MTG3 CardioQ-ODM oesophageal doppler monitor with Dr Dan Conway
Dr Dan Conway, Consultant in Anaesthesia and Critical Care at Manchester Royal Infirmary discusses implementation of the guidance in clinical practice.
This podcast was added on 30 Mar 2011
Interviewer: Hello and welcome to the NICE podcast about the NICE medical technology guidance on the CardioQ-ODM oesophageal doppler monitor. In particular this podcast will be focusing on implementing the recommendations in the guidance.
Interviewer: I am Katie Worrall, implementation lead for this guidance and with me is Dr Daniel Conway Consultant in Anaesthesia and Critical Care at Manchester Royal Infirmary and one of the clinical expert advisers to the Medical Technologies Advisory Committee who developed the NICE recommendations on CardioQ. Dr Conway also led the NHS technology adoption centre project at Manchester Royal Infirmary, one of 3 sites across England who implemented this device in clinical practice. These sites have shared their experiences so others can benefit from the lessons learnt.
During this podcast we will refer to the NHS technology adoption centre as NTAC and the Manchester Royal Infirmary as MRI.
Q1 Interviewer: Hello Dan, what is the CardioQ device?
DC: Hi Katie, so the CardioQ device is a minimally invasive cardiac output monitor it uses a soft probe placed in the oesophagus when patients are asleep and under their anaesthetic. It uses this probe to detect the flow of blood as it goes from the heart, down the descending aorta and to the vital organs.
Q2 Interviewer:Why is it important to monitor cardiac output and intravascular fluid status in patients during surgery?
DC: Well as anyone who has had an operation knows often patients who come to theatre are very dehydrated they may have been starved for a number of hours and it may be that the condition they are having the operation for has left them dehydrated. Unfortunately, traditional monitors such as pulse and blood pressure can’t really detect accurately how dry the patient is. This might be alright for patients having relatively minor surgery or patients who are reasonably fit but for people having major surgery or for those who have some kind of risk factor such as heart disease getting the balance in fluid right is absolutely critical to improving outcomes following surgery. (because) If patients are too dehydrated they don’t get enough blood flow to their vital organs during surgery but equally if patients are over hydrated then the tissues can become very swollen and then they don’t heal very quickly.
Q3 Interviewer:Thank you. In which situations does the NICE guidance recommend the CardioQ is used in?
DC: NICE has recommended that for patients undergoing major or high risk surgery or other surgical patients in whom a clinician would consider using invasive cardiovascular monitoring then the CardioQ Oesophageal Doppler should be used.
Q4 Interviewer:Thank you, and currently how are these patients managed?
DC: Well up to recently the anaesthetist had to rely on highly invasive catheters placed into the great vessels near the heart in order to get the information that could help them guide fluid. Now fortunately there are cardiac output monitors that can give more information with less risk to the patient.
Q5 Interviewer:How will using this medical technology benefit patients?
DC: Well Katie all the evidence from randomised controlled trials and the NTAC implementation project strongly support the idea that when CardioQ is used patients have improved haemodynamics during their surgery, that the fluid balance is just right because we have been using this monitor this then reduces the number of complications that they experience following their surgery. Patients feel better, they are able to mobilise quicker, they are able to get themselves out of hospital much sooner. That is really good for patients but it is also really good for the health service as well.
Q6 Interviewer: How will using this technology improve quality and productivity in the NHS?
DC: Well Katie, because patients who are having major surgery will be spending less time in hospital this should free up hospital beds for more patients to come in and have their surgery sooner. Otherwise the hospital could choose to use the bed for other purposes or they could choose to close the bed temporarily and save on costs whilst still treating the same amount of patients.
Q7 Interviewer:What advice do you have for clinicians who are looking to use this technology in practice?
DC: Well what we found with the NTAC project was that there were two main challenges and barriers to the implementation of this technology. The first was to persuade management to invest in the technology and the second was once the technology has been introduced is to get the anaesthetists using it effectively for all suitable patients.
So taking the first challenge which is persuading the management to invest in the technology what we found was that even for the most senior clinicians it can often be a daunting task to introduce new technology into the theatre environment. This is because of the levels of bureaucracy that have to be overcome in order to get approval for the investment. We found that many clinicians have not had any training in how to write a business case and we found the best way in overcoming that was to create partnerships between engaged local managers and the project clinical leads who would then together write the business case. The other major challenge that we found was something called silo budgeting. Which is where investment from one part of the hospital derives benefit in another part of the hospital and the two managers in the two different parts of the hospital could not reconcile who was going to pay for the investment. The best way that we found to overcome this was to engage somebody at senior executive level who could look at the whole situation and decide where the money was going to come from and usually that would allow this reconciliation to take place.
When we looked at how we could encourage anaesthetists to use the CardioQ as effectively as possible we realised that anaesthetists had to take advantage of as many opportunities as possible to gain experience with using the device. Although this mainly applies to junior doctors we have found that many consultants too felt that in order to confidently use the device they needed to gain more experience. We achieved this by working very closely with colleagues who were prepared to champion the technology with the other anaesthetists we took the resources provided by the manufacturer as part of their standard training and we also had drop in classroom sessions with refreshers and other anaesthetists talking about their experiences using the device and that helped to give people more confidence in using the devices.
We also found that auditing outcomes was really important in achieving sustainability. By looking at important outcomes such as complications and length of stay as well as the patient experience we were able to reinforce the idea that this was working that the project was working, that the efforts that people were putting in to improving patient care by using the CardioQ were paying off and this has allowed us to build upon the number of patients who are benefitting from this technology. So for example in the MRI we started off with only maybe 30 patients per month having the CardioQ now we are closer to 60 and this has been sustained by the positive results from our project.
Q8 Interviewer:Brilliant thank you. Is there any additional advice for managers on how best to support this change in practice?
DC: Well I think that managers really should understand that the work from the randomised controlled trial from the health technology assessment and now from NTAC’s how to why to guide is that CardioQ is a credible means of saving cost within the NHS. The work that is being done by both NTAC and the NICE implementation team is showing just how much money can be saved when these devices are implemented effectively.
Interviewer: Thank you very much Dan. We hope that you will find the information in this podcast useful in helping you implement the guidance in practice. For more information about the NICE medical technology guidance on the CardioQ-ODM oesophageal doppler monitor, including the NICE implementation tools which can all be adapted for local use, please visit our website, www.nice.org.uk/MT. To find out more about the experiences and learning from the NTAC implementation project for CardioQ at MRI and at the other implementation sites, look at the NTAC website and find the “How to Why to” guide. The hyperlink to this website is available on the NICE guidance page.
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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This page was last updated: 19 September 2012