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The Green Lane Paediatric and
Congenital Cardiac Service
Starship Children’s Hospital
Annual Report
July 2004 – June 2005
Collated by Dr Tom Gentles, Clinical Director
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
Table of Contents
1. BACKGROUND...................................................................................................................3
2. SERVICE COMPONENTS................................................................................................ 4
2.1 SUMMARY .............................................................................................................................4
2.2. PAEDIATRIC INPATIENTS......................................................................................................4
2.3. PAEDIATRIC AND CONGENITAL CARDIAC SURGERY ...........................................................4
2.4 PAEDIATRIC OUTPATIENTS ...................................................................................................7
2.5 PERIPHERAL CLINICS ............................................................................................................9
2.6 FETAL CARDIOLOGY ...........................................................................................................10
2.7 ADULT CONGENITAL HEART DISEASE SERVICE ................................................................11
2.8 CARDIAC INHERITED DISEASE ............................................................................................12
3. INVESTIGATIVE SERVICES ........................................................................................ 13
3.1 ECHOCARDIOGRAPHY .........................................................................................................13
3.2 CARDIAC MRI.....................................................................................................................14
3.3 CARDIAC CATHETERISATION..............................................................................................15
3.4 ELECTROCARDIOGRAPHY AND EXERCISE TESTS ................................................................17
3.5 ELECTROPHYSIOLOGY ........................................................................................................18
3.6 PACEMAKER........................................................................................................................18
3.7. CARDIAC REGISTRY ...........................................................................................................18
4. NURSING........................................................................................................................... 19
4.1 NURSING LEADERSHIP VISION WITHIN PCCS ....................................................................19
4.2 OCCUPANCY .......................................................................................................................19
4.3 NURSING STAFF AND RECRUITMENT ..................................................................................20
4.4 NURSING EDUCATION .........................................................................................................20
4.5 PROFESSIONAL DEVELOPMENT ......................................................................................... 20
4.6 DEVELOPMENT OF NURSING ROLES ...................................................................................20
4.7 HOME INR TESTING ............................................................................................................21
5. ACADEMIC....................................................................................................................... 22
5.1 PEER REVIEWED ARTICLES ................................................................................................22
5.2. BOOK CHAPTERS ................................................................................................................23
5.3 OTHER PUBLICATIONS ........................................................................................................23
5.4 INVITED PRESENTATIONS ...................................................................................................23
5.5 PRESENTATIONS AND ABSTRACTS......................................................................................24
6. MEDICAL STAFF ............................................................................................................ 26
6.1 CONSULTANT MEDICAL STAFF...........................................................................................26
6.2 SURGICAL STAFF ................................................................................................................26
6.3 JUNIOR MEDICAL STAFF .....................................................................................................26
Page 2
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
1. Background
The Green Lane Paediatric and Congenital Cardiac Service is a national service based at the
Starship Children’s Hospital.
It is the sole provider of cardiology and cardiac surgical services for infants and children with
congenital and acquired heart disease in New Zealand and also provides a fetal cardiology
service and investigation and treatment of those born with congenital heart disease who are
now adults. The service provides an extensive network of outreach clinics and also provides
consultation and support to clinicians caring for patients within the regional hospital setting.
In addition there is an active clinical research and audit programme that includes collaborative
ventures with academic groups nationally and internationally.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2. Service Components
2.1 Summary
The service has a number of interrelated components including:
• Paediatric inpatient (medical and surgical)
• Paediatric and congenital cardiac treatment (surgical and catheter based)
• Paediatric Outpatient
• Peripheral Clinics
• Fetal Cardiology
• Adult Congenital Cardiology
• Cardiac Inherited Disease
Investigative Services include
• Echocardiography
• Cardiac Catheterisation
• Exercise testing
• Cardiac MRI
Ancillary services contracted from adult cardiology
• Electrophysiology laboratory
• Pacemaker diagnostics
• Electrophysiology and electrocardiography technical staff
• Cardiac catheterisation laboratory support staff
Ancillary services contracted from Adult Cardiothoracic Surgery and Operating Theatres.
• Perfusionists
• Theatre nurses
• Anaesthetists & anaesthetic technicians
2.2. Paediatric inpatients
There is a dedicated 22 bed ward including a 4 bed High Dependency Unit. The service
shares a 16 bed paediatric intensive care unit, utilising on average 4 beds. The intensive care
unit is staffed by paediatric intensivists.
All inpatients are tertiary referrals, with the majority originating outside the Northern Region
2.3 Paediatric and Congenital Cardiac Surgery
Paediatric cardiac surgery is undertaken in a dedicated cardiac theatre at Starship Children’s
Hospital under the leadership of Mrs Kirsten Finucane. Adult congenital cardiac surgery is
undertaken by the same surgical team in the adult cardiac operating theatre in the adjoining
Auckland City Hospital. Postoperatively patients are transferred to the Paediatric Intensive
Care Unit or to the Cardiac Intensive Care Unit in the case of adults.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2.3.1 Surgical volumes and outcomes
The following statistics are counts of admissions that result in cardiac surgery and exclude
patients cannulated for ECMO for non cardiac reasons, and premature neonates who
underwent ligation of a patent ductus arteriosus in the neonatal intensive care unit.
Surgical admissions and length of stay have remained stable over the past 5 years (Figure 1).
400
350
300
250
200
150
100
50
0
2000-01
2001-02
2002-03
2003-04
2004-05
Bypass
286
259
281
282
275
Non Bypass
51
71
66
66
72
Grand Total
337
330
347
348
347
Figure 1. Surgical admissions by year and type of procedure
Approximately one half of surgical admissions are for infants aged <1 year, and 10% are for
adults with congenital heart disease (age ≥15 years) (Figure 2).
