STANDARDS FOR ADULT RESPIRATORY AND SLEEP SERVICES

IN NEW ZEALAND
A document produced for the Thorc!c Soc!et" of Au#tr$! nd
Ne% Ze$nd &Ne% Ze$nd 'rnch(
In!t!$ Report )*+*, re-!#ed )**., /00/ nd /001
1
Summr" nd Recommendt!on#
Summr" of the current #!tut!on
The importance of a well organised, efficient and accessible Respiratory Service in
the New Zealand Health Care system scarcely needs emphasising. Respiratory
disease is a maor health problem in New Zealand. !n fact, respiratory disorders are
the most common reason for primary health care cons"ltations and are responsible
for #$%$& percent of all medical admissions.
'ith the increasing prevalence of respiratory conditions s"ch as asthma, Chronic
(bstr"ctive )"lmonary *isease +C()*,, T-, (bstr"ctive Sleep .pnoea +(S., and
p"lmonary malignancy, the costs, in h"man and economic terms, are large and
contin"e to escalate. /o"r respiratory disorders +0ower Respiratory Tract !nfections
+0RT!s,, C()*, T- and l"ng cancer, are amongst the 1& leading ca"ses of disease
b"rden in the world
1
and fo"r respiratory disorders +C()*, 0RT!s, asthma, and l"ng
cancer, are amongst the 1& leading ca"ses of disease b"rden in New Zealand.
1
.sthma and C()* are the highest2ran3ing ca"ses of years lost to disability +40*, in
males in New Zealand and ran3 third and seventh respectively for females.
#

Respiratory disease has now overta3en coronary heart disease and cancer as the
most common ca"se of mortality.
5
Respiratory illness is the most common ca"se of6
long term illness among children, 7* "tilisation and general practice visits, as well as
hospital admissions and therefore costs the health system more than any other
medical disorder.
/"rther, clinicians are now recognising the importance of other conditions, s"ch as a
range of sleeping disorders, bronchiolitis and interstitial l"ng disorders.
(ver the past #& years, the b"rden of respiratory illness has increased s"bstantially
and will contin"e to do so, with greater conse8"ent demands on primary and
secondary health care services. The 'orld Health (rgani9ation +'H(, has defined
respiratory disorders as one of the 3ey areas re8"iring special attention in the 11st
cent"ry and advised that new models of care sho"ld be considered.
The b"rden of respiratory illness can be red"ced and, in many instances, prevented.
.voiding or stopping smo3ing,
$
vaccination, better early childhood respiratory care,
improved occ"pational s"rveillance, better access to specialist care and
investigations and screening, all contrib"te to red"ction and:or prevention of
respiratory illness. 7arlier diagnosis "sing spirometry in the comm"nity,
;
together
with s"bse8"ent introd"ction of effective therapy at an earlier time, co"ld also be
e<pected to red"ce the b"rden of respiratory disease over time.
The c"rrent str"ct"re of the New Zealand health care system mitigates against early
diagnosis. The maority of respiratory physicians wor3 in p"blic hospitals and are
more fre8"ently referred patients with advanced disease.
i
!t is important to recognise that financial barriers to primary health care, incl"ding
e<cessive co2payments on dr"g therapy, have an adverse effect on respiratory
disorders. The timing of intervention d"ring ac"te e<acerbations of respiratory
conditions is of critical importance to s"ccessf"l management. /inancial barriers are
an important reason behind New Zealand=s high admission rates for asthma, C()*,
bronchiectasis and pne"monia. The c"rrent )rimary Health Care Strategy, which
has beg"n to address some of these iss"es, incl"ding co2payments on prescriptions
sho"ld therefore contrib"te to red"ctions in both morbidity and mortality for patients
with a range of respiratory disorders.
'ith the development of 11 *istrict Health -oards +*H-s,, we believe there is an
"rgent need to develop an infrastr"ct"re to advise and s"pport the management of
respiratory disorders in each of the districts. . template for comprehensive regional
respiratory services has been developed and is described in this report, "sing staff
that move across traditional health care bo"ndaries and facilitate contin"ity of care
between the comm"nity and hospital. However, beca"se e<pert respiratory opinion
is not readily available in some *H-s and there are s"bstantial variations in the
practice of respiratory medicine in New Zealand, we perceive a need for both
regional and national overview. 'e therefore propose the infrastr"ct"re defined in
/ig"re 1 and which is similar to that envisaged "nder the Cancer Control Strategy
+New Zealand,
http6::www.moh.govt.n9:moh.nsf:&:#*>$&5.*15&C>7/&CC1$;*??&&&7$.1;:@/ile:
CancerControlStrategy.pdf
-eca"se most respiratory disorders can be managed in the comm"nity if the
appropriate infrastr"ct"re e<ists, developing a system for improved management of
respiratory disorders may offer a model that can readily be adopted by other
specialities.
