Q4 Which CCG area/s does the service cover? - please select all that apply

Transcription

1 Q4 Which CCG area/s does the service cover? - please select all that apply Answered: 31 Skipped: 0 NHS Airedale, Wharfedale and Craven CCG NHS Barnsley CCG NHS Bassetlaw CCG NHS Bradford City CCG NHS Bradford Districts CCG NHS Calderdale CCG NHS Doncaster CCG NHS East Riding of Yorkshire CCG NHS Greater Huddersfield CCG NHS Hambleton Richmondshire and Whitby CCG NHS Harrogate and Rural District CCG NHS Hull CCG NHS Leeds North CCG NHS Leeds South and East CCG NHS Leeds West CCG NHS North East Lincolnshire CCG NHS North Kirklees CCG NHS North Lincolnshire CCG NHS Rotherham CCG NHS Scarborough and Ryedale CCG NHS Sheffield CCG NHS Vale of York CCG NHS Wakefield CCG Other (please specify) 10% 3 10% 3 0% 0 10% 3 10% 3 0% 0 Total Respondents: 31 # Other (please specify) Date There are no responses. 1 / 15

2 Q5 Do you currently perform ECG on 100% of patients as standard practice prior to prescribing AChEIs? Answered: 31 Skipped: 0 Yes 45% (14) No 55% (17) Yes No 45% 14 55% 17 Total 31 2 / 15

3 Q6 What criteria do you use to determine the need for an ECG prior to starting on AChEI's? Answered: 17 Skipped: 14 # Date 1 History of SVT, cardiac arrhythmias, bradycardia. History of 2 or more cardiac risk factors. Pulse below 50 bpm. Pulse below 60 bom with symptoms. 12/8/ :08 PM 2 Pulse below 60 bpm New arrythmia History of significant cardiovascular disease 12/3/ :26 PM 3 previous heart issues any anomaly on vitals such as pulse or BP Hear vascular problems 12/3/ :19 PM 4 i refer to the guidance in Rowland et al (2007) from Advances in Psychiatric treatment- 11/27/2015 4:29 PM 5 Compliance with the procedure. 11/27/ :06 AM 6 Pre-existing IHD affecting rhythm of heart rate (i.e. heart blocks/af) Known history of multiple syncope attacks Heart Failure with Dyspnoea. Bradycardia on Examination+ Irregularly irregular pulse on examination, Less than 60 beats/min 7 Look at Past Medical History Medication Check Pulse - If bradycardia and symptomatic, will have ECG, however, many GP's refer into memory service with ECG on record. 11/27/2015 9:54 AM 11/27/2015 8:29 AM 8 1. Brady cardia or arrhythmia in the pulse recording. 2. History of supraventricular arrhythmia - not on pacemaker 11/26/2015 1:02 PM 9 Lowered pulse rate, episodes of dizziness and syncope, family history of heart problems, any patient cardiac history 11/17/2015 9:58 AM 10 Pulse less than 60beats/minute 11/16/2015 4:39 PM 11 Individual practice of consultant psychiatrist dependnet on whether concerns about cardiac function have been raised. 12 -history of syncope or blackouts -history of heart disease -slow/irregular pulse -abnormalities on past ecg's (we can access the ecg's done at the general hospital with a shared computer system) 11/16/2015 2:42 PM 11/14/2015 6:07 PM 13 Pulse rate less than 60. History of superventricular bradycardia or unexplained syncope. 11/10/ :42 PM 14 Bradycardia 11/10/2015 8:47 AM 15 Bradycardia (bp <55 with no pharmacological cause e.g. Beta blockers). Recent cardiovascular event and no ECG 11/9/2015 2:23 PM 16 If they have significant cardiac issues ( or family history) If baseline pulse/ BP is not normal 11/9/2015 2:12 PM 17 Having a routine ECG is part of Dementia Assessment protocol. Aim for 100% but for some patients impossible to get an ECG for a variety of practical reasons associated with dealing with an elderly cognitively impaired population. If no cardiac history and no bradycardia I will occasionally prescribe without ECG based on risk benefit analysis which is documented. 11/9/2015 1:58 PM 3 / 15

