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Bradycardia and Emergency Pacing Study Day (CCU, QEUH)

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Monday 4th April
10-5(ish)

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Pacing and Cardiac Devices in Critical Care

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Pacing and Cardiac Devices in Critical Care

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Wednesday  30th March 2022
9-12.

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COVID-19 Supervision and Assessment

The COVID-19 pandemic has meant some changes to the supervision and assessment arrangements for nursing and midwifery students in practice in Scotland to enable them, if they so wish/are able, to support the health and care system during this time of emergency. This webpage has been set up to signpost or host some resources that students and their supervisors and assessors may find useful to access.

Student Support Guidance during COVID-19 Outbreak

The NMC have introduced emergency programme standards to enable more flexibility to ensure students get appropriate support and supervision in this challenging time. The NMC emergency programme standards for nursing and midwifery education can be accessed here

Student Support guidance for Scotland during COVID-19 Outbreak for medical, nursing and midwifery students which is based on NHS England national guidance has been endorsed for use in Scotland by the Chief Medical Officer, the Chief Nursing Officer, the Scottish Terms and Conditions Committee, the Nursing and Midwifery Council, and the General Medical Council. In summary it indicates that:

Nursing and Midwifery Students in year one will continue with their studies and remain on their programme. However, the nature of the programme will be adapted so that students will see their academic studies continue but their clinical placement time will be paused.

Nursing and Midwifery students not in first year and not in the final six months of their pre-registration programme will be given the option to opt into a revised programme structure of 80% in clinical practice 20% academic study. This is voluntary and if students do not feel able to opt in to this they will be supported by their university to consider the options available to them.

Nursing and Midwifery students in their final six months of their pre-registration programme will be given the option to opt in to a revised programme structure whereby they move in to clinical practice during this emergency period. It will not be possible for students to be supernumerary during their time in clinical practice during this emergency situation, but they will receive appropriate support and supervision within an appropriate delegation framework.

You may wish to read the full document and a copy of this guidance can be found below:
Nursing and Midwifery and Medical Student Support Guidance
Delegation Framework

The NMC emergency programme standards indicate that a framework should be used to aid clinical decision making when delegating to those "non supernumerary" students who have opted into the revised programme structure when they are out in the practice learning environment. The resources below outline the recommended delegation framework that should be used as a clinical decision-making guide when delegating in practice. It will support practitioners who are returning to the register during COVID19 or existing practitioners to delegate effectively and safely to non supernumeray paid students who will be out in practice learning environments.

This framework is shared with permission from the Northern Ireland Practice and Education Council for Nursing and Midwifery Practice and is a framework for delegation of nursing and midwifery practice and is suitable for all healthcare practioners working in Scotland at this time.

The framework can be accessed here. A pocket guide can also be downloaded for use and can be accessed here. This delegation framework can also be found on TURAS learn where tehere are a number of other delegation resources that health and social care practitioners may find useful during this time of service redesign. Access at https//learn.nes.scot/28973/coronavirus-covid-19/delegation

Deciding to Delegate - a support resource for health professions across health and social care can be accessed on vimeo here

Deciding to Delegate - using the delegation framework in nursing practice - 3 scenarios can be accessed at https://vimeo.com/403694033

Essential Learning (Induction)

Those 2nd, 3rd and 4th year nursing and midwifery students who opt in to a revised programme structure will be paid for the contribution they will make to the workforce. As part of the employment process students require to undertake essential learning a copy of these requirements can be seen below.
Nursing and Midwifery Students Essential Learning (Induction)
Please note that this essential learning document signposted students to the latest versions of COVID-19 resources at time of publication on 21 April 2020. However, with evolving evidence emerging daily in relation to COVID-19, students are advised to review the Health Protection Scotland website at https://www.hps.scot.nhs.uk for the most up to date information.
Please note that for students who received the 2nd April (version 1) of the Nursing and Midwifery Students' Essential Learning (Induction) the 4 nations have since agreed to utilise the following guidance (available on the Health Protection Scotland COVID-19 site) associated with resuscitation: COVID-19 Resources: Guidance for first responders and others in close contact with symptomatic people with potential COVID-19 https://www.hps.scot.nhs.uk/web-resources-container/covid-19-guidance-for-first-responders-and-others-in-close-contact-with-symptomatic-people-with-potential-covid-19/ The Nursing and Midwifery Students' Essential Learning (Induction) document will be updated as Health Protection Scotland guidance is updated.
Frequently Asked Questions for Mentors, Sign Off Mentors, Practice Teachers

A number of frequently asked questions from mentors and practice teachers with regards to supervision and assessment during the COVID-19 crisis can be found here

Practice Supervisor and Practice Assessor Resources

The NMC emergency programme standards enable more flexibility to ensure students get appropriate support and supervision and may see the enactment of the Standards for Student Supervision and Assessment (SSSA) within Scotland prior to our original September 2020 date. In order to support this possible change the NMAHP Practice Education team have produced a shortened voiceover PowerPoint that provides an overview of the new NMC Standards of Prroficiency for Nurses and Midwives and the Standards for Student Supervision and Assessment (SSSA). The powerpoint with accompanying notes can be accessed here. The same presentation is also available in wevideo and vimeo format.
Please note that the students on paid placement during the COVID-19 crisis are to be assessed against the proficiencies, essential skills clusters and learning outcomes detailed in their ongoing achievement record (OAR). Undergraduate programmes based on the Future nurse: Standards of proficiency for registered nurses and Standards of proficiency for midwifes do not begin in Scotland until September 2020 or September 2021.
Preparation for Practice Supervisors and Practice Assessors

This is an interim Practice Supervisor and Practice Assessor Learning Resource, developed in partnership by the national expert working group led by NHS Education for Scotland (NES) to support the implementation of the new standards for student supervision and assessment from the Nursing and Midwifery Council (NMC, 2018).