.s a professional body we wo"ld li3e to offer o"r services and those of o"r members
to the Ainistry of Health +AoH, and *H-s to s"pport what we hope will become an
e<citing period of change in health care delivery. !n anticipation of this, TS.NZ have
developed this proposal in collaboration with R.CB), R.C), .NZSRS and specialist
n"rses, radiologists and physiotherapists affiliated with the TS.NZ.
Recommendt!on#
The Ainistry of Health +Ainistry of Health, needs to recognise respiratory disorders
as a maor health problem in New Zealand and create an infrastr"ct"re to provide
oversight and direction of management of respiratory diseases in New Zealand,
centrally co2ordinate activities, and s"pport the development of the initiatives
described in this doc"ment.
There is an "rgent need for health ed"cation and greater self2management of
respiratory disease. !ncreased ed"cational services, partic"larly at primary care
level, are strongly recommended and incentives for these and for more
comprehensive management of ac"tely "nwell respiratory patients need to be p"t
in place.
>,?,C,1&
.ccess to respiratory physicians and to new technology +sleep laboratories, high2
resol"tion Comp"ted Tomography +CT, scans, and detailed l"ng f"nction testing,
needs to be improved to identify disease at an earlier stage.
ii
Beneral practice facilities for respiratory diagnosis and management need to be
better s"pported and made more efficient with greater financial incentive for
managing ac"te respiratory illness in the comm"nity.
Secondary and tertiary care facilities m"st be of a more "niform standard. .t the
same time, first referrals to o"tpatient clinics sho"ld be increased and reimb"rsed
more appropriately, and long term follow "p patients sho"ld be better monitored
and ret"rned in greater n"mber to their general practitioner. )rioritisation criteria
for admission and o"tpatient care have already been developed and implemented
by the Ainistry of Health in association with the TS.NZ +.ppendi< !!!,.
!nformation on waiting times to o"tpatient clinic attendance are not c"rrently
collected and reported on. Collection and eval"ation of waiting times is necessary
to determine if the prioritisation criteria are being followed.
Case management of high ris3 +eg, fre8"ent hospitalisation, !CD admissions,
needs f"rther st"dy and s"pport.
Breater provision of day patient facilities co"ld red"ce inpatient caseloads
provided staffing and facilities are ade8"ate. !t is recommended there be at least
1.& /T7 specialist respiratory physician per >$%1&&,&&& pop"lation
11,11,1#,15,1$
in
New Zealand, together with ade8"ate resident medical, n"rsing and allied health
staff and other s"pport personnel.
.ccess and impact indicators for respiratory disorders are not well definedE
o"tcomes need to be assessed and compared nationally and internationally.
. respiratory adviser sho"ld be appointed to each of the *H-s with an opport"nity
for reg"lar regional meetings +centred on ."c3land, Hamilton, 'ellington,
Christch"rch and *"nedin, and a representative from each of the regions sho"ld
sit on a National 7<ec"tive Committee. The National 7<ec"tive Committee wo"ld
also receive representation from the TS.NZ, primary, secondary and tertiary care
comm"nities, n"rsing, allied health, lay societies and Aaori and )acific
comm"nities and wo"ld report both to the Ainistry of Health and to *H-s.