100%
80%
60%
40%
20%
0%
2000-01
2001-02
<1month
2002-03
1-12 month
1-5 years
2003-04
5-15 years
2004-05
>15 years
Figure 2. Surgical admissions by age
Surgical mortality is low and has continued to fall despite increasing numbers of complex
procedures including Norwood palliation for hypoplastic left heart syndrome. Early mortality
rates quoted below relate to deaths within the surgical admission or within 30 days of
operation. Patients are counted once per admission even if they had multiple procedures
during an admission (Tables 1-3). A detailed data analysis of surgical results over the past 11
years has been prepared for publication. It demonstrates improvements in mortality across all
types of procedures with results that compare favourably internationally.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
Table 1. Early Mortality by Year
Year
2000-01
2001-02
2002-03
2003-04
2004-05
Total
Early Deaths
10
12
5
8
6
41
Total
337
330
347
348
347
1709
Percent Early Mortality
2.97%
3.64%
1.44%
2.30%
1.73%
2.40%
Table 2. Early mortality by Operation Type (2000-01 to 2004-05)
Type
Bypass
Non Bypass
Total
Early Deaths
34
7
41
Total
1383
326
1709
Percent Early Mortality
2.46%
2.15%
2.40%
Table 3. Early mortality by age (2000-01 to 2004-05)
Age
<1month
1-12 month
1-5 years
5-15 years
>15 years
Grand Total
Early Deaths
19
13
2
2
5
41
Total
302
522
351
356
178
1709
Percent Early Mortality
6.29%
2.49%
0.57%
0.56%
2.81%
2.40%
Much of this improvement is related to increasing specialisation of paediatric services,
culminating in the move to the Starship Children’s Hospital in December 2003. The focus is
now on reducing neurological morbidity, particularly in the neonates, and study in this area is
underway with collaboration from Melbourne. A second and future focus is on reducing the
interval mortality in infants with single ventricle undergoing staged palliative procedures by
improving surveillance – a particular challenge given our widely dispersed patient population.
Surgical patients are admitted from throughout New Zealand and the South Pacific. There
have been no changes in referring patterns (Figure 3).
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2000-01
2001-02
2002-03
2003-04
2004-05
Auckland
Bay of Plenty
Canterbury
Counties
Hawkes Bay
Hutt
Lakes
MidCentral
Nelson/Marlborough
Northland
Otago
Other (O/Seas)
Pacific Island
South Canterbury
Southland
Tairawhiti
Taranaki
W aikato
W airarapa
W aitem ata
W anganui
W ellington
W est Coast
Figure 3. Domicile of surgical patients
Page 6
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
Inpatient reimbursement is measured in Weiss – an algorithm an imperfect measure of output,
that attempts to account for complexity and total cost of patient care. The range of cases,
intervention and complexity makes this system inaccurate (Figure 4).
4500
4000
3500
3000
2500
2000
1500
1000
500
0
W eiss
2000-01
2001-02
2002-03
2003-04
2004-05
2935
3486
3908
3766
3746
Figure 4. Weiss by year
2.3.2 Theatre utilisation
A single theatre is utilised for nine sessions (1/2 days) per week and often runs into the
evenings. (Two bypass cases per day are performed and as case complexity has increased the
average operation time now approaches five hours.)
When the service moved to the Starship Hospital it was planned to open to two cardiac
theatres. The second theatre was never commissioned despite an established need as
manifested by a deterioration in waiting times over the past five years with a significant
proportion of children waiting beyond the recommended time for surgery. This presents a
risk to patients and to the hospital; several sentinel events have occurred in waiting list
patients. In addition the current arrangement results in significant overtime for theatre staff
and an inability to schedule with any degree of flexibility.
A proposal to commission a second theatre two days per week is currently with hospital
management. This will allow an increase in throughput without further extending the work
hours and overtime requirements for staff, by increasing flexibility to schedule the longer
cases. There will also be the added advantage of allowing an increase the throughput in
summer and autumn, when PICU and ward beds available. Recruitment and training of staff
may be problematic and may delay commissioning a further six months.
2.4 Paediatric Outpatients
There are 8 outpatient clinics per week, including an arrhythmia clinic and two Day Stay
sessions. Eighty percent of outpatients are tertiary (referred from paediatricians or
cardiologists). Secondary referrals reside almost entirely in the ADHB region.
Volumes have increased over the past 5 years (Figure 5). This has largely been related to an
increase in follow-up visits. These trends are indicative of multiple changes in practice.
• Primary referrals from out of region have been devolved to paediatricians in West, North,
and South Auckland
• There has been an increasing trend for heart disease to be diagnosed prenatally or in the
new born nursery
• Increased numbers of infants and children are surviving complex cardiac surgery
• More intensive surveillance of at risk groups has resulted in earlier treatment and
reduction in long-term morbidity and mortality.
Page 7
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2500
2000
1500
1000
500
0
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2004-2005
New Appt
667
724
601
579
617
642
Follow-up
829
973
984
1166
1167
1546
Figure 5. Paediatric
Cardiology Outpatient Visits
Cardiac investigation is frequently included as part of the outpatient visit (Figure 6).
100%
80%
New Appt
Follow-up
60%
40%
20%
Figure 6. Investigations per clinic
visit (2004)
0%
CXR
ECG
Echo
Holter
Page 8
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2.5 Peripheral Clinics
Peripheral paediatric cardiology clinics are undertaken in all major metropolitan centres and
in most regional centres. There are 103 clinic days per year including 5 in dedicated adult
congenital clinics). The 1057 patients seen in 2004-05 were solely the result of tertiary
referral.