The units are intended as learning materials to support local training and preparation of practice supervisiors and practice assessors. The inteded audience are those involved in the support, supervision and assessment of pre and post-registration nursing and midwifery students. During this COVID19 period the learning resource has been made available in pdf format with some of the content truncated. The full version will be available as an online module on TURAS Learn later in the year.

Teaching and Learning in Practice - a resource to support clinical practitioners

Teaching in the clinical envrionment may be about supporting a colleague to use new equipment, learn a new procedure or develop underpinning theory around an aspect of care they are delivering. Understanding some principles of teaching practice and theory can help ensure your teaching is effective. One such resource is available here.

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The COVID-19 pandemic has meant some changes to the supervision and assessment arrangements for nursing and midwifery students in practice in Scotland to enable them, if they so wish/are able, to support the health and care system during this time of emergency.

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Learn Blood Transfusion Section  LBT: Safe Transfusion Practice

Statutory / Mandatory Section
GGC: 001 Fire Safety
GGC: 002 Health and Safety, An Introduction
GGC: 003 Reducing Risks of Violence & Aggression
GGC: 004 Equality, Diversity and Human Rights
GGC: 005 Manual Handling Theory
GGC: 006 Public Protection (Adult & Child)
GGC: 007 Standard Infection Control Precautions
GGC: 008 Security & Threat
NES: Safe Information Handling - Foundation

Role Specific Mandatory Modules Section
GGC: 061 Management of Needlestick&Similar Injurie
GGC: 062 Managing Skin Care at Work for Managers (managers only)
GGC: 063 Managing Skin Care for Responsible Person
GGC: Falls Prevention Training

Infection Prevention and Control
Section: NES: Scottish IPC Education Pathway – Foundation
- Hand Hygiene
- Prevention and Management of Occupational Exposure

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Due Dates for Mentorship Updates, Annuala and Triennial 2019

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Due Dates for Mentorship Updates, Annuala and Triennial 2019

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Nursing and Midwifery CPD Portfolio - Sign in

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The Nursing and Midwifery CPD Portfolio has been developed to enable nurses and midwives across Scotland to generate, record, reflect upon and share evidence of their learning and continuing professional development. This evidence can then be used by nurses and midwives as part of appraisals, career development, programmes of learning and for regulatory purposes, including NMC revalidation.

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all you need to know to get you started....

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training calendar

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Select titles for further information and click link to open flyers where available.

Additional Palliative / End of Life Care education and training is often provided by hospices. Search for 'education' on each website or call and ask to speak to the education coordinator for the latest information.

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Palliative Care Education / Training Calendar

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Select titles for further information and click link to open flyers where available. Additional Palliative / End of Life Care education and training is often provided by hospices . Search for 'education' on each website or call and ask to speak to the education coordinator for the latest information.

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https://nww.ggcbank.allocate-cloud.com/BankStaff/(S(rzvmatkulyoyi3squfgz04l3))/UserLogin.aspx

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Bank Staff                           Quick Reference Guide

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Bank Staff                           Quick Reference Guide

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Achievement of Sign-Off Mentor Status Doc

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Achievement of Sign-Off Mentor Status Doc

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Achievement of Sign-off Mentor Status document interactive version revised 07-03-13

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May 2017

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compared 2 non invasive treatments and reduced the rate of angiograms.....

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pan-Glasgow involvement...
demonstrated that in patients with suspected angina, investigation by cardiovascular magnetic resonance resulted in a lower probability of unnecessary angiography within 12 months than NICE guideline–directed care

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Importance Among patients with suspected coronary heart disease (CHD), rates of invasive angiography are considered too high.

Objective To test the hypothesis that among patients with suspected CHD, cardiovascular magnetic resonance (CMR)-guided care is superior to National Institute for Health and Care Excellence (NICE) guidelines-directed care and myocardial perfusion scintigraphy (MPS)-guided care in reducing unnecessary angiography.

Design, Setting, and Participants Multicenter, 3-parallel group, randomized clinical trial using a pragmatic comparative effectiveness design. From 6 UK hospitals, 1202 symptomatic patients with suspected CHD and a CHD pretest likelihood of 10% to 90% were recruited. First randomization was November 23, 2012; last 12-month follow-up was March 12, 2016.

Interventions Patients were randomly assigned (240:481:481) to management according to UK NICE guidelines or to guided care based on the results of CMR or MPS testing.

Main Outcomes and Measures The primary end point was protocol-defined unnecessary coronary angiography (normal fractional flow reserve >0.8 or quantitative coronary angiography [QCA] showing no percentage diameter stenosis ≥70% in 1 view or ≥50% in 2 orthogonal views in all coronary vessels ≥2.5 mm diameter) within 12 months. Secondary end points included positive angiography, major adverse cardiovascular events (MACEs), and procedural complications.

