Implementation of a computer-guided consultation in the Liverpool Sleep Service
The Liverpool Sleep Centre provides secondary and tertiary care for Liverpool and a large part of the North West. It is the second busiest centre in terms of Sleep studies and referrals (GIRFT data) and has the largest cohort of Narcolepsy (chronic sleep disorder) patients in the North West.
Liverpool has the top two most deprived areas in the UK and a huge demand for respiratory and non-respiratory sleep services due to the combination of obesity, social deprivation and mental health problems. Prior to COVID the service was in crisis due to long wait times. Referrals increased from 1,400 per year in 2012 to over 5,000 per year in 2019.
Previously, all referrals to the sleep service were vetted, underwent a sleep study and the results of which together with the information contained in the referral letter were reviewed by a Consultant in a virtual clinic with treatment decisions made in such clinics.
In order to meet this demand, the service required 5 Consultant virtual clinics consisting of 20 patients each.
The main concern in the service was safety of the patients who were awaiting review and the inability to prioritise patients except by consultant review. The team had no single database as information was spread over a number of systems leading to inefficiencies and difficulties of monitoring performance or auditing the service.
Due to long waits in the diagnostic service in the North West, a number of inexperienced services had been started which had led to instances of hypoventilation being missed and poor quality care.
To provide better care to patients with the use of technology to address the challenges the team experienced.
Since 2015, a team of the Sleep Consultants partnered with SleepHealth Solutions to develop a clinical decision support system (CDSS) for Sleep medicine. The team validated the product against expert clinicians and confirmed that it performs at least as well as a Sleep physician even when used by a non specialist.
Following a test programme in 2018-19, the Aintree hospital site (LUHFT) procured the CDSS in 2021 and all staff were trained in its use prior to the start date.
From March 2021 to January 2022, 1,047 patients with suspected obstructive sleep apnoea syndrome (OSAS) were assessed by paramedical staff using the CDSS. Only 14% of these patients subsequently required a consultant review either in a virtual or a face to face clinic (translating into just 0.5 clinics weekly).
The CDSS is a digital ecosystem comprising multiple intelligent consultations encompassing the entire sleep pathway including assessment and diagnosis, Continuous Positive Airway Pressure (CPAP) set up, monitoring on CPAP and issuing consumables thus acting as an end to end system solution and an Electronic Patient Record.
The CDSS features a “clinical dashboard” allowing the service to track activity, monitor referral to treatment performance and identify high risk patients e.g. sleepy drivers, hypoventilation in real time. Difficult cases are highlighted for a weekly multidisciplinary team meeting and to filter patients with hypoventilation into more intense follow up clinics. The CDSS generates automated clinical letters for each review thus greatly reducing secretarial time and costs for the service.
The implementation of the system has resulted in pathway transformation enabling Consultant resource to be channelled to where it is most required and enhancing service capacity, efficiency and patient safety.
The number of consultant review clinics is reduced at the start of the pathway (post diagnostic test) by 86%. This is approximately 12 programmed activity (PA) per week of consultant time.
In addition, consultants are now able to only review patients with complex sleep problems or hypoventilation. Most patients reviewed by physiologists do not require further review if there are no alerts from the software or physiology team.
Safety has improved as the clinical dashboard provides greater visibility of the patients which can be tracked through the pathway. The team can download the whole database into excel or SPSS and audit their performance as well as checking for demographics and any trends.
The team has reported that the most deprived areas tend to have poorest compliance for CPAP so this group could be highlighted for more intensive review to reduce health inequalities in their system.
The staff like using the software and have reported that they feel they are getting training in Sleep medicine as they can now take a very detailed Sleep history and the software helps alert them to abnormalities. The team have had a number of medical students through the service who have also used it very effectively.
The software has improved efficiencies in CPAP set up by 40-50% as the programme acts as an EPR enabling the CPAP practitioners to rapidly start the CPAP pickup with built in drop down menus.
The team have discovered high rates of insomnia in their patients which is interesting as these patients can be rejected by “Respiratory” Sleep centres. The vast majority had OSA as a cause of maintenance insomnia showing that it is important to investigate so-called primary insomnia and exclude common sleep disorders first. The team have reported the first 350 patients but are now up to over 700 and will continue to review their patient cohort and inform referrers/CCGs.
The clinical team has noted the educational value of the software for patients and staff members and they regularly have medical students, clinical scientists and respiratory nurses training on the software. This ensures consistency across the department and high levels of satisfaction in their students and junior staff.
A clinical digital support system to allow a specialist or non-specialist to undertake assessment of patients with a sleep condition.
- The system supports initial assessments including patient history, examination and prompting investigation
- Reviews supporting interpretation of sleep tests using intelligent algorithms
- Automates patient letters, reports and alerts
The system can be used remotely or during face-to-face consultations in secondary care/specialist sleep centres.
Key learning points
- The development of the software has been long and time consuming. All work on the software by the clinicians has been unpaid and performed out of hours. It has taken many months to convince the hospital that investing in alternative pathways rather than paying for waiting list initiative clinics is a good idea.
- Having a searchable database, a clinical dashboard with overview of patients and a specialist Sleep EPR is already paying dividends. The staff are better educated as they are learning how to take a proper sleep history and the data and information that the team have on the patients is very valuable for research and audit.
- The team has already shown that insomnia is extremely prevalent in their population despite the fact that they do not have a formal insomnia service. The team is able to pick out sleepy drivers or those patients with restless legs syndrome or hypoventilation and can track how the service is performing each week.
- Perseverance is key to this type of project as lots of testing of algorithms is required as well as validation. In addition, finance has been the big stumbling block but showing the improved throughput for CPAP set up and improved patient safety should persuade CCGs that this is more cost effective than paying for waiting list initiative clinics.
- To speak to commissioners, primary care providers and procurement team and explain the rationale behind the pathway change and get as many people on board as possible.
Patients can attend face-to-face at Liverpool Sleep service to pick up their sleep study kit and a staff member fill out the initial review. Alternatively, a dedicated call centre has been introduced to telephone patients who are unable to attend in person or fill out the review digitally. This ensures consistent and accurate information and does not exclude those with limited access to SMART phones or those with lower digital literacy.
Find out more
- Implementation of a computer guided consultation (intelligent clinical decision support system software) in the Liverpool sleep service: the creation of a digital ecosystem to transform patient pathways
- Implementation of a computer guided sleep consultation with an initial technician review allows early characterisation and prioritisation of patients for management
- Use of a computer guided consultation (clinical decision support system) enables detailed characterisation of patients presenting to a teaching centre sleep service and shows that insomnia is frequently reported in this patient group
Dr Sonya Craig, Sleep and respiratory physician, University Hospital Aintree
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