.n infrastr"ct"re to advise and s"pport the management of respiratory disorders in
each *H- needs to be developed. 'e recommend this is actioned as follows6
perform an assessment of the b"rden of l"ng disease in New Zealand
collect and collate information by *H- to assess whether any deficiencies in
practice presently e<ist
"pdate paediatric respiratory service, 8"ality of care and primary care
components of the Standards Recommendations
credential *H-s to ens"re basic respiratory services are available and of
reasonable standard +.ppendi< F!G,
wor3 in close association with the Ainistry of Health and )"blic Health
*epartments to develop evidence based strategies to red"ce the prevalence of
respiratory disease.
disease specific management systems co"ld then be proposed "sing a
common b"t fle<ible template to develop integrated models of care.
iii
Ac2no%$ed3ement#
The RNZCB), .NZSRS, RNZS) and R.C) have all made important contrib"tions
to this doc"ment6
Standards for New Zealand Respiratory Services 1CC; Committee6 *r H Barrett
+Chairman,, *r C *rennan, *r . 'atson, *r C 'ong, and )rof TG (=*onnell. The
Committee wo"ld li3e to gratef"lly ac3nowledge the contrib"tions made by6
RNZCB)s, *r N Iaral"s, *r . Harrison, . )rof H Iolbe, *r I 'hyte, *r T Christmas,
*r . Geale, )rof H Rea, *r ! .sher, *r . 'ells and *r A 'ilsher.
Standards for New Zealand Respiratory Services 1&&16 . )rof H Barrett +Chairman,,
. )rof R Taylor +)resident,. 'e wo"ld li3e to gratef"lly ac3nowledge contrib"tions
by6 . )rof H Iolbe, . )rof A 'ilsher, *r . Neil, *r * Ailne, Ar ) .lison,
As C Chalmers, )rof ! Town, As A Swanney, Ars ) 4o"ng, and *r )eter Hansen.
iv
A4out th!# Pu4$!ct!on
The New Zealand -ranch of the TS.NZ has prod"ced this doc"ment, JStandards for
.d"lt Respiratory and Sleep Services in New ZealandK to present its views on the
best config"ration for Respiratory Services for the f"t"re against the c"rrent bac3drop
of increasing service demands and contin"ing financial constraint. The report
encompasses the philosophy of the 'H( in ac3nowledging the need for health
policy form"lation, reg"lation and assessment of performance by collection and
analysis of o"tcome generated data. The aim is to help develop an efficient
respiratory health system which is of good 8"ality, responsive to the pop"lation=s
needs and which is reso"rced with a fair and e8"itable distrib"tion of money.
This report appeared initially in 1C?C and was s"bstantially rewritten in 1CC;. !t was
revised in 1&&1 and again in 1&&5 to reflect changes in health care and in respiratory
medicine in New Zealand over the past five years. The latest revision no longer
incorporates comprehensive sections on primary care or paediatric respiratory
disorders. These wo"ld be a priority if a national committee were form"lated.
Figure 1
Proposed structure for management of respiratory disorders in New Zealand
D5'
Re#p!rtor"
Ad-!#or
F!-e Re3!on$ Re#p!rtor" Ad-!#or" 6roup#
Respiratory *H- advisors, p"blic health
representative, primary care representative, *H-
e<ec"tive member, one asthma:cancer:T-:C/ society
member, Aaori representatives
Nt!on$ Re#p!rtor" Ad-!#or" 6roup
(ne representative from each regional advisory gro"p,
TS.NZ, RCNZB), R.C), AoH, )"blic Health,
"niversity +epidemiologist,, lay society, )acific, Aaori
gro"ps, health economist
7!n!#tr" of 5e$th
7!n!#ter of 5e$th
D!rector 6ener$ of 5e$th
v
T4$e )8 Summr" of m!n!mum re#p!rtor" #er-!ce# re9u!red %!th!n -r!ou#
#ector# of he$th
Those services offered at a local level wo"ld be e<pected to be available at a district level and so on.