Among 1202 symptomatic patients (mean age, 56.3 years [SD, 9.0]; women, 564 [46.9%] ; mean CHD pretest likelihood, 49.5% [SD, 23.8%]), number of patients with invasive coronary angiography after 12 months was 102 in the NICE guidelines group (42.5% [95% CI, 36.2%-49.0%])], 85 in the CMR group (17.7% [95% CI, 14.4%-21.4%]); and 78 in the MPS group (16.2% [95% CI, 13.0%-19.8%]). Study-defined unnecessary angiography occurred in 69 (28.8%) in the NICE guidelines group, 36 (7.5%) in the CMR group, and 34 (7.1%) in the MPS group; adjusted odds ratio of unnecessary angiography: CMR group vs NICE guidelines group, 0.21 (95% CI, 0.12-0.34, Results P < .001); CMR group vs the MPS group, 1.27 (95% CI, 0.79-2.03, P  = .32). Positive angiography proportions were 12.1% (95% CI, 8.2%-16.9%; 29/240 patients) for the NICE guidelines group, 9.8% (95% CI, 7.3%-12.8%; 47/481 patients) for the CMR group, and 8.7% (95% CI, 6.4%-11.6%; 42/481 patients) for the MPS group. A MACE was reported at a minimum of 12 months in 1.7% of patients in the NICE guidelines group, 2.5% in the CMR group, and 2.5% in the MPS group (adjusted hazard ratios: CMR group vs NICE guidelines group, 1.37 [95% CI, 0.52-3.57]; CMR group vs MPS group, 0.95 [95% CI, 0.46-1.95]).

Conclusions and Relevance In patients with suspected angina, investigation by CMR resulted in a lower probability of unnecessary angiography within 12 months than NICE guideline-directed care, with no statistically significant difference between CMR and MPS strategies. There were no statistically significant differences in MACE rates.

Clinicaltrials.gov Identifier: Trial Registration NCT01664858.

Coronary heart disease (CHD) is a leading cause of death and disability worldwide. Several methods are available to diagnose CHD, risk-stratify patients, and determine the need for revascularization. Myocardial perfusion scintigraphy (MPS) by single-photon emission computed tomography is the most commonly used test worldwide for the assessment of myocardial ischemia, with robust evidence supporting its prognostic value. However, cardiovascular magnetic resonance (CMR) is increasingly recognized as having high diagnostic accuracy and prognostic value.

Despite the widespread availability and recommendations for noninvasive imaging in international guidelines, invasive coronary angiography is commonly used early in diagnostic pathways in patients with suspected CHD. Evidence from large populations presenting with chest pain has confirmed that the majority will not have significant obstructive coronary disease; a large US study reported that approximately 60% of elective cardiac catheterizations found no obstructive CHD. Thus, avoiding unnecessary angiography should reduce patient risk and provide significant financial savings.

Current guidelines for investigation of stable chest pain advocate management based on the pretest likelihood of CHD. However, pretest likelihood models can overestimate CHD risk, therefore paradoxically increasing the probability of invasive coronary angiography. To date, there are no large-scale comparative effectiveness trials of different functional imaging strategies recommended by current guidelines.

The Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 (CE-MARC 2) trial was designed to test the hypothesis that in patients with suspected CHD, CMR-guided care is superior to national guidelines-directed care and MPS-guided care in reducing the occurrence of unnecessary invasive angiography within 12 months.

Key Points

Question In patients with suspected coronary heart disease, does a strategy involving cardiovascular magnetic resonance (CMR) result in less unnecessary angiography than a myocardial perfusion scintigraphy (MPS) strategy or a national guideline that included sending high-risk patients directly to angiography?

Findings In this clinical trial, both CMR and MPS strategies significantly reduced unnecessary angiography rates compared with national guidelines (7.5% for CMR, 7.1% for MPS, 28.8% for national guidelines); no statistically significant differences were seen between CMR and MPS strategies. There was no statistically significant difference in major cardiovascular event rates at 12 months between the 3 groups.

Meaning Noninvasive functional imaging strategies reduced unnecessary angiography compared with guidelines-directed care.

CE-MARC 2 was a multicenter, 3-parallel group, randomized clinical trial. It used a pragmatic comparative effectiveness design to determine the efficacy and safety of 3 strategies (CMR-guided care, MPS-guided care [following American College of Cardiology Foundation and American Heart Association appropriate use criteria], and UK National Institute for Health and Care Excellence [NICE] guidelines [CG95]) for investigating patients with suspected CHD. The study was conducted in accordance with the protocol (available with the statistical analysis plan in Supplement 1), which was approved by the UK National Research Ethics Service (12/YH/0404) and institutional review boards of the participating centers. Study conduct was in accordance with the Declaration of Helsinki; all patients provided written informed consent.

Patients with suspected angina pectoris were eligible if they were 30 years or older, had a CHD pretest likelihood of 10% to 90%, and were suitable for revascularization. Exclusion criteria included nonanginal chest pain, a normal MPS or cardiac computed tomography (CCT) result within the previous 2 years, being clinically unstable, previous myocardial infarction, previous coronary revascularization, and contraindication to any study noninvasive imaging test (eTable 4 in Supplement 2). Self-reported race/ethnicity was collected using Office for National Statistics fixed categories.