4 Q7 For those patients who don't have an ECG do you do any other type of screening for rhythm disorders? Answered: 17 Skipped: 14 Yes - please tell us more below No 94% 16 6% 1 Total 17 # If Yes please tell us more here Date 1 Pulse check. 12/8/ :08 PM 2 Pulse (radial) check BP 12/3/ :26 PM 3 pulse check/history- if pulse <60/min, or syncope/dizzy turns present, tend to ask for ECG in these circumstances 11/27/2015 4:29 PM 4 Pulse rate 11/27/ :06 AM 5 Only for people with symptomatic bradycardia, I tend ask for the GP to refer to a cardiologist for opinion regarding the need for 24h tape that may result in +/- pace maker being put in. 11/27/2015 9:54 AM 6 Will always check pulse manually prior and after increase in medication 11/27/2015 8:29 AM 7 Pulse check for rate and rhythm 11/26/2015 1:02 PM 8 Taking pulse for one minute, discussing with Consultant whether there is the clinical indiciation for ECG 11/17/2015 9:58 AM 9 Pulse will indicate whether rythm is regular or irregular 11/16/2015 4:39 PM 10 pulse check 11/16/2015 2:42 PM 11 Check for symptoms -syncope, blackouts, fatigue Pulse rate/rhythm -pre treatment, post treatment, before dose increase 11/14/2015 6:07 PM 12 Not sure if pulse rate counts, see above 11/10/ :42 PM 13 Checking pulse rate and rhythm in clinic.. 11/10/2015 8:47 AM 14 Past medical history Pulse rate and rhythm 11/9/2015 2:23 PM 15 Checking of pulse at intial assessment Obtaining medical records from GP 11/9/2015 2:12 PM 16 Pulse and blood pressure recording. 11/9/2015 1:58 PM 4 / 15

5 Q8 Please tell us here approximately what percentage of PATIENTS have an ECG prior to starting on AChEI's? Answered: 17 Skipped: 14 12% 12% () 47% 29% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 76% to 99% 51% to 75% 26% to 50% 0% to 25% 76% to 99% 51% to 75% 26% to 50% 0% to 25% Total Weighted Average () 12% 2 12% 2 47% 8 29% / 15

6 Q9 Does access to ECG create barriers and/or influence your prescribing? if so how? (eg use memantine instead of AChEI)? Answered: 17 Skipped: 14 Yes - please give further details below No 41% 7 59% 10 Total 17 # if yes give further details here Date 1 I would get a cardiac opinion use memantine for those whose ECG dictate that ACEI unsuitable 12/3/ :19 PM 2 Not all patients need ECG in my opinion, on examination if the pulse is normal. I tend to prescribe and ask patients and carers to be aware of a small risk of Bradycardia and Blackouts. But if patient's have an ECG already that shows mild heart block with pulse above 60, I tend to prescribe and explain that there is a slightly higher risk of Bradycardia and Blackouts. In some cases I have tried lower than usual staring dose i.e. Donepezil 2.5 mg or Rivastigmine 1.5 mg once daily to see what the response is especially if they have a supportive carer. If patients have severe heart block and are symptomatic and if there is an abnormal ECG available prior to treatment, then I have considered Memantine instead of AChEI. 3 Yes, in that if identifed by myself, ECG is done by GP as our service does not have access to ECG on site. This adds a variable time factor. Certainly can influence my prescibing if patient has evidence of heart block - will prescribe memantine or if slightly bradycardic and asymptomatic / normal ECG, i can justify trial of AchEI with patient. 4 Memantine is safer with bradycardia and supraventricular abnormalities. There has been a recent tend in GPs declining to undertake the ECG when requested for the above indications. Old Age Psychiatry service cannot take full ownership of a newly identifies bradycardia or cardiac arrhythmia. 11/27/ :04 AM 11/27/2015 8:36 AM 11/26/2015 1:09 PM 5 We have portable machines within the team 11/17/ :01 AM 6 Where cardiac function is unclear or compromised, memantine considered as an alternative or referral fro cardiology advice on AChEI prescription 7 There is little evidence in the literature that performing an ECG influences outcome. Second degree heart block and bifascicular block are absolute contraindications to AChEI's and in these circumstances the Doncaster protocol allows memantineif there are no contraindications. 11/16/2015 2:44 PM 11/9/2015 3:29 PM 8 If evidence of bundle branch block or other abnormalities contraindicating AChEI thdn will consider alternative 11/9/2015 2:24 PM 9 Often it is time consuming to get an ECG done by GP colleague. Memantine is preferred option in case of significant cardiac issue though cardiologist's opinion is sought if necessary 11/9/2015 2:17 PM 6 / 15