Loc$
&:;0,000 popu$t!on(
D!#tr!ct
&;0</;0,000 popu$t!on(
Re3!on$
&=/;0,000 popu$t!on(
Nt!on$
*iagnostic
facilities
)7/ meters
Spirometry
7<piratory flow:vol"me
c"rve +or flow:vol"me
loop,
.rterial blood gases
and pH
(<imetry:overnight
o<imetry
S3in allergy testing
Aanto"< testing
)le"ral aspiration and
biopsy
Spirometry
)lethysmography +or
dil"tion methods, and
*0C(
-ronchial challenge
/N. l"ng +CT g"ided,L
/ibre2optic bronchoscopy
Transbronchial biopsy
+-.0,
Transtracheal needle
aspiration
)artial sleep st"dies
N"clear medicine scans
CT scans, AR! scans
/"ll l"ng f"nction,
cardiop"lmonary
e<ercise and bronchial
provocation tests
7<pired nitric o<ide
)"lmonary
angiographyL
/"ll polysomnography
Transc"taneo"s C(1
monitoring
A"ltiple sleep latency
testing
Rigid bronchoscopy
Thoracoscopic l"ng
biopsy
Reference T-
laboratory
Aolec"lar biology
diagnostic
services
7pidemiology
.ffiliated
services
152ho"r chest
radiology
CT scansLL
Standard pathology
and microbiologyLL
!CD
Cardiology, (R0
(ncology and
radiotherapy
Thoracic s"rgery
Specialised thoracic
histology:cytology:
radiology services
!nterventional
services
-ronchial artery
embolisation
0"ng
transplantation,
l"ng vol"me
red"ction s"rgery,
p"lmonary
thrombo2
endarterectomy,
laser therapy,
brachytherapy,
stenting of airway
Clinical
services
7d"cation6 asthma,
bronchiectasis, C()*E
)T-E palliative careE
rehabilitation for
respiratory patientsE
domiciliary o<ygenLL
)rovision of C).), -i ).)
*omiciliary o<ygen, T-,
palliative care,
rehabilitation teams
)rovision of C).),
non2invasive
ventilation and related
services
Aanagement of m"lti2
dr"g
Resistant )T-
A"ltidisciplinary C/
team
A"ltidisciplinary
p"lmonary
hypertension team
Transplant team
L Radiologist needs to have developed s"fficient e<pertise to be allowed to perform.
LL Need to be affiliated with regional hospital s"ch that diffic"lt cases can be disc"ssed.
vi
Content#
S"mmary and Recommendations...................................................................................i
.c3nowledgements....................................................................................................... iv
.bo"t this )"blication..................................................................................................... v
Contents....................................................................................................................... vii
Blossary....................................................................................................................... <ii
Blossary....................................................................................................................... <ii
1 !ntrod"ction............................................................................................................... 1$
1 !ntrod"ction............................................................................................................... 1$
1.1 )"rpose and "se of g"idelines......................................................................1$
1.1 The scope of respiratory services.................................................................1$
1.# The b"rden of respiratory disease.................................................................1;
1.5 Aaori and )acific health................................................................................1?
1.$ Service history..............................................................................................1?
1.; /"t"re directions for respiratory services......................................................1C
1.> )redictions.................................................................................................... 11
1.? New technologies.......................................................................................... 11
1 B"idelines for *evelopment of Respiratory Services................................................1$
1 B"idelines for *evelopment of Respiratory Services................................................1$
1.1 )revention of disease....................................................................................1$
1.1 Aaori and )acific health................................................................................1$
1.# C"lt"rally acceptable care.............................................................................1;
1.5 7thnicity data................................................................................................ 1>
1.$ )rimary and comm"nity care........................................................................1>
1.; Health ed"cation and self2management of respiratory disorders..................1?
1.> Secondary and tertiary health care...............................................................1?
1.? M"ality ass"rance and peer review...............................................................1C
# Respiratory Services in Beneral )ractice..................................................................#1
# Respiratory Services in Beneral )ractice..................................................................#1
#.1 7d"cation...................................................................................................... #1
#.1 Referral to secondary and tertiary care.........................................................#1
#.# M"ality control............................................................................................... #1
#.5 )lanning services.......................................................................................... #1
#.$ !ntegrated electronic information systems.....................................................#1
5 Specialist Respiratory Services.................................................................................##
5 Specialist Respiratory Services.................................................................................##
5.1 Respiratory services at a national level.........................................................##
vii
5.1 Respiratory services at a regional level.........................................................##
5.# Respiratory services at a r"ral level +below $&,&&&,......................................5&
$ S"pport /acilities for !npatient Respiratory Services at a Regional 0evel..................51
$ S"pport /acilities for !npatient Respiratory Services at a Regional 0evel..................51
; Re8"irements for ("tpatient Respiratory Services at a Regional 0evel....................5$
; Re8"irements for ("tpatient Respiratory Services at a Regional 0evel....................5$
> Ainim"m Re8"irement for Staffing at a Regional and *istrict 0evel..........................5;
> Ainim"m Re8"irement for Staffing at a Regional and *istrict 0evel..........................5;
>.1 Senior cons"ltant staff...................................................................................5;
>.1 Resident medical staff...................................................................................5>
>.# N"rsing staff.................................................................................................. 5>
>.5 Respiratory n"rse practitioner.......................................................................5?