Patients were assigned using minimization, incorporating a random element and 1:2:2 allocation ratio through an automated 24-hour secure-access telephone service by the Clinical Trials Unit. Allocation was to 1 of 5 equally sized groups (A:B:C:D:E, stratifying on center, age [30-64 years and ≥65 years], CHD pretest likelihood [10%-29%, 30%-60%, 61%-90%], and sex) following whether management was by NICE guidelines-directed care (NICE guidelines group; group A) CMR-guided care (CMR group; groups B or C) or MPS-guided care (MPS group; groups D or E). Patients randomized to the NICE guidelines group were scheduled for CCT for patients with a pretest likelihood of 10% to 29%, MPS for patients with a pretest likelihood of 30% to 60% or sent directly to coronary angiography for patients with CHD pretest likelihoods of 61% to 90%.

All investigations were performed and interpreted by certified local physicians using protocols conforming to international standards. Quality assurance was undertaken centrally throughout the trial by blinded, independent, modality-specific imaging experts (eTable 3 in Supplement 2). Ten percent of scans for each modality at each recruiting center were centrally reviewed for image quality and report accuracy. Detailed protocols for each imaging modality and criteria for reporting a positive result have been published; a positive scan for CMR, MPS, or CCT resulted in protocol-defined invasive coronary angiography and fractional flow reserve (FFR) measurement. FFR measurement (PressureWire, St Jude Medical) was performed in all coronary vessels of 2.5 mm diameter or more with a 40% to 90% stenosis. When FFR measurement was not possible for clinical or safety reasons, quantitative coronary angiography (QCA) was performed. All FFR and QCA results were analyzed at the Glasgow Angiographic Core Laboratory by a single, independent, blinded observer. Positive angiography was defined as any lesion with an FFR value of 0.8 or less, or, if FFR measurement was not performed, a percentage diameter stenosis of 70% or higher in 1 view or 50% or higher in 2 orthogonal views.

The primary end point was protocol-defined unnecessary coronary angiography occurring within 12 months, defined by a normal FFR value (or QCA) in all vessels 2.5 mm or more in diameter. By design, this included any unnecessary angiography occurring after a false-positive test result, patients with high CHD pretest likelihood sent directly to coronary angiography (NICE guidelines group only), and imaging results that were either inconclusive or negative but overruled by the responsible physician. Secondary end points included a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, unplanned coronary revascularization, and hospital admission for cardiovascular cause), and positive angiography rates (recommended by the independent data monitoring and ethics committee). Complications directly related to trial investigations resulting in prolonged hospital stay or specific treatment were prespecified as safety secondary end points. Quality-of-life outcomes and cost-effectiveness analyses will be reported subsequently.

An independent data monitoring and ethics committee and trial steering committee assessed study conduct, integrity, and safety every 6 months (eTable 2 in Supplement 2).

Allowing for 20% noncompletion, 1200 patients would provide the study with 99% power to detect a difference in unnecessary angiography between CMR-guided care and NICE guidelines-directed care (using 2:1 allocation), and 94% power between CMR-guided and MPS-guided care based on projected unnecessary angiography proportions of 4.5% for the CMR group, 11.7% for the MPS group, and 30% for the NICE guidelines group (2-sided, 5% significance for continuity-corrected χ ² test).

Logistic regressions were used to model odds of an unnecessary angiogram for CMR-guided management vs both NICE- and MPS-guided management, including stratification factors (treating centers as fixed effects). Analyses used intention-to-treat populations and were repeated in per-protocol populations. Multiple imputation (by fully conditional specification) was used for missing baseline, test, and end point data to ensure all participants could be included in the analysis, and avoid treating unknown values as certainly known (eg, with mean imputation and no-event imputation). Ten fully imputed analysis data sets were generated because the proportion of patients with any missing data was less than 10%, and primary end point analyses on each data set were combined to produce the overall intention-to-treat effect using Rubin rules.

The proportion of patients in each group with a MACE at 12 months and absolute differences in MACE rates were calculated. Confidence intervals for proportions and their differences were calculated by exact methods. Time to first MACE was modeled using Cox proportional hazards regression, including stratification and other prespecified factors (hypertension, ethnicity, smoking, and diabetes) and illustrated using Kaplan-Meier estimates. CMR and MPS groups were combined into a single "functional imaging" group to compare unnecessary angiography vs NICE guidelines-directed care in the 61% to 90% and 10% to 29% CHD pretest likelihood subgroups. Subgroup analyses were undertaken by including interaction effects in regression models. Statistical tests were 2-sided and called significant at the 5% level. Analyses used SAS (SAS Institute), version 9.4, after all randomized patients had completed the 12-month follow-up; there were no interim analyses.

Between November 23, 2012, and March 13, 2015, 13 957 patients were screened, of whom 2205 were eligible ( Figure 1 lists reasons for noneligibility and nonconsent). From 6 UK centers (Leeds, Glasgow, Leicester, Bristol, Oxford, London [St Georges]), 1202 patients (55% of eligible) were recruited and allocated to NICE guidelines-directed care (n = 240) or management by CMR (n = 481) or MPS (n = 481) ( Figure 1).

