* Please describe the challenges or problems your solution set out to solve.
440,000 people in England have cardiac pacemaker or defibrillators, each with a 75% lifetime chance of needing an MRI. Despite annual investment of over £100million in ‘MRI-safe’ devices, patients often cannot access MRI due to historical (unfounded) safety concerns and lack of provision (Appendix-A,B), leading to delays in diagnosis and treatment.
We conducted a nationwide survey and calculated that 50-70,000 such patients are denied essential scans (growing 10% per year)[1,5,6] – a 70-fold underprovision(Appendix-C). Based on these results we developed and implemented local training, pathways and protocols to deliver timely provision of MRI to device patients, currently being expanding nationally.
* Please describe the actions you took to achieve your result.
Anecdotal experience from patients with cardiac devices and referring clinicians (eg. Arrhythmia Alliance, pacemakerclub.com, Appendix-B,D),[3,4,7] together with our national survey data has highlighted difficulties with access to MRI. This leads to diagnostic delays, longer hospital stays and inability to deliver optimal therapy (eg. ‘Cyberknife’). Patients requested a ‘one-stop’ service for MRI, whereby devices could be re-programmed and scans acquired at a single location on a single visit.
To provide this streamlined ‘one-stop’ service at St Bartholomew’s Hospital, we trained a team including administrators, physicians, physiologists and radiographers, and developed and implemented a standard operating procedure(Appendix-E). This was designed to prevent unnecessary request refusals, prevent delays both to scheduling and during scanning, and so improve patient experience, outcome and safety.
Following requests from referrers, we worked with physicists at the National Institutes of Health (USA) to design cardiac MRI sequences optimized for device patients, leading to significantly fewer non-diagnostic scans and enhanced clinical impact (Society of Cardiac MRI Investigator Finalist 2017, publication submitted JACC). These optimised scans are now included in the clinical pathway to aid cardiac arrhythmia ablation. With time, we have gained economies of scale: radiographers now scan device patients without direct consultant supervision, and we are one of two UK centres to scan non-MRI conditional devices.
The financial implications of the project were minimal – the changes involved were primarily organizational and logistical, incorporating better cross-disciplinary communication. Patients do require device checks to be performed pre- and post-scan, meaning increased demand on pacing staff.
We have local agreement to bill for two device checks per scan to cover this(Appendix-F) and, in response to rapidly rising demand, after inviting world experts to visit (UPenn, USA), we developed the business case for a specialist “device-MRI practitioner”, responsible for administrative and technical service aspects.
The clinical benefit is high – common requests are for suspected cord compression, stroke and cancer, or planning for radiotherapy or neurosurgery. Early diagnosis makes clinical and economic sense;[9,10] the financial cost alone of a late cancer diagnosis is £4,000 and an extra bed day costs £222.
Given essentially absent service prior, clinical and cost benefits are not simply incremental: patients would have had no access to standard care. In the short term, prompt decision making means early patient discharge and alternative suboptimal investigations avoided. In the medium to long term, health savings accrue with downstream cost savings of reduced population morbidity, and associated social care.
* Please list the most significant results
• Over 24 months, MRI provision to device patients increased six-fold to become the largest centre nationally, 20 times the national average (Appendix-G).
• Waiting time reduction: 60(IQR:34-71) to 15(IQR: 4-45) days.
• No complications, despite scanning increasingly complex cardiac devices.
• Inpatients: n=41 (19%). 83% expedited patient flow (discharge, inpatient procedures); 3 bed-days faster for internal referrals (Appendix-G).
• Cancer investigation: n=24 (11%). 8(IQR:0-32) day wait; 83% allowed treatment within the national 62- day standard. No pre-intervention service.
• External referrals: n=85 (40%). No pre-intervention service. 41 days faster for internal referrals (Appendix-G).
• No reduction in total departmental activity.
• Zero fixed costs.
* Describe how your project has spread to other teams, departments or organisations
• Locally, our service is embedded into patient pathways eg. for life-threatening heart rhythms.
• Regionally, demand (without publicising) has created a supra-regional hub (Appendix-H).
• Training: hosting and delivering BSCMR-endorsed training courses, with a commissioned educational articles in-press.
• Industry collaboration: Siemens are incorporating our metal artefact reduction strategy as product on all MRI scanners.
• NHS Innovation Clinical Entrepreneur Fellowship awarded to promote and improve MRI scan provision to device patients.
• National Society involvement: Four national societies (BSCMR, BHRS, ABN, BSCI) and patient group (Arrhythmia Alliance) collaborating with us to help scale provision. BHRS Guidelines have changed in response to our recommendations.