Clinic
Blenheim
Christchurch
Dunedin
Gisborne
Hastings
Invercargill
Nelson
Palmerston North
Rotorua
Tahiti
Taranaki
Tauranga
Waikato
Wellington
Whakatane
Whangarei
Total
2002-03
47
3
5
2
4
4
3
4
2
11
5
2
5
97
2003-04
1
44
1
1
3
2
1
6
3
5
4
2
8
6
1
3
91
2004-05
1
44
4
2
5
3
1
5
4
5
4
4
7
6
1
7
103
In addition to outreach clinics the service places considerable emphasis on maintaining
children in their home regions. Although there are no paediatric cardiologists resident outside
Auckland there are a number of paediatricians and cardiologists with subspecialty skills in
this area who provide high quality surveillance of cardiac children. There is close liaison
between these clinicians and the Green Lane Paediatric and Congenital Cardiac Service. The
degree of support is considerable and involves telephone consultation and frequently review
of echocardiograms, electrocardiograms and other cardiac investigations. Consultation of this
nature that resulted in written responses are summarised below (Figure 7).
100
80
60
40
20
0
April
May
June
July
August
Follow-up
46
49
37
11
42
September
55
First Contact
37
45
9
15
27
29
Page 9
Figure 7. Consultation where the
patient was not seen by a
cardiologist but a written opinion
was given based on review of patient
data (clinical summary, and/or
echocardiogram,
MRI,
Holter
monitor, or electrocardiogram)
between April and September 2005.
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2.6 Fetal cardiology
There are 1.5 clinics per week in conjunction with the high risk obstetric service. Volumes
fetal echocardiograms have been steady (Figure 8).
200
150
100
50
0
Total
2001-02
2002-03
2003-04
2004-05
175
206
187
198
Figure 8. Fetal Cardiology outpatient
volumes.
Patients are referred from the upper half of the North Island (Figure 9) while fetal diagnosis
from the rest of the country is dealt with via review of video tapes of echocardiograms.
South Island
Other North
Island
Bay of Plenty
Waikato
Northland
Counties
Manukau
Waitemata
Auckland
0
100
200
300
400
Figure 9 Domicile of patients
seen in fetal cardiology clinic
July 2001-June 2005.
Forty percent of referrals are for known or suspected fetal cardiac anomalies. The remainder
are referral for high risk screening.
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
2001-02
2002-03
2003-04
2004-05
Followup
26.9%
20.4%
13.9%
19.2%
Others
10.9%
17.5%
23.5%
18.7%
Suspected CHD/arrythmia
41.1%
35.4%
31.6%
41.4%
Family history
21.1%
26.7%
31.0%
20.7%
Page 10
Figure 10. Indications for fetal
cardiology outpatient referral
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2.7 Adult Congenital Heart Disease Service
The Adult Congenital Heart Disease (ACHD) Service has continued to develop in response to
the needs of this rapidly expanding population. The core team comprises two cardiologists
(Drs Tim Hornung and Clare O’Donnell) from the PCCS staff, Dr Ivor Gerber from the adult
cardiac service and the adult congenital specialist nurse, Annette Neugebauer, who work
closely with the PCCS surgical and ICU teams. In addition, an adult cardiac registrar is
rotated to the PCCS team and spends much of their attachment gaining experience with this
group of patients. We have valuable input from a health psychologist, Lucy Barnes, but have
been unable to secure funding to allow Lucy to become a permanent team member.
Cardiac surgeons from the Paediatric and Congenital Cardiac Service (Mrs Finucane and Dr
Rumball) undertake surgical procedures on these patients in the adult cardiology operating
theatres. Patients convalesce in the adult cardiac ICU and adult cardiac surgical ward.
The service has conducted a weekly clinic at Green Lane Hospital with also a developing
network of Outreach Clinics (currently Tauranga, Waikato, Christchurch, Wellington,
Palmerston North and New Plymouth). We are fortunate to have cardiologists with an
interest in congenital heart disease in a number of centres around the country and close liaison
is maintained to assist with evaluation and care of adult congenital patients, with transfer to
Auckland as necessary for assessment or treatment. Inpatients over the age of 15 are
accommodated in Wards 31, 42 and the Cardiothoracic ICU and a number of study days have
been held to assist staff from these and other departments in the hospital in caring for these
complex patients.
A Transition Clinic has been launched to assist in patients transferring from the paediatric
service to the adult congenital service and other educational resources have been developed,
including web-based information, handouts and personal credit card sized cards to assist
patients and their families.
Patient volumes are summarised below (Figure 11).
32
36
96
Figure 11. Adult Congenital
Heart Disease 2004-05
378
Surgical admissions
Cardiac Catheterisation
Outpatients
Medical admissions
Page 11
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
2.8 Cardiac Inherited Disease Group (CIDG)
CIDG locally comprises the coordinator (Jackie Crawford) and the clinical leader, Dr Jon
Skinner. The laboratory diagnostics for LQTS has transferred from the University to the
Auckland District Health Board (Lab Plus). Carey Nel is the Auckland University based full
time research assistant. She will be focusing on the gene negative cohort.
There have been 23 referrals from Australia. In New Zealand there are 85 LQTS referrals, (40
gene positive), a registry of 62 families with HCM, 12 with DCM, 4 with Marfans, 55 with
ARVC- including 15 referrals over the last year. Sudden death post mortem referrals continue
to arrive at about 1-2 per month. 40 have been or are in processing.
Clinical innovations have included the coordinated HCM/genetic counselling clinic,
coordinated by Jackie and led by Dr Jim Stewart and Jenny Warrington.
Other time has been spent on Grant applications, political representation- re the new Coroners
Bill. The development of Tragady, the trans-Tasman task force on Sudden Death in the
Young. The CIDG website is being further developed (www.cidg.org) and monthly
teleconferences are held between Auckland, Wellington, Waikato and Christchurch. The
coordinator has spent much time in organising these meetings, taking and scribing the minutes
and developing the many and complex ethics applications.