The mean age of patients was 56.3 years (SD, 9.0), 638 patients (53%) were men, the mean body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was 29.1 (SD, 5.2), and 1107 patients (92%) were classified ethnically as white ( Table 1). The study population had a substantial burden of cardiovascular risk factors: 150 patients (12.5%) had diabetes, 458 patients (38.1%) had hypertension, 702 patients (58.4%) were past or current tobacco users, 483 patients (40.2%) had dyslipidemia, and 651 patients (54.2%) had a family history of premature CHD. Patients had a median of 2 of these 5 risk factors. All patients were symptomatic, with 401 patients (33.4%) reporting typical chest pain and 801 patients (66.6%) reporting atypical chest pain as their primary symptom. The assessment of cardiac risk, calculated according to the 2013 atherosclerotic cardiovascular disease risk score from the American College of Cardiology Foundation and American Heart Association guidelines, showed that 441 of 923 patients (47.8%) had a 10-year risk of events of 7.5% or higher. The mean pretest likelihood of obstructive CHD according to the Duke score was 49.5% (SD, 23.8%).

Of 481 patients assigned to the CMR group, 435 patients (90.4%) had CMR as the initial test (median time from randomization, 20 days [interquartile range, 13-34]), 5 patients (1.0%) had MPS, 5 patients (1.0%) went directly to angiography, and 23 patients (4.8%) had no test. Of 481 patients assigned to the MPS group, 446 patients (92.7%) had MPS as the initial test (median time from randomization, 28 days [interquartile range, 22-39]), 4 patients (0.8%) had CMR, 5 patients (1.0%) went directly to angiography, and 21 patients (4.4%) had no test. Of 240 patients assigned to the NICE guidelines group, 56 patients (23.3%) had CCT (median time from randomization, 34 days [interquartile range, 14-44]), 86 patients (35.8%) had MPS, 85 patients (35.4%) went directly to angiography, and 11 patients (4.6%) had no test. The numbers of patients adherent to receiving both their initial randomized test and per-protocol compliance with their test result were 200 patients (83.3%) in the NICE guidelines group, 414 patients (86.1%) in the CMR group, and 368 patients (76.5%) in the MPS group.

Study sites reported their interpretation of the initial test as positive for CHD in 54 of 435 patients (12.4%) in the CMR group, in 81 of 446 patients (18.2%) in the MPS group, and in 19 of 142 patients (13.4%) in the NICE guidelines group. There was no difference in revascularization rates ( Figure 1) between the 3 groups ( P  = .47). The rate of patients with incomplete data required for analysis of the primary end point was low: 18 of 240 patients (7.5%) in the NICE guidelines group, 50 of 481 patients (10.4%) in the CMR group, and 33 of 481 patients (6.9%) in the MPS group. Of these, 11 of 240 patients (4.6%) in the NICE guidelines group, 23 of 481 patients (4.8%) in the CMR group, and 21 of 481 patients (4.4%) in the MPS group were related to missing test results.

Overall, 265 patients (22.0%) underwent at least 1 coronary angiogram (10 patients underwent 2 angiograms) within 12 months of randomization: 102 of 240 patients (42.5%) in the NICE guidelines group, 85 of 481 patients (17.7%) in the CMR group, and 78 of 481 patients (16.2%) in the MPS group. The primary end point of unnecessary angiography occurred in 69 patients (28.8%) in the NICE guidelines group, 36 patients (7.5%) in the CMR group, and 34 patients (7.1%) in the MPS group. Of these angiograms, 98 angiograms (70.5%) had no visual stenosis and were not assessed further, 40 angiograms (28.8%) reached the conclusion by FFR measurement and 1 angiogram (0.7%) involved QCA only. The adjusted odds ratio of unnecessary angiography for the CMR group vs the NICE guidelines group was 0.21 (95% CI, 0.12-0.34; P < .001) and 1.27 (95% CI, 0.79-2.03; P = .32) for the CMR group vs the MPS group. Table 2 shows individual components of the primary end point. For both comparisons, the primary analysis was repeated in the per-protocol population, with no effect on the trial results. Sensitivity analyses using random center effects or adjusting for further risk factors (hypertension, ethnicity, smoking status) or using the per-protocol population did not change overall trial conclusions (eTable 5 in Supplement 2). Exploratory subgroup analyses showed consistent results across subgroups ( Figure 2).

Positive angiography was observed in 29 patients (12.1% [95% CI, 8.2%-16.9%]) in the NICE guidelines group, 47 patients (9.8% [95% CI, 7.3%-12.8%]) in the CMR group, and 42 patients (8.7% [95% CI, 6.4%-11.6%) in the MPS group ( P = .36). During the minimum 1-year follow-up (median, 15.8 months [interquartile range, 12.1-24.2]), 36 patients (3.0%) had at least 1 MACE: NICE guidelines group, 6 patients (2.5%); CMR group, 15 patients (3.1%); MPS group, 15 patients (3.1%) ( Table 2). Annualized MACE rates were 1.6% for the NICE guidelines group, 2.0% for the CMR group, and 2.0% for the MPS group. Adjusted hazard ratios for MACE were 1.37 (95% CI, 0.52-3.57; P = .52) for the CMR group vs the NICE guidelines group and 0.95 (95% CI, 0.46-1.95; P = .88) for the CMR group vs the MPS group. Hard events (cardiovascular death and myocardial infarction) occurred in 3 patients (1.3%) in the NICE guidelines group, 5 patients (1.0%) in the CMR group, and 4 patients (0.8%) in the MPS group ( P = .93). Figure 3 shows the Kaplan-Meier cumulative incidence estimate of first MACE. In the study, 5 test-related medical complications were reported: CMR (1 case: mild urticarial reaction), MPS (0 cases), CCT (1 case: vasovagal episode), and angiography (3 cases: ventricular tachycardia, pseudo-aneurysm and popliteal deep venous thrombosis, right coronary artery spasm and transient ST elevation).