>.$ Respiratory physiotherapists.........................................................................5?
>.; Secretarial, clerical and administrative staff..................................................5?
>.> Respiratory physiology scientists : technologists : technicians......................5C
>.? Staff definitions,............................................................................................5C
>.C Recommendations........................................................................................5C
? Respiratory Services at a S"bspecialty 0evel............................................................$1
? Respiratory Services at a S"bspecialty 0evel............................................................$1
?.1 T"berc"losis.................................................................................................. $1
?.1 Cystic fibrosis................................................................................................$#
?.# -ronchiectasis...............................................................................................$$
?.5 (cc"pational l"ng disease............................................................................$C
?.$ Sleep disordered breathing service +ad"lts,..................................................;&
?.; 0"ng cancer.................................................................................................. ;#
?.> !nterstitial l"ng diseases................................................................................;;
?.? )"lmonary vasc"lar disorders.......................................................................;>
?.C .sthma.......................................................................................................... ;?
?.1& Chronic obstr"ctive p"lmonary disease +C()*,7rror6 Reference so"rce not
fo"nd,7rror6 Reference so"rce not fo"nd...................................................>1
!ntegration of Aedical Services with Comm"nity Bro"ps.............................................>5
!ntegration of Aedical Services with Comm"nity Bro"ps.............................................>5
Health Service *ata Re8"irements..............................................................................>$
Health Service *ata Re8"irements..............................................................................>$
Research and 7d"cation Re8"irements.......................................................................>;
Research and 7d"cation Re8"irements.......................................................................>;
viii
.ppendi< !6 National hospital admissions for respiratory diseases 1C>&%C?, and
proections for 1&&$............................................................................................>>
.ppendi< !6 National hospital admissions for respiratory diseases 1C>&%C?, and
proections for 1&&$............................................................................................>>
.ppendi< !!6 Aeas"rement of performance and o"tcome indicators.............................>?
.ppendi< !!6 Aeas"rement of performance and o"tcome indicators.............................>?
1. 0"ng cancer.................................................................................................... >?
1. .sthma............................................................................................................ >C
.ppendi< !!!6 Respiratory medicine national referral g"idelines....................................?;
.ppendi< !!!6 Respiratory medicine national referral g"idelines....................................?;
.ppendi< !G6 TS.NZ:R.C) standards for training in respiratory medicine re8"irements
for physician training, ad"lt medicine, 1&&1........................................................?>
.ppendi< !G6 TS.NZ:R.C) standards for training in respiratory medicine re8"irements
for physician training, ad"lt medicine, 1&&1........................................................?>
Thoracic and Sleep Aedicine S"pervising Committee........................................?>
!ntrod"ction......................................................................................................... ?>
Thoracic medicine............................................................................................... ?>
Sleep medicine................................................................................................... C1
.ppendi< G6 Respiratory standards:training in other specialty areas............................CC
.ppendi< G6 Respiratory standards:training in other specialty areas............................CC
1. Cardiorespiratory physiotherapy.....................................................................CC
1. The n"rse practitioner and the preparation of the respiratory n"rse,.............1&&
#. Radiology s"pport for respiratory services....................................................1&1
5. )roposal on the definition of the str"ct"re of general thoracic s"rgery in New
Zealand.................................................................................................... 1&#
.ppendi< G!6 -ronchoscopy services.........................................................................1&>
.ppendi< G!6 -ronchoscopy services.........................................................................1&>
M"ality ass"rance............................................................................................. 1&>
