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SACH Ultrasound
Courses
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Dr Stellan Batsman Dr Jari Havela Caj Skoglund
Visited Blairgowrie, Brechin, Pitkerro; Stonehaven & Forfar Leith & Edinburgh If this is Tuesday…
Norrbotten visitors tour Tayside. - January 2010
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Tromso 2010 – Preparatory Visit for Life Long Learning Programme application
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SACH Centre for Ultrasound, AECC
Courses
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Commissioned by Scottish Association of Community Hospitals. Run in Skottland For GPs/Midwives
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Dr Hamish D. Greig
GP Out of Hours, Angus.
Formerly a GP Principal in Brechin, 22yrs
Prev Chair of The Scottish Association of
Community Hospitals (SACH)
Organiser of SACH Ultrasound Courses
Who am I?
General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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Vad heter ni?- Dr Hamish D. Greig
• For yke? - GP Out of Hours, Angus.
• Varifran?- Jag kommer fran Brechin, Skottland.
• Praktikant du US,
• Sa roligt att ses igen!
Talar du Engelska?
General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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Vad heter ni?- Dr Hamish D. Greig
• For yke? –Natt lakare, Angus.
• Varifran?- Jag kommer fran Brechin, Skottland.
• Praktikant du US, “lillebror” du Dr Budgie Hussain
• Sa roligt att ses igen!
Talar du Engelska?
General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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Vad jag ska talar 1. I am a clinician not a Sonographer -Lakare 2. I use ultrasound as a tool- immediate 3. I am aware I am a Praktikant –we must all realise our limitations 4. Javisst, I can talk for Scotland –I am here both days – come and talk to me! 5. My presentations contain more information than we can cover but it will be available to you.
• Tack for inviting me/SACH. • Dr Pervez Hussain “Budgie” is the real hero
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GP Ultrasound in rural practice, Scotland Vilhelmina 2013
Geography of Brechin
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GP Ultrasound in rural practice, Scotland Vilhelmina 2013
Geography of Brechin
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NW area of
Brechin
Practice
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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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Sweden or Scotland?
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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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Links
• Screening data
• Clinical cases
• Ultrasound Courses
• Aberdeenshire
• Community Health Partnership aspects
• Course Programme Scans
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Principles • Adds to Clinical skills • Follow RCGP/RCR
Guidelines 1993; 2010 • Awareness of
limitations • Aim –improved
diagnoses and referrals
Opportunities • Early pregnancy • Pregnancy viability - accepted practice • General Abdominal – esp GB and kidneys • Pelvic Ultrasound • Prostate/bladder • Aneurysms –screen/FU
SACH Ultrasound
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SACH /Univ Bournemouth ULTRASOUND COURSE
SACH Ultrasound Courses • Theoretical & Practical course
with support for supervised practice to obtain Univ Bournemouth Certificate. RCGP/RCR Guidelines
• 3-4:1 Delegates:tutor per station • In cahoots with Dr Budgie
Hussain & team, • Centre for Ultrasound, University
of Bournemouth.
CHIC
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SACH /Univ Bournemouth ULTRASOUND COURSE
Aims To improve access for patients to
diagnostic tests within the community
To reduce unnecessary travel / a Sustainability agenda
To support Remote & rural practice esp intermediate care and community hospitals
Model for other subjects/use of Telemedicine
CHIC
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! Introductory Course ! Log book –Abdomen,
Pelvis & Obstetrics ! Case studies " Accreditation • CPD/mentoring " Post grad Certificate " US Diploma
• NHS Education in Scotland Support
• Prof Gillian Needham FRCR
• University of Bournemouth AECC
• Dr P Budgie Hussain and Dr David Kay FRCR
SACH Ultrasound
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GP US Scotland • Dr Joan Noble MRCGP
FRCP • Dr R Liddell Dip US • 18 yrs experience • 1-2 sessions per week • Referrals from partners
and specialists
• Advantages • Waiting time <2 weeks • Immediate if required • Enables quicker diagnosis and
more accurate treatment • Referrals more accurate with
scan prints & report - often OP not required
• Accepted Direct for surgery • So Patients & Surgeons happy!
SACH Ultrasound
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Vilhelmina April 13 13-11-09
Evaluation Ultrasound Course Carnoustie 2011
“Very useful and appropriate course - structured with lectures fitting into the practical process; a lot of practical training.” GP
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Vilhelmina April 13 13-11-09
Evaluation Ultrasound Course Carnoustie 2011
What did you think? Was the course? Excellent V.Good Good Adequate Poor?
