Professor Michael Walsh, NCPS ENT, Head and Neck Surgery Specialty Advisor, in collaboration with the NCPS team, has developed the ENT Head and Neck specialty Model of Care.

This diverse specialty includes care of patients with a wide range of conditions, ranging from simple conditions treated medically to extraordinarily complex oncologic and other resections. Unlike many other surgical specialties, general ENT encompasses care of a large proportion of out-patients who receive medical treatment only – almost 80% of all OPD referrals. Currently in Ireland, over 70,000 patients are awaiting a routine ENT Outpatient appointment, a number that is increasing each year. The ENT Model of Care seeks to expand the options available to patients who require straightforward ENT evaluation and treatment.

An area under evaluation in the Model of Care is the workforce plan needed to expand services in the areas of Audiology, Speech Therapy, Postural Rehabilitation Physiotherapy, and Nursing, including Advanced Nurse Practitioners. The Model of Care will be launched during the Charter Day Meeting in 2019.

Speaking at the opening of a HSE Value Improvement Programme conference hosted at RCSI in September 2018, RCSI President Mr Kenneth Mealy said that projected demographic changes make it imperative that we build capacity to allow better use of the valuable assets within our hospitals. He advised “the evidence suggests that if we could improve theatre efficiency by 10% in half of the operating theatres in the country, we could prevent our surgical waiting lists from continuing to increase.” The conference brought together surgical teams including surgeons, anaesthetists, nurses and health care administrators for a discussion on methods to improve operating theatre efficiency.

Mr Kieran Tangney, Director of the Quality and Process Improvement Centre (QPIC) in RCSI, explained how RCSI’s Theatre Quality Improvement Programme (TQIP) allows for a systematic assessment of all of the steps in a surgical patients’ journey. “TQIP supports healthcare teams to enhance their process improvement capability and supports their ability to design more effective ways of working together. Taking a multidisciplinary team approach is key to sustainable improvement. It enables participating hospitals team to design safe, effective and efficient delivery of care for their patients. This approach directly benefits staff and their patients, as better designed work processes allows more time for direct patient care. The keys to success are a combination of senior management oversight and support to encourage theatre staff to address issues in pre-admission planning, theatre scheduling and preparation, and staff engagement. TQIP promotes better use of theatre resources and encourages greater patient satisfaction and safety”.

RCSI and the NCPS are now seeking HSE support to roll the programme out nationally in all public hospitals. 

The Department of Surgical Affairs, National Clinical Programme in Surgery in collaboration with the RVEEH, Sligo University Hospital, and University Hospital Waterford was one of the recipients for the premier awards in the Irish Health Care Sector on 17th October 2018 at the Irish Health Care Awards. The awards recognise the highest achievers in Irish Medicine that have made a positive contribution to Patient Care in Ireland in 2018. The National Clinical Programme for ENT Education in Primary Care, which is led by Ms Camilla Carroll in her role as National Primary Care ENT Education Lead, RVEEH, SUH and UHW collaborated in training primary care practitioners, GPs and practice nurses to carryout ear microsuction in the primary care setting to significantly redesign the current model of care for cerumen impaction, stream-line the patients’ journey and free up ENT OPD services for management of more complex conditions.  Congratulations to the winning team!

Left to right: Nurse Elaine Kenahan, Mary Flynn NCPS, Dr Rory Hasson GP, Ms Camilla Carroll National Primary Care ENT Education Lead, Dr Owen McDermott GP, Mr Deepak Kumar Chief Audiologist RVEEH, Prof Michael Walsh NCPS ENT Clinical Advisor. Absent from picture: Mr Kieran Ryan Surgical Affairs, Nurse Patricia Quilty and Cathy Fox

Background

Age-related ENT conditions place a significant burden on the healthcare system. Cerumen impaction is present in approximately 60% of patients over 65 years and has been linked to the progression of cognitive impairment. Many of these older patients are not suitable for cerumen removal in Primary Care using the traditional method of irrigation, because the patient is taking a prescribed anticoagulant medication. The procedure of choice is then microsuction, which currently is delivered in a hospital OPD setting by an ENT Surgeon. 30% of ENT OPD referrals (approximately 18,500 patients annually) are patients suffering from cerumen impaction requiring microsuction.