.ppendi< G!!6 0aser, stenting and brachytherapy.......................................................1&C
.ppendi< G!!6 0aser, stenting and brachytherapy.......................................................1&C
N"mbers........................................................................................................... 1&C
B"idelines for re2referral...................................................................................1&C
National vs regional..........................................................................................1&C
M"ality ass"rance meas"res.............................................................................1&C
.ppendi< G!!!6 Respiratory f"nction assessment........................................................11&
.ppendi< G!!!6 Respiratory f"nction assessment........................................................11&
Recommendations............................................................................................ 11&
i<
.ppendi< !F6 0"ng transplantation.............................................................................111
.ppendi< !F6 0"ng transplantation.............................................................................111
Criteria for acceptance for l"ng transplantation.................................................111
Criteria for l"ng transplantation in patients with cystic fibrosis...........................11#
.ppendi< F6 0"ng vol"me red"ction s"rgery..............................................................115
.ppendi< F6 0"ng vol"me red"ction s"rgery..............................................................115
!ntrod"ction....................................................................................................... 115
)atient eval"ation and selection +note recently modified in TS.NZ position paper
which accompanies this g"ideline,...........................................................115
. position statement of the Thoracic Society of ."stralia and New Zealand.....11$
.ppendi< F!6 Service specification % home o<ygen therapy services.........................111
.ppendi< F!6 Service specification % home o<ygen therapy services.........................111
.ppendi< F!!6 Sleep related breathing disorders, a position paper of the New Zealand
branch of the Thoracic Society of ."stralia and New Zealand..........................111
.ppendi< F!!6 Sleep related breathing disorders, a position paper of the New Zealand
branch of the Thoracic Society of ."stralia and New Zealand..........................111
(verview........................................................................................................... 111
-ac3gro"nd....................................................................................................... 11$
(ther ca"ses of e<cessive daytime sleepiness +7*S,......................................11C
.ppendi< F!!!6 Chronic disease management6 recommendations on asthma services for
*istrict Health -oards....................................................................................... 1#;
.ppendi< F!!!6 Chronic disease management6 recommendations on asthma services for
*istrict Health -oards....................................................................................... 1#;
Iey recommendations for *H-s to incorporate into their strategic plans..........1#;
-ac3gro"nd....................................................................................................... 1#;
)"rpose of this doc"ment.................................................................................1#>
1. )rimary care services....................................................................................1#?
1. Secondary care services...............................................................................1#C
#. Regional co2ordination and integration..........................................................1#C
5. !wi and )acific providers...............................................................................15&
$. 7d"cation services........................................................................................ 15&
;. B"ideline development and dissemination....................................................151
>. .ppropriate "se of pharmace"ticals..............................................................151
?. Comm"nity organisations..............................................................................151
C. /"t"re initiatives............................................................................................151
.ppendi< F!G6 .ccreditation of Specialist Services....................................................15#
.ppendi< F!G6 .ccreditation of Specialist Services....................................................15#
1. . model of a credentialing process which co"ld be applied to respiratory
services based on recommendations of the Ainistry of Health................15#
<
1. .ccreditation of sleep disorders services
http6::www.sleepa"s.on.net:accreditationsleep.pdf..................................15;
#. .ccreditation of respiratory f"nction assessment services............................1;&
References................................................................................................................. 1>>
References................................................................................................................. 1>>
<i
6$o##r"
.irflow limitation Narrowing of l"ng airways ca"sing
+.irways
obstr"ction,
