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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. Page 3 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. Page 4 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. Page 5 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. Page 18 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 6 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, Page 20 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. Page 21 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. Page 22 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. Page 23 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. Page 24 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