7 Q10 What results of ECG are significant enough to change practice and how? Answered: 30 Skipped: 1 # Date 1 We search for evidence of arrythmias, sustained low heart rate or other conduction issues that would indicate a contra-indication or other underlying health issues, prior to prescribing a drug that could have systemic effects on cardiac function. 12/9/2015 9:21 AM 2 Less than 25% 12/8/ :09 PM 3 If ECG showing second 2 or 3 degree bloc or significant bradycardia /slow hear rhythm patient would be at greater risk of cardiac arrhythmias 12/7/ :34 AM 4 Symptomatic Bradycardia Supraventricular conduction disorders/heart Block Sick Sinus Syndrome 12/3/ :26 PM 5 Heart block bradycardia AF I wouldnt routinely prescribe ACEI without advise in AF I wouldnt precribe if patient has heart block or bradycardia 6 bundle branch blocks, heart blocks would prevent prescribing. First degree heart block would lead to request for cardiology opinion 7 Bradycardia in the absence of beta blockers we would ask the GP to review and consider Memantine rather than AChEis. If taking beta blockers and bradycardic we would ask the GP to review this and consider a dose reduction or an alternative management for hypertension before prescribing AChEis. (This could be done on checking pulse alone.) Heart block we would refer to cardiology before considering what to prescribe. Prolonged QTc we would prescribe and repeat ECG to ensure AChEis is not increasing prolongation. We would also review other medications (eg Citalopram) which may be exacerbating the problem. 8 bradycardia- if on beta blockers ask primary care to review with a view stopping/switching to a differnt class of drugs If not on a bet blocker- seek opinion of a cardilogist- they have been very helpful Rhythm abnormaliitescomplex rhythms/ventricular arrythmias- seek cariology opinion 9 significant bradycardia LBBB other rhythym disorders may make me wary but would monitor ECG (I am in-patient psychiatrist so have that luxury). 12/3/ :19 PM 11/27/2015 4:32 PM 11/27/2015 1:50 PM 11/27/ :40 PM 11/27/ :08 AM 10 Moderate to severeaf on ECG Incomplete heart block on symptomatic patients. Multiple ectopics 11/27/ :04 AM 11 Evidence of heart block / significant bradycardia with symptoms on ECG - would consider memantine over AChEI. 11/27/2015 8:36 AM 12 significant conduction system abnormalities 11/27/2015 6:19 AM 13 Heart blocks and left bundle branch blocks would indicate Acetycholinesterase inhibitor represents higher risk. May initiate Memantine instead. 14 Where cardio-vascular contra-indications are identified AChEis will not be prescribed. In borderline cases a second opinion would be sought from the cardiologists. 15 Pulse rate and PR intervals are looked at. Any that are outside normal limits would influence prescribing. We would always carry one out prior to prescribinmg 16 If alerted to any of the indiciators identified earlier then would consider use of Memantine or offer alternative post diagniotic support if not eligible for AChEI 11/26/2015 1:09 PM 11/23/ :05 AM 11/18/2015 3:44 PM 11/17/ :01 AM 17 Ventricular arrthymias, symptomatic and bradycardia, multiple cardiac abnormailties with impaird renal function 11/16/2015 4:40 PM 18 PR interval sick sinus syndrome heart block bradycardia 11/16/2015 3:10 PM 19 bradycardia, bundle branch blocks, atrial fibrillation 11/16/2015 2:44 PM 20 We liaise closely with cardiology colleagues in York They like people who have significant first degree heart block to have a 24 hour tape before we prescribe. Often they advise a reduction in dose of beta blockers if bradycardia <55 I'd probably not prescribe if bradycardia <55 that's unexplained (not from beta blockers), 2nd/3rd degree heart block, bifasicular block, tri-fasicular block. Some with higher degrees of heart block we refer a for pacemaker if GP happy (and then we can prescribe!) 11/14/2015 6:07 PM 21 Significant Heart block / Bradycardia 11/12/2015 9:18 AM 22 Where Bradycardia, heart block or other conduction abnormalities are apparent on ECG, the potential for unwanted effects from acetylcholinesterase medication is considered. Often in this situation there will be a decision not to treat with Achei and to treat if appopriate with Memantine instead, or not treat with anti-dementia medication. 11/10/2015 1:16 PM 7 / 15