Appropriate for your - Personal needs? 100%
Appropriate for your - Service needs? 88% 12%
Was the quality of presentations? 100% Was the quality of the workshops? 100% Was the format of the course? 100% The Quality of the venue? 100% The Scope to network? 88% 12%
Overall educational experience? 100%
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SACH Vilhelmina April 2013
Vilhelmina April 13 13-11-09
Nairn Integrated Primary Care centre and Community Hospital
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GP US Scotland Audit • Of 49 cases Scanned • Referrals saved
14 AN + 2 EPU 3 Gynae + 3 urology 14 Raigmore Scans
• ~ 72% that would otherwise have gone elsewhere
• Aortic Aneurysm Screen • Male 65-75 yrs (600) • 555 attended 92.5% • Full CVS Diab screen • AAA – 27 = 5% • 6 operations + 21 F Up • 41 incr BP + 2 new Diab
SACH Ultrasound
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GP US Arran Scotland • Aortic Aneurysm
Screen • Each year 65th
Birthday = 90 / yr • 3 AAA all small • Further 4 ops in 5yrs
after the project
Criteria for referral • > 4.5 cm require review
by specialist with result • Or accelerated progress
• National Screening Program + Arran
Receptionists scanning!
SACH Ultrasound
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GP US Scotland • Early Pregnancy Loss
Working Group • “GPs can provide a
service”. • For example One year
in Nairn • 22 pat 5 Rh-ve
Results • 14 Vag bleeding • + 8 Routine Scans • 20 GP Scan +
• 8 Evac RPOC • 2 Nat Resolution
• 45% Sole care GP • 3 ongoing Pregnancies • 7 Natural Resolution
SACH Ultrasound
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GP US Scotland • Early Pregnancy Loss • Advantages of GP
Scan • Familiar Staff & Place • Continuity of Care • Partner present almost
all the time
• No bad news in AN Clinic • Immediacy of Scan and
result –counselling • Rescan by same person if
required. • More Appropriate use of
Specialist resources
SACH Ultrasound
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Case 1 – (Natt yrke) 19yr old female 12hrs hypogastric pain Para 0+1 1st trimestre Bleeding ++ which has
settled. ?Early abortion ?Missed
abortion
On exam. • Uterus Just Palpable • Lower abdomen
slightly tender, general, not localised pain
• Urinalysis HCG + ve Blood +
SACH Ultrasound
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Case 1 19yr old female 12hrs hypogastric pain Para 0+1 Seen x1 already - now
00.30 am Anxiety, no transport,
supportive partner.
Uterus with amorphous mass RPOC
SACH Ultrasound
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Case 2 phone call 21yr old female 12hrs hypogastric pain Para 0+1 Seen x1 already
– during evening HCG +
Urinalysis Neg so given Dihydrocodeine
Observe & Review SOS
SACH Ultrasound
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Case 2 (attend Community hospital)
21yr old female Rural patient Glenclova 13hrs hypogastric pain Para 0+1 BO 5 days ago Seen x 1 already…. Has
brought Mother and bag
On exam. • Uterus Just Palpable • Lower abdomen tender • Bowel palpable – BS++ • ?Constipation ?Early
abortion
SACH Ultrasound
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Case 2 21yr old female 14hrs hypogastric pain Para 0+1 Worried ++ Seen x 1 already - now
01.30 am Previously advised
admission might be required
SACH Ultrasound
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Case 3 42yr old female 12/52 1-2 hrs bleeding/<period Para 2+ 0 Lower Abd ache Urinalysis Blood + Counselled - Conservative
management.
SACH Ultrasound
Unfortunately, sometimes you do not find what you want. – blighted ovum. Sac 8/52
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Case 4 30yr man Restless Pain RUQ & R
loin to R Groin Haematuria ?dilated calyces
SACH Ultrasound
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SACH Ultrasound
Case 4 30yr man Pain RUQ & R loin
Haematuria Dilated
calyces –obstructed kidney 2ry to Calculus
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SACH /Univ Bournemouth ULTRASOUND
COURSE. Resources eg Centre for Ultrasound http://www.cusultrasound.co.uk/contact-and-
location.aspx
BMUS Video Library http://www.bmus.org/about-ultrasound/au-
videocase.asp
http://www.ultrasoundcases.info/ http://www.cetl.org.uk/learning/tutorials.html
CHIC
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10 Hospitals within 1 CHP that work as a network providing complementary services to the local area
Guiding Principle:-‐ “Care should be delivered
locally whenever it is safe and feasible to do so”
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Community Hospitals in rural practice, Scotland Hemavan April 2009
Aberdeenshire Community Hospitals –”Shire”
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Challenges for Aberdeenshire CHP • Local Change
– Intermediate Care Audits x 2 – 25% of patients in Acute bed could be cared for in an
alternative setting – 40% shift in Outpatient activity from 2ry to 1ry Care – Changing routes of admission - Emergency Care Centre – Assessing the impact of changes in Acute Sector bed
configuration and usage – Our own ambitious plans to develop the capacity of primary
and community care services
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Community Hospitals in rural practice, Scotland Vilhelmina April 2013 prev Hemavan
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• Endoscopy – Upper & lower GI endoscopy - 4 centres • Ultrasound Scans – Accredited GP Service – General & Gynae /