The database , though still not in use, continues to be developed and is planned to go into
operation for the onset of the national LQTS gene forensic testing sometime in 2006.
Page 12
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
3. Investigative services
3.1 Echocardiography
The service employees 4 sonographers working 3 FTE. Two of the sonographers rotate 6
months about with the adult cardiology service.
Equipment includes 4 cardiac ultrasound machines (Sonos 5500), one of which was donated
by the Variety Club (1998), and another by the Starship Foundation (2003). Paediatric
inpatient and outpatients and Adult Congenital inpatients are examined at the Starship
Hospital facility, while Adult Congenital Outpatients are examined at the Green Lane Clinical
Centre by sonographers from the Paediatric and Congenital Cardiac Service.
The number of echocardiograms is increasing at an annual rate of 8-10% in inpatients and
outpatients (Figure 12) reflecting the growing importance of echocardiography in diagnosis
and surveillance. There has been a greater increment in Adult Congenital Heart
echocardiography although overall numbers are considerably smaller.
160
3500
140
3000
120
2500
100
2000
80
1500
60
1000
40
500
20
0
0
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
2004-05
Paediatric Transthoracic
1834
2052
2187
2145
2442
2616
2825
Paediatric Epicardial
Total Paediatric
1961
2161
2311
2271
2569
2775
3006
Paediatric Transoesophageal
Figure 12a. Paediatric Echocardiograms
– Total and Transthoracic
1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05
1
5
14
15
18
20
33
126
104
110
111
109
139
148
Figure 12b. Paediatric Echocardiograms
- Epicardial and transoesophageal
600
2500
500
2000
400
1500
300
1000
200
100
500
0
0
Inpatient
Outpatient
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
ACHD Transoesophageal
13
41
32
38
47
45
50
2279
ACHD Transthoracic
65
168
200
217
340
369
437
1492
ACHD Total
78
209
232
256
387
414
488
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
2004-05
1342
1570
1666
1652
1798
1946
697
799
877
875
1158
1243
Figure 12c. Echocardiograms
In patient and Outpatient
Figure 12d. Echocardiograms -Adult
Congenital Heart Disease (ACHD)
Page 13
2004-05
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
A number of paediatric echocardiograms involve sedation particularly in infants aged 3 – 24
months. These are undertaken within the clinic area of the department and are supervised by a
cardiologist and a suitably qualified nurse. There were no adverse events in the 173 infants
sedated over the past year.
Numbers of echocardiograms undertaken for other services have increased since moving to
The Starship Children’s Hospital from Green Lane Hospital (Figure 13).
1
140
120
100
80
60
40
20
0
2003/ 2003/ 2004/ 2004/ 2004/ 2004/ 2005/ 2005/
1
2
2
3
4
3
4
1
14
64
83
59
95
122
93
97
Figure 13.
Echocardiograms for
other services (by
quarter).
3.2 Cardiac MRI
The Cardiac MR Service, run jointly by Dr Chris Occleshaw and Dr Tim Hornung, performed
170 MR scans on children and adults with congenital cardiac disease, including
approximately 40 cases performed under general anaesthesia. Additional cases on patients
from the South Island were performed by Dr Sharyn MacDonald in Christchurch. The
opening of the Centre for Advanced Mr Imagining at Auckland University in December 2004
allowed for the majority of our cases to be performed in this facility, which was purposedesigned for cardiac patients and has full anaesthesia and resuscitation facilities. The waiting
time for a booking was sharply reduced and the cost per case was also reduced due to the very
advantageous contract arranged between the University of Auckland and the ADHB.(Figure 14)
250
200
150
100
50
0
Cardiac MR
2001-02 2002-03 2003-04 2004-05
68
131
201
Page 14
170
Figure 14. Cardiac MRI in
children and adults with
congenital cardiac disease
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
3.3 Cardiac Catheterisation
Cardiac catheterisation is undertaken with a dedicated paediatric laboratory using Seimens
biplane equipment. A number of personnel are involved in addition to the catheterising
cardiologist including nursing staff, physiology technicians, radiographers, anaesthesia staff, a
cardiac radiologist and, on occasion an echocardiologist.
There were a total of 341 cardiac catheterisation procedures undertaken in 2004-05 (excluding
electrophysiological studies), including 197 (58%) interventional procedures (Figure 13). The
median procedure time was 80 minutes (range 2-300) with a median of 17 minutes
fluoroscopy (range 1-80 minutes). Over 90% of cases were done under general anaesthesia,
and 39% (137) involved transoesophageal (72) or transthoracic (65) echocardiography.
Volumes of procedures are increasing but are constrained by available sessions. The number
of sessions increased from 4 to 5 in 2005 with utilisation of the fifth session constrained by
cardiologist availability (approximately 65% staffed). Throughput was adversely affected by a
series of software and hardware breakdowns with the biplane imaging equipment. Six cases
were stopped mid procedure and many cases were cancelled on the same day or the day
before the procedure. This culminated in temporary closure of the laboratory while major
maintenance and componentry replacement was undertaken. During this time emergency and
suitable elective cases were performed using the adult catheterisation laboratory’s single
plane system.
There is a requirement for increased volumes: At the start of 2006 there were 137 pts
scheduled mainly in the first half of the year. It remains to be seen whether the addition of a
5th session and functioning equipment will reduce the pressure on the waiting time to 2
months as was previously the case.
400
350
300
250
200
150
Figure 15. Cardiac
Catheterisation volumes
( electrophysiology studies
excluded)
100
50
0
1994
-95
1995
-96
1996
-97
1997
-98
1998
-99
Diagnostic
1999
-00
2000
-01
2001
-02
Interventional
Page 15
2003
-04
2004
-05
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
Age at Catheterisation
0-1 year
1-15 years
> 15 years
Total
90 (27%)
172 (51%)
79 (23%)
341______
Dr Nigel Wilson is the team leader in the catheterisation laboratory is the most involved
cardiologist. Dr Peter Ruygrok is responsible for atrial septal defect closure in older (adult)
patients. A registrar assisted in 309 cases (89%). A second consultant cardiologist will
frequently scrub in for complex and high risk interventions and in this occurred in 54 cases
(16%).