Functional Imaging Assessment

Using functional imaging as a first-line strategy (CMR or MPS) in patients with a 61% to 90% (high; n = 389) CHD pretest likelihood resulted in substantially reduced odds of unnecessary angiography compared with the NICE guidelines group; 29 of 307 patients (9.4%) for functional imaging groups vs 51 of 82 patients (62.2%) for the NICE guidelines group, odds ratio (OR) 0.048 (95% CI, 0.02-0.10), P < .001. Among those with less than 30% (low; n = 330) CHD pretest likelihood, the odds of unnecessary angiography were also numerically lower by a functional imaging approach compared with anatomical (CCT) assessment (13 of 269 patients (4.8%) for funtional imaging vs 7 of 61 patients (11.5%) for anatomical assessment; OR, 0.44 [95% CI, 0.17-1.17]; P  = .099).

CE-MARC 2 was a multicenter, randomized clinical trial in a large community-based population of symptomatic patients undergoing assessment for suspected CHD, in whom further investigation was appropriate according to international guidelines. A CMR-guided strategy significantly reduced unnecessary angiography occurrence compared with NICE guidelines-guided care, but was not significantly different from an MPS-guided strategy (following US appropriate use criteria). Between the 3 strategies, there was no difference in MACE rates at 12 months or disease detection (positive angiography) rates.

There is concern that coronary angiography is overused in the diagnostic pathway of suspected CHD and that the majority of patients investigated will not have significant obstructive coronary disease. Avoiding unnecessary invasive angiography could have significant financial benefits, avoids exposing patients to unnecessary risk, and is also a strong patient desire. For this reason, this outcome was chosen as the patient-focused primary end point.

Current international guidelines for investigation and management of suspected CHD all suggest risk stratification based on pretest likelihood estimation. The Duke score, used in NICE guidelines, is based upon the original Diamond Forrester model, but includes additional demographic factors to further stratify risk. These models, derived more than 3 decades ago, tend to overestimate CHD risk because patient demographics, risk factors, and treatment have changed considerably over time. In the CE-MARC 2 trial, the reduction in unnecessary angiography by a CMR or MPS strategy appears largely driven by the overestimation of disease probability from using the Duke score. Current NICE guidelines categorize a pretest likelihood of 60% to 90% as being at high-risk of CHD, and recommend direct referral for angiography. In the CE-MARC 2 trial, this explained the majority of patients in the NICE-guidelines group who got referred for angiography (82 of 102 patients; 80.4%), and the majority of unnecessary angiograms (59 of 69 patients; 85.5%). This was further emphasized by the preplanned, subanalysis of any functional imaging (CMR or MPS) in the 60% to 90% (high risk) pretest likelihood population, which showed substantially reduced odds of unnecessary angiography in this combined subgroup compared with the NICE guideline group.

Overall, rates of disease detection (positive angiography) were comparable for the 3 strategies, suggesting no penalty for using functional imaging as a gatekeeper for angiography, even in high-risk subgroups. Consistent with published studies, the CE-MARC 2 trial showed a low overall rate of MACE in a stable chest pain population, with no early difference between strategies.

It remains a point of debate as to whether all of protocol-defined unnecessary angiograms in this study were clinically unnecessary; some would argue that negative tests are the "price to pay" for not missing important disease in others. This assumes a population perspective, and our trial primary end point was derived after close consultation with patient and public representatives: from an individual patient perspective, an angiogram that does not change their treatment or their clinical outcome is considered by patients to have been unnecessary. Guidelines are clear that physicians do not need to undertake angiography to either diagnose angina or offer primary prevention and symptom control.

To our knowledge, there have been no randomized clinical trials comparing the performance of current management guidelines and a broad functional imaging approach in terms of important clinical end points. Although cross-sectional imaging (CMR and CCT) has improved diagnostic ability, benefits in terms of health outcomes are more difficult to demonstrate, partly due to complexity of subsequent treatment effects. Functional vs anatomical assessment as a potential gatekeeper to the catheterization laboratory is a topic of ongoing debate. The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial showed no improvement in clinical outcomes using CCT vs a variety of functional tests in patients investigated for suspected CHD; whereas the CCT strategy increased rates of cardiac catheterization (12.2% for CCT vs 8.1% for a variety of functional tests, P = .02) and 90 day coronary revascularization (6.2% for CCT vs 3.2% for a variety of functional tests, P  < .001). This may be important following a recent observational study of 544 US centers showing higher rates of inappropriate percutaneous coronary intervention at sites performing the highest rates of angiography, suggesting anatomical assessment could predispose patients to unnecessary therapy. Although numbers are small, in the CE-MARC 2 trial an increased rate of unnecessary angiography was suggested in the low-risk subgroup of the NICE guidelines group, the majority of whom underwent CCT.