-reathlessness and whee9ing
.lpha212
antiprotease
. blood protein which prevents en9ymatic tiss"e destr"ctionE absence
of alpha212antiprotease is associated with hereditary emphysema
.ngiography *emonstration of blood vessels on <2ray by inection of dye
.sthma 7pisodic narrowing of airways, often with an allergic basis
.topic .llergic +positive s3in tests for allergies,
-i2level non2invasive
ventilation
Aechanical treatment for managing respiratory fail"re
-iplane screening F2ray in two planes at right angles sim"ltaneo"sly
-lood gas Aeas"rement of o<ygen and carbon dio<ide in blood
-rachytherapy Treatment for l"ng cancer
-ronchial challenge Tests of degree of reactivity of the airways in asthma
-ronchiectasis . destr"ctive disease of the airways
-ronchitis !nflammation of the airways d"e to irritation, especially smo3ing
-ronchography F2ray of the airway by installation of a dye
-ronchop"lmonary
dysplasia +-)*,
. chronic l"ng condition affecting infants born premat"rely
-ronchoscopy *irect e<amination of the airways thro"gh a rigid or fle<ible instr"ment
Cardiop"lmonary
e<ercise test
Aonitors the cardiac, circ"latory and respiratory responses to e<ercise
Chemosensitivity Responsiveness of the breathing centres of the brain to stim"li
Comp"terised
tomography +CT,
*etailed <2ray e<amination "sing comp"ter technology
Corticosteroid Nat"ral or synthetic anti2inflammatory hormone
C).) Contin"o"s positive airway press"re % "sed in treating sleep related
breathing disorders
Cystic fibrosis Congenital disease ca"sing l"ng damage, especially bronchiectasis
d"e to pl"gging with stic3y m"c"s
Cytopathology Aicroscopic e<amination of cells from the l"ng
*iff"sing capacity Aeas"rement of the rate of gas transfer from the l"ng into the
p"lmonary circ"lation
*omiciliary o<ygen (<ygen treatment in the home
*yspnoea -reathlessness
7chocardiography Dltrasonic e<amination of the heart
<ii
7mphysema . destr"ctive condition of distal air sacs of the l"ng
7mpyema )"s in the ple"ral space aro"nd the l"ng
/ine needle aspirate
+/N.,
-iopsy of l"ng tiss"e thro"gh the chest wall
/low vol"me loop Aeas"rement of inspiratory and e<piratory vol"me and flow rate
Balli"m Radioactive material "sed for scanning
Bammaglob"lin . fraction of ser"m protein with protective properties against infection
Bas transfer Aeas"rement of the "pta3e of o<ygen thro"gh the l"ng
Haemoptysis Co"ghing "p blood
!maging 7<amination of the l"ng by <2ray or n"clear medicine techni8"es
!mm"ne2s"ppressed 0ac3ing normal imm"ne defence mechanisms
!nert gas . gas that is not absorbed when breathed into the l"ng
!nterstitial l"ng
disease
. variety of conditions ca"sing scarring and fibrosis of the l"ng
Aagnetic resonance
imaging +AR!,
. new radiologic techni8"e for identifying disease processes in tiss"e
Aicrobiology 7<amination of secretions of tiss"e for organisms
Aorbidity The prevalence and characteristics of disease
Nasal C).) C).) % contin"o"s positive airway press"re % an effective treatment
for obstr"ctive sleep apnoea syndrome
Neb"liser . device for administering high dose inhaled dr"g
N"clear medicine The speciality of organ imaging "sing radioactive materials
(scillation . techni8"e for meas"ring l"ng f"nction by rapid alternation of air
movement
)ea3 flow meter . portable device for meas"ring l"ng f"nction
)erf"sion l"ng scan 7<amination of the blood flow thro"gh the l"ng by n"clear medicine
techni8"es
)lethysmography Aeas"rement of l"ng vol"me "sing a constant press"re chamber
press"re % tight chamber
)le"ral drainage !nsertion of a t"be into the space aro"nd l"ng
)ne"monia .n ac"te respiratory illness with radiographic p"lmonary shadowing
that is at least segmental or present in more than one lobe and is not
pre2e<isting nor of other 3nown ca"se.
)ne"mothora< .n air lea3 from the l"ng into the space aro"nd the l"ng
)olysomnography . comprehensive diagnostic techni8"e "sed to eval"ate sleep
disorders, incl"ding obstr"ctive sleep apnoea syndrome, central sleep
apnoea syndrome, sleep2related hypoventilation and disorders
<iii
prod"cing hypersomnolence s"ch as narcolepsy
)rophyla<is )revention of disease by dr"g therapy or vaccination
Radiograph F2ray
Respiratory fail"re /ail"re of the l"ng to maintain normal o<ygen or carbon dio<ide levels
in the blood
Scan +n"clear, N"clear medication imaging of the l"ng
Spirometer .n instr"ment for meas"ring l"ng vol"mes and flow rates
S"rfactant . s"bstance comprising lipid and protein fo"nd in the terminal l"ng air
sacs and necessary for maintaining patency and l"ng f"nction
Transbronchial
biopsy
-iopsy of small portions of l"ng thro"gh a bronchoscope
Gasc"lar disease *isease affecting the blood vessels of the l"ng
Gentilation l"ng
scan
N"clear medicine imaging of the pattern of distrib"tion of inhaled
gases into the l"ng
<iv
) Introduct!on
)>) Purpo#e nd u#e of 3u!de$!ne#
These strategic g"idelines are primarily written for professionals planning, developing
and managing Respiratory Services in the Ainistry of Health and *H-s. !f accepted,
these g"idelines wo"ld "nderpin the activities of a National Respiratory .dvisory
Committee and of regional committees.
The g"idelines loo3 to incl"de the f"ll scope of services from prevention of respiratory
illness, to promotion of primary and comm"nity health care, to hospital based
services and amb"latory care. Their p"rpose is to facilitate the development of an
efficient, accessible and e8"itable Respiratory Service in all regions of New Zealand.