There is evidence of increasing skill level with a decreased procedure time and fluoroscopy
time for ASD closures over the last 7 years (Figure 17).
Figure 17. Mean FT and PT times (min) from 1997 to 2004
3.3.1. Diagnostic Cardiac Catheterisation
Outcomes of Diagnostic Catheterisation (n=143)
Aims achieved
Incomplete angiogram
Incomplete haemodynamics
Not recorded
134 (94%)
2 (1%)
1 (1%)
6 (4%)
3.3.2 Interventional Cardiac Catheterisation
Fifty eight percent (196/339) of cardiac catheters were interventional procedures. These
included: ASD closure
42
PDA transcatheter closure
32
Vessel angioplasty
35
Balloon valvuloplasty
25
Stents
19
Ventricular septal defect closure 10
Balloon atrial septostomy
9
Miscellaneous
24
Page 16
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
Outcomes of Interventional Catheterisation (n=196)
Successful
Partially successful
Unsuccessful
Not recorded
161 (82%)
11 (6%)
18 (9%)
6 (3%)
Transcatheter closure of perimembranous ventricular septal defects was introduced following
a visit by Professor Ziyad Hijazi, from the University of Chicago.
3.3.3 Complications
There were 40 complications in the 339 diagnostic and interventional procedures (12%).
There were no deaths. Four patients required surgery because of device embolisation (1
immediate and 3 semi-acutely). Complications are listed in the table below:
Complication Type
Number
Description
Life threatening
Significant
8 (2.4%)
7 (2.0%)
Minor
25 (7.5%)
CPR - 4 (3 closed, one open)
Brachial plexus injury – 2
Hypotension requiring treatment
Surgery for device embolisation - 4
Pulse reduction responding to heparin
Failed access
Arrhythmia requiring antiarrhythmic medication or DC
cardioversion
3.4 Electrocardiography and Exercise tests
Numbers of electrocardiograms have increased over the past 24 months in part related to
increased outpatient clinic volumes and referrals within the Starship Hospital (Figure 17).
3000
100
2500
80
2000
60
1500
40
1000
20
500
0
2000-2001 2001-2002 2002-2003 2003-2004 2004-2005
ECG
2068
2022
2285
2351
2650
ETT
43
80
86
66
73
Page 17
0
Figure 17. ECGs and
Exercise Tests. Numbers
exclude cardiopulmonary
exercise testing undertaken
at the Green Lane Clinical
Centre.
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
3.5 Electrophysiology
Paediatric and congenital electrophysiology utilises a biplane electrophysiology laboratory
within the adult cardiac catheterisation suite. Technical staff are drawn from the cardiac
physiology department. Of the 169 ablations over the past 3 years there have been 15 failures
(9%) and no major complications. One patient developed LBBB and mild mitral regurgitation
that had resolved 3 months after the procedure (Figure 18).
80
EP Study only
Ablation
60
40
Figure 18. Electrophysiology
studies. Filled = children, empty
= adults.
Numbers were reduced 2003-04
because of move to new hospital.
20
0
2002-03
2003-04
2004-05
3.6 Pacemaker
From July 2004 to June 2005, 22 permanent pacemakers were implanted, 73% of these were
dual chamber rate responsive (DDDR) units. In the ACHD group 7 DDDR pacemakers were
implanted. Implantable loop recorders were placed in 4 paediatric patients and in one ACHD
patient. Implantable defibrillators were placed in 2 paediatric patients.
Staff from the Department of Cardiac Physiology provide technical support during
implantation of devices such as permanent pacemakers, implantable loop recorders and
implantable defibrillators. The technical staff perform the follow-up checks on these devices
within the Auckland, Northland and Hawkes Bay region. They also act as advisors to other
pacemaker follow-up centres throughout NZ with regard to programming, troubleshooting
and planning of further pacemaker surgery.
3.7 Cardiac Registry
During this time the Cardiac Registry was returned to being a useful teaching collection. An
audit was begun in July 2004 to ascertain the correct data regarding which organs had been
retained. It was discovered that several specimens had been affected by formalin crystals and
thus an additional audit regarding this problem was undertaken, completed and hopefully
corrected.
The Registry was used for individual teaching sessions. After a hiatus of four years, the
Registry specimens were again used in an Echocardiographic course which included cardiac
morphology demonstrations and hands-on teaching sessions.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
4. Nursing
Charge Nurse Ward 23B
Stephanie Hlohovsky
Nurse Educator
Michal Noonan
Paediatric Cardiac liaison Nurse
Heather Spinetto
Paediatric Cardiac Surgical Nurse Specialist
Marion Hamer (acting)
2005 marks the first full calendar year for Stephanie Hlohovsky as Charge Nurse of the Green
Lane Paediatric and Congenital Cardiac Service at Starship Hospital. It has been a positive
year for nursing with continued low staff turn over, new staff recruitment, ongoing education
and the creation of two new nursing roles within the service.
4.1 Nursing Leadership Vision within PCCS
•
•
•
•
•
•
•
Provision of a high standard of clinical care at the bedside, striving for excellence.
A model of nursing care that is innovative, family focused and efficient with high
satisfaction from the public consumer.
Sound basis of research and audit, with evidence based practice.
Provision of ongoing clinical support and education at the bedside.
“Growing our own” senior nursing staff.
Sound documentation and pathways.
Unit of Nursing Excellence—where nurses want to come and work.
