1072 patients pmp 10% benefit from CRT implants: hours pmp pa 10% (10 cases pmp) 20 hours pmp pa 30% (30 cases pmp) generator changes 45 hours pmp pa Total CRT implant time 440 hours pmp pa 528 hours pmp pa 141 sessions pmp pa 0.3 laboratories pmp * It is not possible to do a partial number of cases in each programmed activity (eg 1.6 CRTs in 3.5 hours); only whole Future cardiac laboratory requirements for electro-physiology studies and ablation It is expected that these will be a considerable increase in cardiac electrophysiology ablation treatments, specifically for atrial fibrillation, complex ablation procedures, ablation in Adults with Congenital Heart Disease (ACHD), more ablations of ventricular tachycardia, etc. Perhaps the future need would be for double those numbers of cardiac ablations used in present planning estimates (not the numbers of actual cardiac electro-physiology ablations currently performed)? These could be very conservative estimates of future need if ablation techniques for atrial fibrillation become widespread, and their use considerably increases. Diagnostic & therapeutic invasive cardiac electro-physiology studies: each hours pmp pa hours pmp pa sessions pmp pa laboratories pmp * It is not possible to do a partial number of cases in each programmed activity (eg 2.6 studies in 3.5 hours); only whole

15 Page 15 of 15 Summary: Current and future laboratory requirements for device implants and cardiac ablations Service Current laboratory need Future laboratory need Pacemaker implants 0.7 laboratories pmp 1.5 laboratories pmp ICD implants 0.1 laboratories pmp 1.1 laboratories pmp CRT implants? 0.3 laboratories pmp Cardiac EP study + ablations laboratories pmp laboratories pmp Total laboratories pmp laboratories pmp Cross-sectional cardiac imaging requirements Cardiac CT Cardiac CT is a rapidly evolving technique. Current developments in multi- (64- or 128-) slice, simultaneous, fast acquisition, cardiac CT imaging with sufficient resolution might replace diagnostic (epicardial) coronary angiography within the next few years. Until this technology becomes available, it is very difficult to quantify how many current patients undergoing diagnostic coronary angiography might have similar useful diagnostic information provided by future cardiac CT imaging. It is difficult to quantify how many fewer diagnostic coronary angiography studies would be performed as a result in future compared with the present. It is also difficult to quantify the current requirement for cardiac CT scanners, both for current indications for scanning as well as for future use, especially before the technology and imaging procedures are more widely used. Cardiac MR Again, Cardiac MR is a rapidly evolving technique. Cardiac MR is expected to be used increasingly in the future for studies of cardiac anatomy and function, but it is not possible to precisely estimate these requirements; it is difficult to quantify the current and future requirement for cardiac MR scanners. Perhaps for an empirical estimation, the current requirements might be for one dedicated cardiac MR scanner in each tertiary cardiac centre? David Hackett Chairman, Professional Standards & Peer Review Committee British Cardiac Society December 2004