8 23 significant sino-atrial or atrioventricular block. ie. complete heart block, complete left bundle branch block, bifasicular block. recent onset ie. fast atrial fibrillation, uncontrolled failure, sinus bradycardia May not prescribe Acetylcholinesterace Inhibitors but may consider Memantine 11/10/2015 1:00 PM 24 Superventricular bradycardia. Avoid cholinesterase inhibitors. 11/10/ :43 PM 25 Abnormalities of ventricular conduction. This precludes AChIE and invites consideration of memantine, instead. 11/10/ :31 AM 26 Presence of Bradycardia and significantly long PR interval on an ECG.. 11/10/2015 8:48 AM 27 See 9. above. Bradycardia is a relative contraindication and bifascicular block an absolute contraindication. In general terms AChEI's are safe and well tolerated drugs - psychiatrists and GPs prescribe many other drugs that are more toxic to heart rhythm and neurovascular instability without recourse to routine ECG. 28 Significant first degree heart block - either prescribe lower dose of cholinesterase inhibitor or prescribe memantine instead. If cholinesterase used repeat ECG before any increase in dose. Triphasic block - refer to cardiology and consider memantine in the meantime. Significant bradycardia - review other medication that may slow heart rate and delay treatment with cholinesterase inhibitor or consider memantine. 11/9/2015 3:29 PM 11/9/2015 3:29 PM 29 As anove 11/9/2015 2:24 PM 30 Significant arrhythmia Active IHD/ recent MI Evidence of heart failure 11/9/2015 2:17 PM 8 / 15

9 Q11 Please tell us here approximately how many ECG's are done each year (either in house or external) prior to starting patients on AChEI's? Answered: 29 Skipped: 2 # Date 1 Difficult to say with accurarcy as this is not recorded. looking at diagnosis figures it may be aroung per year requested from GPs 12/9/2015 9:30 AM 2 I do not have this information to hand. If you require this I will need to seek information from several sources. 12/8/ :11 PM /7/ :35 AM /3/ :26 PM 5? 12/3/ :20 PM 6 no idea! Approx 1 in 5 referrals I ask for one, but many GPs still send one with referral though we don't ask for this. Sorry can't be more specific! 11/27/2015 4:35 PM /27/2015 1:58 PM 8 approximately 60 11/27/ :42 PM 9 40?? 11/27/ :09 AM 10 Not sure 11/27/ :05 AM 11 difficult to answer as on referral sheet for memory service 11/27/2015 8:38 AM 12 don't know as the question is not clear about my own practice or service wide 11/27/2015 6:22 AM /26/2015 1:10 PM /23/ :08 AM /17/ :04 AM /16/2015 4:41 PM 17 not available 11/16/2015 3:10 PM 18 unknown 11/16/2015 2:45 PM in my sector -I only work half time 11/14/2015 6:08 PM 20 Unsure 11/12/2015 9:24 AM 21 Approximately /10/2015 1:17 PM /10/2015 1:00 PM 23 I don't have access to that data 11/10/ :45 PM /10/ :36 AM 25 probably 10 11/10/2015 8:49 AM 26 In my sector (12,000 over 65s) aproximately /9/2015 3:31 PM /9/2015 3:30 PM 28 ~20 11/9/2015 2:25 PM /9/2015 2:18 PM 9 / 15