4.2 Occupancy
•
•
•
Ward 23B has 22 physical beds and is resourced to run at 70% occupancy MondayFriday i.e. 16 beds and 55% occupancy i.e. 12 beds Saturday and Sunday.
Based on these figures our average occupancy was 97.8% (Figure 19).
We have met our target of Nurse Hours/Patient day with an average of 8.1 NHPPD.
120%
12
100%
10
80%
8
60%
% Occupancy
07/ 08/ 09/ 10/ 11/ 12/ 01/ 02/ 03/ 04/ 05/ 06/
04 04 04 04 04 04 05 05 05 05 05 05
90% 104 97% 81% 107 95% 82% 106 94% 89% 107 96%
RN hours/patient day 8.6 7.8 8.1 10.1 7.5 8.5 10.5 8
9.2 8.6 7.8 8.6
Figure 19. % Occupancy and Registered Nurse hours per patient day.
Page 19
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
4.3 Nursing Staff and Recruitment
Currently ward 23B has 30 Staff Nurses giving a FTE of 22.3. The Total budgeted
FTE is 24.7 giving 23B a vacancy of 2.4 FTE. Of these 12.5 FTE (56%) are level 3
and 4 Nurses, 5.4 FTE (24%) are level 2 Nurses, 3.6 FTE (16%) are New Graduate
Nurses and .8 FTE (3%)are Enrolled Nurses.
• 1 Clinic Nurse (.6 FTE)
• 2 Clinical Nurse Specialists (2 FTE)
• 1 Nurse Educator (.6 FTE)
• 1 Resource Nurse ( Temporary Position)
We are actively recruiting and will have our vacancies filled by Feb 2006. We continue to
have a low staff turnover and are fortunate to have nurses returning to ward 23B after their
experiences overseas.
•
Recognizing the shortage of experienced paediatric nurses and acknowledging our desire of
“Growing our own” senior nursing staff we have taken advantage of the ADHB New graduate
program and have successfully supported 4 New Graduates in 2005. Based on the success
form 2005 we have decided to increase our quota for New Graduates and will be taking 3 for
next intake.
4.4 Nursing Education
Nursing Staff each attended 3 – 5 days of ongoing education offered through Learning and
Development at ADHB. We also provided two days of Cardiac Nursing Specific Education
and a senior Nurses Professional development Day.
Consistent with our vision of providing ongoing clinical support and education at the bedside,
nursing staff attend weekly education sessions every Wednesday at 1100hrs.
Paediatric Cardiology has also been involved with providing education to other clinical areas
within ADHB as well as WDHB, CMDHB, NDHB, AUT and Unitec.
Michal Noonan has completed her Masters of Nursing (2005).
We are currently working with PICU and Massey University in developing a paper specific to
Paediatric Cardiac Nursing and hope to offer the paper in the latter part of 2006.
4.5 Professional Development
Starship’s Paediatric Cardiology nursing staff were well represented at the World
Congress of Paediatric Cardiology in Buenos Aires Argentina. A team of seven nurses
attended the conference. Of these seven, three presented posters, one gave a
presentation and one moderated a session.
4.6 Development of Nursing Roles
The role of coordinator has been in the PCCS service for some years, and focuses on the
operational running of the morning shift, Monday to Friday. With our desire to provide a
high standard of clinical care at the bedside and a model of nursing care that is innovative,
family focused and efficient with high satisfaction from the public consumer we have
expanded the co-ordinator role to a clinical resource nursing position. The purpose of the role
is to provide expert clinical assistance and teaching to the nurse at the bedside. The charge
nurse has taken on a more clinically visible role. The charge nurse is present for handover,
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
PICU rounds, and ward rounds. The clinical resource nurse starts later in the morning and
provide support later into the day. This role is a trial position that will be evaluated in June
2006.
Given the complexity of our Cardiac Surgical patients and the limited support available for
the Cardiac Surgeons we are in the process of Developing a Surgical Nurse Practitioner Role
for the Cardiac Services. This new role would incorporate case management, teaching, liaison
with families, and through best practice, role modelling good clinical care. Discharge
planning is key to the role. This would account for 50% - 60% of the ward workload, ensuring
the Charge Nurse has greater input into the standard of care and model of care provided. This
role would have to be at a specialist level with an expectation of audit and research attached
to the role. Currently Marion Hamer is acting in this role. Pat O’Brien form Boston is coming
in February 2006 to help us further explore and develop the Nurse Practitioner and how it
would work in the Starship context.
4.7 Home INR testing
Home INR testing programme was reviewed this year.
The finger-prick INR home testing programme was instigated 1999.
The programme incorporates
• training of the child and their family for home INR testing,
• quality assurance activities
• risk management practices.
Although initially trialled in Auckland, by 2000 all New Zealand cardiac children discharged
from hospital requiring anticoagulant therapy were put on the programme.
A five year period, 2000-2004 inclusive was evaluated .
• 181 enrolments (75% , 15yrs of age)
• 147 self testing, 11 assisted by community nursing services, 21 discontinued (2
unrelated deaths)
The review included only cardiac children on warfarin managed by the Auckland Paediatric
Cardiac Service (n=60), and identifies age and clinical reason for initiation on to the
programme and any bleeding events that have occurred.
Results of admissions for adverse events showed :
Total admissions 11 (10 patients one child admitted x2)
6.8 hospital admissions /100 patient years of warfarin
There were no thrombotic events during this study period.
1.87 serious bleeds / 100 patient years of warfarin (0.6% serious bleeds per year)
Conclusion
• The Auckland programme for INR home testing achieves a rate of 1.25 serious bleeds
per 100 patient years of warfarin. This compare favourably with international
published data.
• Spontaneous events were more common in younger age group however risk taking
behaviour in adolescents increased the possibility of consequential events in the older
age group.