obstetrics - an extension of clinical skills – Course provided locally by CHP, SACH & accredited provider with NES & Grampian HB support. ~2000 scans done in the last year
• Cardiac assessment – Exercise Treadmill + Echo +/- Holter monitor Cardiomemo
• Chemotherapy – oral Chemo clinics for Bowel CA
• A&E – 11 units all linked via Telelink to Aberdeen A&E - Network
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Community Hospitals in rural practice, Scotland Hemavan April 2009
Aberdeenshire Community Hospitals –”Shire”
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• Endoscopy – Upper & lower GI endoscopy - 4 centres
• Ultrasound Scans – Accredited GP Service – General & Gynae / obstetrics - an extension of clinical skills – Course provided locally by Community Health Partnership, SACH & accredited provider with NHS Education for Scotland & Grampian HB support. ~2000 scans done in the last year
• Cardiac assessment – Exercise Treadmill + Echo +/- Holter monitor Cardiomemo; Risk Stratification for surgery
• Chemotherapy – oral Chemo clinics for Bowel CA
• A&E – 11 units all linked via Telelink to Aberdeen A&E - Network
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Community Hospitals in rural practice, Scotland Hemavan April 2009
Aberdeenshire Community Hospitals –”Shire”
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Fraserburgh Banff
Huntly
Insch
Inverurie
Aboyne
Banchory
Stonehaven
Turriff Peterhead
Key:-‐ Dermatology Minor Surgery Orthopaedics Modernised Elderly Care Services Diabetes INR Testing ENT Psychogeriatrics
Endoscopy Ultrasound Cardiac Assessment
Ellon
Westhill Portlethen
Alford
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Shire simulation 2007
Aberdeen
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SACH /Univ Bournemouth ULTRASOUND
COURSE.���CHIC
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Aberdeenshire “The Shire” Ultrasound Endoscopy - Upper GI & Σoscopy (Screening
for Colon CA) Cardiology -Stratification of CHD patients
Exercise ECG/Echocardiogram Minor Surgery Dermatology Orthopaedics ..etc…
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SACH /Univ Bournemouth ULTRASOUND
COURSE.���CHIC
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Case spread:- General Abdominal work Obstetrics –not anomaly screening Gynaecology (+/- Transvaginal app.) Urinary Tract Investigation Musculoskeletal problems Deep Venous Thrombosis in conjunction
with other tests Thyroid problems Guidance eg Insertion of lines/ LP/Taps
41
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SACH /Univ Bournemouth ULTRASOUND
COURSE.���• Aberdeenshire CHP - GPWSI Ultrasound Service
• 2009/10 Audit of GPwSI Scans Onward Referred To Secondary Care.
Total Scans 2266 from 11 GPWSI (of 14) Onward referrals 381 =16% Now 2013 7%
But these are not a true reflection of the service as this includes all scans referred elsewhere.
CHIC
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Vilhelmina April 13 13-11-09
Chart 1: Aberdeenshire GPSI Ultrasound Scanning Activity 2010/11
Source: Health Intelligence (CHP Monitoring Proforma) 43
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Aberdeenshire CHP - GPWSI Ultrasound Service���2009/10 Audit of GPwSI Scans ���Onward Referred To Secondary Care. CHIC
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Reason for Onward Referral
No. Scans Referred
Comments
Second opinion 63 Includes patients with complex history / known abnormalities/prev surgery; GPSI request for rescan; ongoing symptoms; Follow up after previous secondary care scans/appointment.
Type of Scan not done by individual GPwSI
TV/Pelvic -105
TV 36; Pelvic 69
Testicular - 13
Liver related 90 Cancer/poss cancer 28
Gynae/?Pregnancy/IVF 24
Kidney 10 Muscular/MSK 6 Other/Misc 42 Requested by Patient/ At GP request/?Mass/? Haematoma/? Abscess/ Child/
Aortic Aneurysm/ Spleen/ Complex cyst/ Bowel/referral to Urology/?hernia/ patient in wheelchair. incl scan not done in Community - 1 x DVT 1 x thyroid
381 44
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Aberdeenshire CHP - GPWSI Ultrasound Service���2009/10 Audit of GPwSI Scans ���Onward Referred To Secondary Care. CHIC
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SACH /Univ Bournemouth ULTRASOUND
COURSE.���Resources amongst others
BMUS Video Library http://www.bmus.org/about-ultrasound/au-
videocase.asp
http://www.ultrasoundcases.info/
http://www.cetl.org.uk/learning/tutorials.html
CHIC
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SACH Vilhelmina April 2013
Vilhelmina 2013 13-11-09
Adamson Memorial Hospital, Cupar, Fife
P Zanre Photo
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SACH /Univ Bournemouth ULTRASOUND
COURSE.���SACH /NES courses • 3 day course Theoretical + Practical
–”Hands on” Diagnostic US • Log book + Accreditation • 45 GPs + 4 A&E/urology + 12
midwives • 40 + Accreditations 2006-9 • ****Star NHS Grampian • Tayside & Nairn GPwSi • Skye & Arran
CHIC
13-11-09 Vilhelmina 2013
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Vilhelmina April 13 13-11-09
Chart 3: Aberdeenshire Minor Surgery Attendances (Percentage), 2004-2010
49
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Vilhelmina April 13 13-11-09
Chart 7: Aberdeenshire Community Cardiology Activity, 2011/12
50
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Det var allt! Tack myket
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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013
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