Project Design

The project team designed a “fit for purpose” educational skills model to train primary care professionals, GPs and practice nurses in the skill of ear microsuction, with a view to managing non-complex ear conditions, such as cerumen impaction in primary care. The pilot programme was funded by the HSE through the National Clinical Programme in Surgery. The educational programme was delivered by ENT experts in 3 regional centres, namely Dublin, Sligo and Waterford. 60 primary care participants were enrolled into the ear microsuction training programme, which commenced in January 2018. The programme timeline is outlined below:

• Initial attendance at the Expert Delivered Practical Skills Workshop,
• subsequent participant delivered microsuction care to 20 patients (to be completed by March 2019) logging each patient interaction in a reflective logbook
• re-assessment of microsuction skills at an interval of 6 months from initial workshop attendance, with logbook review

1,200 patients will have been treated in the primary care setting, upon completion of this pilot programme by March 2019.

Practical Skills Workshop

The project team designed a standardised practical skills workshop to teach ear microsuction to GPs and practice nurses. A competency-based educational model was utilised based on adult learning theories, with a focus on skills transfer in a situated learning environment (Figure 1). The workshop was delivered over 6 hours and included didactic teaching, practical skills stations, with simulation and virtual reality ear models.  

Figure 1: Ref: Lave and Wenger. Situated learning: legitimate peripheral participation, 1991.

31 participants were trained in the RVEEH Dublin, 15 were trained in Sligo and 14 were trained in Waterford. The 60 trained participants are currently performing ear microsuction in the primary care setting, with completion of the case load expected in March 2019 and reassessment in April 2019.

Impact of this program

The project team designed and delivered an educational programme to upskill 60 primary care professionals in the procedure of ear microsuction. These primary care practitioners will have safely treated 1,200 patients by March 2019. These patients would previously have had to attend a hospital based ENT Surgeon for delivery of care. 

The initial set-up cost to the primary care practice is €1,319.89, with a €5.94 disposable equipment cost per patient (Figure 2).

Figure 2

The ultimate aim of this integrated care programme is to develop a national network of credentialed primary care practicitoners, empowered to deliver an adult microsuction service for common ear conditions in a local setting. The patient maintains their connection with their primary care provider and this re-directed delivery of care would have a significant impact on reducing the demand for ENT OPD services, freeing-up the hospital based ENT surgeon to see, treat and manage patients with more complex conditions. This is estimated to be in the region of 32,000 patients per annum.

Vascular surgery was recognized as a medical specialty by the Irish Medical Council in 2014 and earlier this year, the NCPS appointed a Clinical Advisor in Vascular Surgery, Mr Martin Feeley.

As a specialty, vascular surgery is in a period of significant change with more widespread use of minimally invasive arterial and aortic surgery, and increasingly common utilisation of ambulatory endovenous techniques for varicose veins. It is therefore timely that the Model of Care for Vascular Surgery is being developed. Authored by Mr Martin Feeley, in collaboration with the members of the Irish Association of Vascular Surgeons, the Model of Care will define the optimal organisation of services for vascular surgery with an emphasis on service innovation. The Model of Care will not only describe optimal care for high complexity vascular surgery, but will also address high volume, low complexity procedures like varicose veins. This remains a controversial condition with the BMJ reporting in July that the UK National Health Service plans to restrict varicose vein surgery to patients with specific indications such as skin changes thought to be caused by chronic venous insufficiency, superficial vein thrombosis and venous ulceration. (BMJ 2018; 362: k2903).

The Model of Care will be launched during the Charter Day Meeting in 2019.

The National Clinical Programme for Surgery Charter Day 2019 will be held in RCSI on Thursday 7th February 2019. The Charter Programme will feature representation from all surgical specialties and members of multi-disciplinary teams across Ireland. Online registration will be available in due course on the RCSI events page. 

To find more information on the benefits and how to implement a See and Treat Clinic in your hospital, please visit the Metrics, Publications and Policies page on the NCPS website and click 'See and Treat Toolkit'. Alternatively, please contact surgeryprogramme@rcsi.ie.