This study has several important limitations. First, the false-positive and false-negative rates are often quantities of interest in evaluating diagnostic methods. The CE-MARC 2 trial only angiographically verified a subset of patients, contingent on strategy findings, and so cannot provide accurate estimates. The original CE-MARC trial defined the false-positive and false-negative rates for CMR and MPS, and showed CMR-guided strategy as being superior to the MPS-guided strategy. In the current study, there was no statistical difference between the CMR and MPS strategies for reduction in unnecessary angiography, despite the finding from the CE-MARC trial. However, the CE-MARC trial was able to detect small differences due to its paired design (all patients underwent all tests), whereas the current study compared independent groups, which confers lower power.

Second, the study population was predominantly white northern European, therefore findings may not translate to other populations; geographic heterogeneity of CHD incidence is well known.

Third, at trial initiation, contemporary guidelines used the Duke score, with the NICE guidelines classifying high risk for CHD as 60% to 90% pretest likelihood. It is now recognized that this may overestimate CHD risk, such that recent guidelines have adopted a recalibrated risk model.

Fourth, the primary end point was objective (using FFR measurement), although performance was not clinically possible in all cases; blinded core laboratory analysis of QCA data avoided subjective visual angiography interpretation.

Fifth, overall full adherence to the protocol was high, with some unavoidable variation due to individual clinical practice, which could have introduced bias (eg, abnormal imaging results not proceeding to angiography). To mitigate this, analysis was by intention-to-treat principles and the primary end point was purposely all inclusive (ie, false-positives, true-negatives when not believed by clinicians, and also test failures). The slightly different rates of incomplete data (not statistically significant) between study groups was not of concern, as the data completeness rate was high overall. Per-protocol and sensitivity analyses (eTable 5 in Supplement 2) did not alter the trial conclusions.

Sixth, although clinically robust, a MACE is not a proxy for a missed diagnosis or treatment (eg, missed opportunity for revascularization by not having angiography [due to a false-negative result]). However, it remains debatable whether revascularization for stable angina has prognostic benefit over optimal medical therapy, which will be answered by the ongoing International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial.

Seventh, quality of life and cost-effectiveness analyses will be important for understanding the patient-centered perspectives and payer/policy implications of these findings; these data are currently being collected and analyzed.

In patients with suspected angina, investigation by CMR resulted in a lower probability of unnecessary angiography within 12 months than NICE guideline-directed care, with no statistically significant difference between CMR and MPS strategies. There were no statistically significant differences in MACE rates at 12 months after randomization.

Corresponding Author: John P. Greenwood, PhD, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds Institute of Genetics, Health, and Therapeutics Building, Leeds LS2 9JT, United Kingdom ( j.greenwood@leeds.ac.uk).

Group Information: The CE-MARC 2 investigators are listed in eTable 1 in Supplement 2.

Published Online: August 29, 2016. doi: 10.1001/jama.2016.12680

Author Contributions: Dr Sharples had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Greenwood, Ripley, Berry, McCann, Plein, Bijsterveld, Sculpher, Walker, Brown.

Acquisition, analysis, or interpretation of data: All Authors.

Drafting of the manuscript: Greenwood, Ripley, Bucciarelli-Ducci, Prasad, Foley, Everett, Cairns, Sharples, Brown.

Critical revision of the manuscript for important intellectual content: Greenwood, Berry, McCann, Plein, Bucciarelli-Ducci, Dall'Armellina, Bijsterveld, Foley, Mangion, Sculpher, Walker, Everett, Cairns, Sharples, Brown.

Statistical analysis: Everett, Cairns, Sharples, Brown.

Obtained funding: Greenwood, Berry, McCann, Plein, Brown.

Administrative, technical, or material support: Greenwood, Berry, Plein, Dall'Armellina, Bijsterveld, Foley, Mangion, Walker, Sharples.

Study supervision: Greenwood, Ripley, Berry, McCann, Bucciarelli-Ducci, Prasad, Bijsterveld, Foley, Mangion, Walker, Sharples, Brown.

Other - Economic analysis: Sculpher.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Berry reports holding research agreements with Siemens Healthcare and St Jude Medical with his employer, the University of Glasgow. Dr Bucciarelli-Ducci reports consulting for Circle Cardiovascular Imaging. Dr Dall'Armellina reports being a British Heart Foundation intermediate clinical research fellow. Dr Sculpher and Ms Brown report being National Institute for Health Research senior investigators. No other disclosures were reported.

Funding/Support: This trial was funded by grant SP/12/1/29062 and fellowships FS/15/54/31639 (Dr Mangion) and FS/1062/28409 (Dr Plein) from the British Heart Foundation; the Leeds Teaching Hospital Charitable Foundation and the National Institute for Health Research (NIHR), through the Local Clinical Research Networks and the Leeds Clinical Research Facility; the NIHR Biomedical Research Unit in Cardiovascular Disease at the University Hospitals Bristol National Health Service Foundation Trust and the University of Bristol (Dr Bucciarelli-Ducci); by a senior fellowship from the Scottish Funding Council and grant RE/13/5/30177 from the British Heart Foundation Centre of Research Excellence award (Dr Berry); and by NIHR postdoctoral and career development fellowships (Dr McCann).

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The authors are solely responsible for trial design, conduct and analyses, drafting and editing of earlier versions of the manuscript, and its final contents. The views expressed are those of the authors and not necessarily those of the British Heart Foundation, National Health Service, National Institute for Health Research, or Department of Health.