• This programme empowers children, young people and their families to remain in the
community and successfully manage an important aspect of their own health.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
5. Academic
5.1 Peer Reviewed Articles
Prasad SK, Soukias N, Hornung T, Khan M, Pennell DJ, Gatzoulis MA, Mohiaddin RH. Role
of magnetic resonance angiography in the diagnosis of major aortopulmonary collateral
arteries and partial anomalous pulmonary venous drainage. Circulation. 2004;109:207-14.
Lissin LW, Li W, Murphy DJ Jr, Hornung T, Swan L, Mullen M, Kilner P, Gatzoulis MA.
Comparison of transthoracic echocardiography versus cardiovascular magnetic resonance
imaging for the assessment of ventricular function in adults after atrial switch procedures for
complete transposition of the great arteries. Am J Cardiol. 2004;93:654-7.
Li W, Hornung TS, Francis DP, O'Sullivan C, Duncan A, Gatzoulis M, Henein M. Relation of
biventricular function quantified by stress echocardiography to cardiopulmonary exercise
capacity in adults with mustard (atrial switch) procedure for transposition of the great arteries.
Circulation. 2004;110:1380-6.
Soukias N, Hornung TS, Kilner PJ, Frogoudaki A, Davlouros P, Wong T, Gatzoulis MA.
Determinants of atrial arrhythmia late after atriopulmonary Fontan operation. Hellenic J
Cardiol 2004;45:384-90.
Khairy P, Landzberg MJ, Lambert J, O’Donnell C. Long-term outcomes after the atrial
switch for surgical correction of transposition: a meta-analysis comparing the Mustard and
Senning Procedures. Cardiology in the Young 2005;14(3)284-293.
Skinner JR, Chong B, Fawkner M, Webster DR, Hegde M. Use of the newborn screening card
to define cause of death in a twelve year old diagnosed with epilepsy. Journal of Paediatrics
and Child Health 2004;40:651-653
Skinner JR, Chung S-K, Montgomery D, French J, Rees M. Near-miss SIDS due to Brugada
syndrome. Arch Dis Child 2005;90:528-529
Groves A, Knight D, Kuschel K, Skinner JR.
Cardiorespiratory stability during
echocardiography in preterm infants. Arch Dis Child 2005; 90: 86-87
Wilson D, Moore P, Finucane AK Skinner JR. Cardiac Pacing in the management of severe
pallid breath-holding attacks. Journal of Paediatrics and Child Health 2005;41:1-3
Haas NA, Fox S, Skinner JR. Successful use of an intravenous infusion of flecainide and
amiodarone for a refractory combination of postoperative junctional and ectopic tachycardias.
Cardiol Young 2005;15:1-4
Solomon NA, Finucane KA, Skinner JR, Kerr A. Mild supravalvular aortic stenosis with left
coronary obstruction in a neonate. Ann Thorac Surg. 2005 Jun;79(6):2153-5.
Greene AE, Skinner JR, Dubin AM, Collins KK, Van Hare GF. The electrophysiology of
atrioventricular nodal reentry tachycardia following the Mustard or Senning procedure and its
radiofrequency ablation. Cardiol Young 2005; 15(6) 611-6.
Skinner JR, Chung S-K, Montgomery D, et al. Ventricular fibrillation and SCN5A mutation
associated with near-miss SIDS. Arch Dis Child 2005;90(5):528-9.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
Gentles TL, Cowan BR, Occleshaw C, Colan SD, Young AA. Fiber shortening after
coarctation repair: Geometric variation and through-plane motion influence single plane
indices of left ventricular function. J Am Soc Echocardiography 2005;18(11):1131-6.
Cardiorespiratory stability during echocardiography in preterm infants Groves A, Knight D,
Kuschel K, Skinner JR Arch Dis Child 2005; 90: 86-87
Skinner JR Is there a Link between SIDS and long QT interval? Archives of Disease in
Childhood 2005;90(5):445-9.
Cormack B, Wilson NJ, West T, Finucane KF. The Use of Monogen for Pediatric
Postoperative Chylothorax. Annals of Thoracic Surgery 2004: 77:301-305
Yew G, Wilson NJ. Transcatheter Atrial Septal Defect Closure with the Amplatzer Septal
Occluder: 5 Year Follow-Up.
Catheterisation and Cardiovascular Interventions
2005;64(2):193-6.
Van Pelt N, Wilson NJ, Lear G. Severe coronary artery disease in the absence of
supravalvular stenosis in a patient with Williams Syndrome. Pediatric Cardiology
2005;26(5):665-7.
Cutfield J, Ruygrok PN, Wilson NJ, Raudkivi PJ, Greaves SC, Gentles TL, Kerr AJ.
Transcatheter closure of a complex post-myocardial infarction ventricular septal defect after
surgical patch dehiscence. Internal Medicine Journal 2005;35(2):128-30.
5.2. Book chapters
Catheter interventions in coarctation and recoarctation. TS Hornung, LN Benson, PR
McLaughlin. Harrison’s Principles of Internal Medicine Online.
Transposition of the Great Arteries. TS Hornung. In: A Textbook of Adult Congenital Heart
Disease, Eds. Gatzoulis, Webb, Daubeney. In press.
5.3 Other publications
Is there any relationship between SIDS and QT prolongation? International Long-QT
symposium 2004 http://lqts-symposium.org/ing_topics2.shtml
Information for coroners and pathologists and Long-QT syndrome and allied conditions
implicated in sudden cardiac death with a negative post mortem. Royal College of
pathologists of Australasia- December newsletter, 2004. www.rcpanz.org.nz
5.4 Invited Presentations
Gentles TL. Echocardiographic evaluation of left ventricular function. Cardiac Society of
Australia and New Zealand Annual Scientific Meeting, Brisbane, August 2004.