10 Q12 Who is responsible for requesting/carrying out an ECG prior to starting patients on AChEI's Answered: 29 Skipped: 2 GP must obtain prior to... 17% MAS obtains ECG as part... 41% MAS conduct in-house ECG 10% Other (please specify) 31% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% GP must obtain prior to referral to MAS MAS obtains ECG as part of assessment process from external source MAS conduct in-house ECG Other (please specify) 17% 5 41% 12 10% 3 31% 9 Total 29 # Other (please specify) Date 1 Until recently MAS sought from extrenal source. Recently have been done in house. 12/8/ :11 PM 2? 12/3/ :20 PM 3 request to GP to complete ECG in those patients where need for this is felt to be present 11/27/2015 4:35 PM 4 In patient trainee 11/27/ :09 AM 5 I and my team request the ECG for patients who get started the drugs 11/27/2015 6:22 AM 6 Is part of referral criteria so should be done by GP however we can do them within memory service 11/17/ :04 AM 7 either GP's do them beofre referral or after we specifically ask them to 11/14/2015 6:08 PM 8 GP asked to organise ECG where indicated 11/10/ :45 PM 9 Request GP after assessment if needed. 11/10/2015 8:49 AM 10 / 15

11 Q13 How is the cost of the ECG covered? Answered: 29 Skipped: 2 Other (please specify) 28% (8) Contract with acute hospital 7% (2) CCG covers the cost 3% (1) Individual GP practice 48% (14) Block contract with Mental Health service provider 14% (4) Individual GP practice Block contract with Mental Health service provider CCG covers the cost Contract with acute hospital Other (please specify) 48% 14 14% 4 7% 2 28% 8 Total 29 # Other (please specify) Date 1? 12/3/ :20 PM 2 Not sure 11/27/ :42 PM 3 in patients 11/27/ :09 AM 4 not sure 11/27/2015 8:38 AM 5 Don't know 11/27/2015 6:22 AM 6 Cost is covered from existing budget 11/23/ :08 AM 7 As per above 11/17/ :04 AM 8 We have bought ECG machine and materials 11/9/2015 3:30 PM 11 / 15

12 Q14 What are the reporting arrangements for ECG? select all that apply Answered: 29 Skipped: 2 Automatic - reported by machine Reported by cardiac department GP report Psychiatrist self report Other (please specify) 59% 17 21% 6 28% 8 55% 16 17% 5 Total Respondents: 29 # Other (please specify) Date 1 copy sent through by GP 12/9/2015 9:30 AM 2? 12/3/ :20 PM 3 in uncertain findings, will at times (handful per annum) request cardiology opinion on report 11/27/2015 4:35 PM 4 seek cardiology opinion 11/27/ :42 PM 5 all of the above -most come with machine/gp report, I look at themand the tricky ones we ask advice from cardiology collegues 11/14/2015 6:08 PM 12 / 15

13 Q15 On average how long does it take to access an ECG? Answered: 27 Skipped: 4 within 24 hours 26% 2 to 3 days 11% 4 to 7 days 11% 8 to 14 days 37% more than 14 days 15% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% within 24 hours 2 to 3 days 4 to 7 days 8 to 14 days more than 14 days 26% 7 11% 3 11% 3 37% 10 15% 4 Total 27 # If more than 14 days please state how long here Date 1 Again this information is not recorded. Generally it seems to be within about 2 weeks but could not be accurate in this 12/9/2015 9:32 AM weeks 11/10/2015 1:00 PM 3 Sometimes upto a month 11/9/2015 2:19 PM 13 / 15

