ANNUAL CLINICAL SERVICES OVERVIEWVaughan Pearce

Joint Medical Director

CoG Meeting 16 January 2008 (Agenda item 8)

THEMES

• Cooperation with neighbouring Trusts• Expansion of work in the Community• Improving the Clinical Environment• 7 day week / longer day• Strong Research and Development

base• More direct Consultant care

Cooperation with other Trusts• Urology• Gynaecology• Orthodontics/Maxillofacial surgery• Plastic surgery• Chronic kidney disease• Neurology• Haematology• Stroke• Oncology

Expansion of Community Work

• Operating lists• Endoscopy• Dialysis• Outpatients

Surgery

• New Urologist:-to support urological cancer service in N&S Devon.

• Maxillofacial surgeon/Orthodontist to support Head and Neck cancer service in East Peninsula.

• MIO:-Largest Centre in Europe Largest series outside U.S.

Kidney Disease

• Expansion of dialysis capacity• Probable expansion of community

dialysis

Respiratory Disease

• Home based diagnosis,assessment and treatment of sleep apnoea.

Gastroenterology

• New endoscopy unit opens February- implications for radiology and colon cancer screening.

Haematology

• Management of North Devon patients as part of a North and East Devon network.

Cancer

• Development of brachytherapy for prostate cancer.

Emergency Medicine• 3 Acute Physicians• ‘Morning Report’ 7 days Respiratory Elderly Care Gastroenterology Endocrinology Cardiology Neurology(5 days)

Evening Ward Round

Cardiology

• 7 day Primary Angioplasty• Cardiac MRI

Perfusion

Coronaries

Myocardial infarctionHeart failure

‘angina’ during stressAnatomy

Valves

Angiography

Cardiac Magnetic Resonance Imagingat Royal Devon and Exeter NHS Trust

Nick Bellenger MD BSc MRCP

Case 1

65 yr male3 weeks of SOB and chest painAdmitted with trop positive acute coronary syndrome

Angiogram: severe three vessel disease very poor left ventricular function

Usual management:Too high risk for surgery with damaged heart so medical treatment with poor prognosis

Management at

Cardiac MRI:Showed poor function but myocardium is still alive and highly likely to recover

Change in management following MRI:Accepted for bypass surgery with good prognosisAnother patient

showing white area of dead heart muscle

Case 270 yr old maleSudden onset troponin positive of chest pain

Angiogram:Severe narrowings in all three main vessels

Usual treatment:Try to stent all three vessels [putting patient at risk of prolonged procedure plus requiring at least 2 guides, 2 wires, several balloons, 6 stents (£800 each)]

Cardiac MRI:Left coronary territory dead so no need to treatRight coronary territory gets blood from circumflex so no need to treatCircumflex territory alive and important so treat

Management change after MRI:Only treat one vessel with one stent

Narrowing before

No narrowing after x1 stent

Blocked arteryNarrow

Management at

Cardiac Magnetic Resonance Imagingat Royal Devon and Exeter NHS Trust

Patient benefits:• Better care• Best information• Massive impact on management• Safe• Non-invasive• No radiation

Trust benefits:• Better care• Comply with NICE• Reduce nuclear wait• Regional referral income• Regional Research centre• Regional Training centre

Financial benefits:• Save unnecessary revascularization• Save diagnostic duplication• Save unnecessary wait for + cost of CABG• Income generator

Do you need cardiac MRI ?

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• Antibiotic policy and Card• Antibiotic pharmacist• Clean Your Hands Campaign• ‘Saving Lives’• ‘Hygeine Code’• Surgical Site Infection Audits

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