Additional Contributions: We thank all patients who participated in this trial.

# data[].attributes.attachment_link.title
Noninvasive Functional Imaging Strategies and Unnecessary Angiography Rates

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Importance Among patients with suspected coronary heart disease (CHD), rates of invasive angiography are considered too high. Objective To test the hypothesis that among patients with suspected CHD, cardiovascular magnetic resonance (CMR)-guided care is superior to National Institute for Health and Care Excellence (NICE) guidelines-directed care and myocardial perfusion scintigraphy (MPS)-guided care in reducing unnecessary angiography.

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Mentorship Ongoing Achievment Record (MOAR)

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MOAR January 2017 Version 3 (CCU Version)

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NMC Revalidation             Forms and Templates

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NMC Revalidation             Forms and Templates

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Forms and templates for Revalidation | The Nursing and Midwifery Council

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Download essential forms and templates for revalidation

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QEUH Cardiology Education Meeting Presentations

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QEUH Cardiology Education Meeting Presentations

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NES is the education and training body for NHSScotland

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http://www.knowledge.scot.nhs.uk/home.aspx

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The Knowledge Network is the national digital library for health and social care in Scotland.

Whether you are a new or experienced user, our platform offers a wealth of resources tailored to your needs.

Take a guided tour with our video walkthrough or discover the range of knowledge available to you from our user friendly step-by-step guide.
Tour video transcript
Get started

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The Knowledge Network Scotland | NHS Education for Scotland

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The Knowledge Network Scotland - The Knowledge Network: source of knowledge for health and social care in Scotland

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European Society of Cardiology -eLearning

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European Society of Cardiology -eLearning

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https://www.escardio.org/Guidelines-&-Education/E-learning/Discover-the-ESC-e-learning-offer

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Link here:

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We've put some measures in place to support you to meet your revalidation requirements during the Covid-19 emergency.

Visit our website for information including details of revalidation deadline extensions.

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Revalidation | The Nursing and Midwifery Council

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Revalidation is the new process that all nurses and midwives will need to go through in order to renew their registration with the NMC. This microsite is home to all the information you need to guide you through your revalidation journey.

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link here:

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Meetings for GPs, Nurses and other HCPs | Omnia-Med

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We provide meetings for GPs, nurses, consultants and commissioners. Topics covered include Diabetes, Cardiology, Urology, Psychiatry, COPD and Commissioning.

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Online Cardiology Modules from Royal College of Physicians and Surgeons

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Online Cardiology Modules from Royal College of Physicians and Surgeons

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If you are interested in doing any of these let Stuart know, we might be able to pay for them (£25 each)

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eLearning Store - Instant-access online learning modules and packages

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As the only multidisciplinary Royal College in the UK we have been supporting and representing our members for over 400 years by setting the highest possible standards of health care.

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courtesy of John Byrne..

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link here.
(Click on "Agenda" for list view)

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This framework supports role and career development for NMAHP's in Scotland. April 2017 New colour and logo as part of our Digital transformation. August 2017 Content refresh due

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Follow link to their website

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Glasgow Research Facility | NHS Research Scotland | NHS Research Scotland

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Glasgow Research Facility | NHS Research Scotland | NHS Research Scotland

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Here's the degree student assessment document that's in use currently

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Student & Mentor Zone | Health and Life Sciences

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This site contains lots of useful information designed to both enhance student learning and provide support for mentors as they guide and assess students in practice learning areas. The site is not password protected so the resources and information contained here can be easily accessed from either at home or in the workplace.

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 NMC: Standards to support Learning and Assessment in practice 

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 NMC: Standards to support Learning and Assessment in practice 

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from nes Scotland

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Mentorship Course - Nominations due ...but

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Mentorship Course - Nominations due ...but

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CCU not high priority so NO places this term :-(
contact Stuart re next year..

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                     IMPACT

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                     IMPACT

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Two day study course as a nurse observer?
One space available 2-3 times/year.
Funded.
Contact Stuart:
Possible dates:
18 - 19 November 2019

Debbie/Ann (prov.)

16 - 17 December 2019

Jean/Denise (prov.)

20 - 21 January 2020

03 - 04 February 2020

09 - 10 March 2020

05 - 06 May 2020

08 - 09 June 2020

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"I have just completed the face-to-face element of the course and just wanted to let you know that it was very well delivered and a valuable learning opportunity. Nigel and the rest of the faculty were supportive and enthusiastic teachers, delivering a well designed course. I am confident that consolidating my knowledge and skills through the IMPACT course has improved my confidence in the initial approach to acutely unwell medical patients"

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Impact | Ill Medical Patients' Acute Care & Treatment - The IMPACT Course is a two-day course introducing the principles and practice of acute medical care and related knowledge, skills, understanding and attitudes.

# data[].attributes.attachment_link.description
"I have just completed the face-to-face element of the course and just wanted to let you know that it was very well delivered and a valuable learning opportunity. Nigel and the rest of the faculty were supportive and enthusiastic teachers, delivering a well designed course.

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Course detail here
5 days (12hr) study leave
5000 word essay
1000 word reflection
CAT points
Contact Stuart

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Tuesdays for 8 weeks
5 days (12hr) study leave
5000 word essay
1000 word reflection
CAT points

Contact Stuart
Zoe and Gini