14 Q16 Approximately what percentage of the patients you arrange an ECG for have to travel a significant distance (more than 5 miles) to obtain one? Answered: 28 Skipped: 3 14% (no label) 11% 75% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 76% to 100% 51% to 75% 26% to 50% 0% to 25% 76% to 100% 51% to 75% 26% to 50% 0% to 25% Total Weighted Average (no label) 0% 0 14% 4 11% 3 75% / 15

15 Q17 Do have any further comments relating to ECG prior to prescribing AChEI's Answered: 16 Skipped: 15 # Date 1 Answer to 12 is again unknown. The area is mixed urban and rural and some Service Users do have to travel some distance to access their GP practice. 12/9/2015 9:32 AM 2 We are currently reviewing the indications for pre treatment ECG, based on evidence. 12/8/ :12 PM 3 I believe it is essential to obtain bassline ECG before commencing on group of medication which is associated with risk of cardiac arrhythmias.i had numbers of patients when bassline ECG precipitated further investigations for serous heart rhythm problems 4 GPs arrange ECG prior to referral to MAS if Bradycardia/new arrythmia. At MAS (hopsital based clinic) initial assessment if ECG required it is completed at that appointment in Cardiology dept. If initial MAS assessment is by home visit and ECG required GPs are requested to arrange at their practice. 5 'referrer inertia' means many GPs still send ECG with referral even though we dont ask for this. Targetted investigation, using the Rowland 2007 guidance seems to be a reasonable way to approach the situation 6 ECG carried out routinely on intial assessment at MAS. Those who are assessed in the community may have to travel for an ECG to the Acute Hospital. 7 Running memory clinics in close proximity to the local acute Trust and having in-house facility in GP surgeries are very helpful to obtain a tracing on the same day. Tracing is available on the same day. Ver occasinally I give the request form to carer to get it done in the acute hospital/gp surgery on a day more convenient to them. I ask the services to forward them. Usually takes a week. 8 They should ideally part of the investigations that are done by the primary care at the point of referral as the baseline ECG will be helpful for most of the psychotropic medications any way. 9 Even when the ECG is triggered by pulse check prior to initiation of AChEI, the actions required for any pathology detected need to be undertaken by GPs of other specialists in acute hospital. Hence these ECGs should be done by the GP practice. 12/7/ :39 AM 12/3/ :26 PM 11/27/2015 4:37 PM 11/27/2015 2:00 PM 11/27/ :46 PM 11/27/2015 6:24 AM 11/26/2015 1:14 PM 10 MAS support workers conduct the ECG at the persons home. 11/23/ :09 AM 11 A clinically led pragmatic approach always works. Treating the patient not the results. 11/16/2015 4:42 PM 12 had included as a standard item on local MAS referral form, but rarely undertaken prior to referral. Some GPs articulating that it should not be their responsibility, despite inclusion in local shared-care protocol. 13 In an ideal world, either... -all referrals would come with a good quality ecg tracing done in the surgery OR - there were clear guidance when we could safely work without one 11/16/2015 2:46 PM 11/14/2015 6:08 PM 14 Individual practices vary in their willingness to conduct ECGs when requested to do so by memory clinic. 11/10/ :46 PM 15 An ECG is undertaken routinely, for all patients in Memory Services, since it affects prescribing decisions of AChIE but also is a Trust requirement before starting antipsychotic medication. Since antipsychotics are often entertained when there is severe BPSD, so the patient's not able to engage in an ECG at that point, having a baseline ECG on a patient has utility in current AChIE and in potential future antipsychotic considerations with that patient. We're mindful that Sudeep Gill's paper ( evidences how AChIE roughly double risk of syncope, to 3.15% a year. With loss of consciousness and collapse having markedly adverse outcomes, evidencing rational prescribing practice is seen to be a requisite for valid prescribing. 16 By routinely doing ECGs as part of our overall assessment we have co-incidently picked up several patients with complete heart block or evidence of acute MI. We have then been able to send them to casualy as an emergency for medical attention, possibly saving some lives. 11/10/ :46 AM 11/9/2015 3:33 PM 15 / 15