Gentles TL. Assessment of diastolic function in paediatric cardiology. Cardiac Society of
Australia and New Zealand Annual Scientific Meeting, Perth, August 2005.
O’Donnell C. Congestive heart failure management- an update. Starship Paediatric update
2004.
O’Donnell C. Outcomes of Complex Congenital Heart Disease. Paediatric Society, Rotorua,
October 2004.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
N. Wilson. Follow up of Kawasaki Disease. NZ Paediatric Update March 10, 2004.
N. Wilson. Paediatric cardiology: implications for neurological development. Children’s
Therapy conference. 25 March 2004.
N. Wilson. Starship Pediatric Update. Interventional Pediatric Cardiology 14 April 2004.
N. Wilson. IJN Live (Interventional Paediatric Cardiac Catheterisation Symposium.)
Problems and complications of transcatheter PDA occlusion, Kuala Lumpur, Malaysia, 11
June 2004.
N. Wilson. IJN Live (Interventional Paedatric Cardiac Catheterisation Symposium.)
Paediatric Intervention in Asia Pacific region, 13 June 2004.
5.5 Presentations and Abstracts
Yew G. Wilson NJ. Five Year Follow-Up following atrial septal defect (ASD) closure with
the amplatzer septal occluder (ASO) in children and adults. [Abstract] Heart Lung and
Circulation 2004;13S2:S1-S132.
Wilson NJ, Morreau J, Voss L, Stewart J, Lennon D. The influence of subclinical carditis on
the diagnosis of acute rheumatic fever (ARF) [Presentation and Abstract] Heart Lung and
Circulation 2005;14S:S1-S154.
Bijl JM, Ruygrok P, Hornung TS, Wilson NJ, West T. Percutaneous Closure of patent
foramen ovale without general anaesthesia and echocardiographic guidance. [Abstract]
Heart Lung and Circulation 2005;14S:S1-S154.
Gentles TL, Finucane AK, Wilson NJ. Outcome of the left ventricle after surgery for aortic
and mitral regurgitation in children and young adults. [Abstract] Heart Lung and
Circulation 2005;14S:S1-S154.
Wilson NJ, Wilson E, Lennon D, Voss L, Morreau J, Stewart J, Nicholson R. Monoarthritis
as a presentation of acute rheumatic fever (ARF) in a New Zealand setting. [Presentation and
Abstract] Heart Lung & Circulation 2005;145:51-S1-S154.
Skinner JR, Chong B, Fawkner M, Webster DR, Hegde M. Use of the newborn screening
card to define cause of death in a twelve year old diagnosed with epilepsy. Journal of
Paediatrics and Child Health 2004;40:651-653
JR Skinner, Sea-Kyung Chung, J Crawford, J French, MI Rees. SCN5A mutations – a link to
Febrile convulsions and sudden infant death. Heart Lung and Circulation 2004;13S2:S40
Abstract 93
H Borthwick, C Bhala, C McCulley, J Crawford, Sea-Kyung Chung, J French, M I Rees, JR
Skinner. 24 hour beat to beat QT analysis in genetically characterised families with Long-QT
syndrome. Heart Lung and Circulation 2004;13S2:S87 Abstract 205
LM Maher, T Jones, RF Smith, I Tripp, W Smith, JR Skinner. Accuracy and repeatability of
algorithms to predict Accessory pathway location in children with WPW syndrome. Heart
Lung and Circulation 2004;13S2:S23 Abstract 52.
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The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
JR Skinner, C McCulley, J Crawford, S-K Chung, H McAllister, J French, AN Shelling, MI
Rees. Spectrum of Mutations in Long-QT Genes in New Zealand Long-QT Syndrome Cases.
Heart Lung and Circulation 2004;13S2: S89 Abstract 210
Al-Salama T, West T, Riddell F, Searby K, Kerr A, Finucane K, Skinner JR. Outcome for
children receiving a pacemaker implantation at Green Lane Hospital over a 40 year period.
Heart Lung and Circulation 2005;14S:S141 Abstract 349
Page 25
The Green Lane Paediatric and Congenital Cardiac Service
Annual Report 2004-2005
6. Medical Staff
6.1 Consultant Medical Staff
Tom Gentles
Clinical Director
Paediatric & Congenital
Cardiac Service
Director, Paediatric Cardiology
Echocardiography
Fetal Cardiology
Interventional Cardiology
Nigel Wilson
Team Leader:
Cardiac catheterisation
Interventional cardiology
Fetal cardiology
Jon Skinner
Team Leader
Electrophysiology
Inpatient cardiology
Invasive and non-invasive
electrophysiology
Pacing
Inherited cardiac disease
Tim Hornung
Co-team leader
Adult congenital heart disease
Adult Congenital Heart Disease
Cardiac Magnetic Resonance
Imaging
Clare O’Donnell
Co-team Leader
Adult congenital heart disease
Interventional Cardiology
Adult Congenital Heart Disease
Pulmonary Hypertension
Louise Calder
Paediatric Cardiologist
Cardiac Morphology
6.2 Consultant Surgical Staff
Kirsten Finucane
Director Paediatric Cardiac Surgery
Paediatric and Congenital Cardiac
Surgery
Elizabeth Rumball
6.3 Junior Medical Staff
Paediatric Cardiology Fellows
Paediatric Registrars
Cardiology Registrars
Cardiac Surgical Registrars
Paediatric and Congenital
Cardiothoracic Surgery
Darshan Kothari
Dzung Nguyen
Nidal Nahar
Jacob Twiss
Jamie Speeden
Rebecca Griffifth
Colette Muir
Vesna Markovich
Janine Whale
Mariam Buksh
Justin Wilde
Ruvin Gabriel
Darius Korczyk
Boris Lowe
Sunil Sumangala
Glenn McKay
Page 26