They are Nservice= rather than Ndisease management= g"idelines, and do not attempt
to provide detailed protocols for patient care other than by way of occasional
e<amples +pertaining to transplantation, l"ng vol"me red"ction s"rgery, sleep related
breathing disorders and o<ygen therapy,. They indicate the minim"m services,
manpower, e8"ipment and level of training anticipated at the different levels of o"r
health care system.
The New Zealand health system has entered a new era with the formation of *H-s,
which have responsibility for comm"nity and hospital2based health care, th"s
allowing greater integration of primary and specialised health services. !t is e<pected
that *H-s will meet the standards s"ggested in these g"idelines for essential
Respiratory Services within the ne<t five years. However, it is important to recognise
the re8"irement to satisfy present needs, whilst also planning for anticipated needs.
These g"idelines will re8"ire review within five years of p"blication, beca"se of
changing health systems and health needs. The reviewing panel sho"ld incl"de
general practitioners, secondary health care providers, members of the TS.NZ,
representatives of Aaori and )acific people, lay societies and the *H-s and Ainistry
of Health.
)>/ The #cope of re#p!rtor" #er-!ce#
Respiratory services provide comm"nity2 and hospital2based facilities for the
prevention, detection, assessment, investigation and management of diseases of the
respiratory system. The service sho"ld incl"de an ed"cational and co"nselling role.
Conditions that fall within the "risdiction of respiratory services incl"de6
asthma and C()*
malignant intrathoracic diseases +l"ng cancer, mesothelioma, thymoma etc,
sleep related breathing disorders and daytime hypersomnolence
p"lmonary infections, partic"larly pne"monia and t"berc"losis
interstitial l"ng disorders
bronchiolitis, bronchiectasis, cystic fibrosis
bronchop"lmonary dysplasia
occ"pational l"ng diseases
1$
p"lmonary vasc"lar disorders
chest tra"ma
respiratory fail"re d"e to ne"rom"sc"lar disorders, chest wall deformity, obesity
and C()*.
)>? The 4urden of re#p!rtor" d!#e#e
Respiratory disease is a maor contrib"tor to morbidity and mortality in New Zealand
and worldwide.
1. Respiratory illness is the most common reason for cons"ltations in general
practice and acco"nts for #$%$& percent of medical admissions to hospital.
Respiratory disorders ma3e "p nine percent of New Zealand -"rden of *isease
estimates, ran3ing behind cardiovasc"lar disease, cancer +1$ percent of which
are d"e to l"ng cancers, and mental disorders.
1#
However, this estimate does
not incl"de all respiratory disorders +eg, l"ng cancer, sleep related breathing
disorders, which wo"ld acco"nt for another fo"r to five percent. The diversity of
respiratory disease is often not appreciated by those who wor3 o"tside of the
specialty, so it is important to highlight that respiratory disorders, when ta3en
together, 3ill more people than cancer or cardiovasc"lar disease.
1$
1. .sthma is a serio"s ca"se of morbidity in children and yo"ng people, the single
most fre8"ent reason for hospitalisation in childhood,
1;,1>
and the most common
ca"se of 7* attendance in New Zealand.
1?
.sthma is also increasing in
prevalence.
1C
*"ring two different time periods, New Zealand had the highest
asthma mortality rates in the world.
1&,11
C"rrently, New Zealand has the highest
admission rate in the world, and asthma remains a significant ca"se of
respiratory morbidity +loss of time from school, absenteeism from wor3,
s"boptimal performance, etc,. *irect and indirect costs associated with asthma
in New Zealand have been estimated at aro"nd @?1$ million ann"ally.
1C

.sthma ran3s third in New Zealand for specific ca"ses of years lost to disability
+highest in males,
15
and eighth for both males and females in New Zealand
-"rden of *isease estimates.
1#
#. C()* is the fo"rth most common ca"se of hospitalisation in male ad"lts +and
eighth among females,, and is the third most common ca"se of death. The
prevalence of C()* +emphysema:chronic bronchitis, has been estimated to be
aro"nd ?#5:1&&,&&& +of any age, b"t the C()* prevalence in the New Zealand
pop"lation aged over 5$ years is estimated to be aro"nd 5&,&&&.
11
*irect costs
of C()* management in New Zealand have not been acc"rately defined b"t
are estimated at between @11&%1#5 million per year and indirect costs are
"s"ally at least as high. C()* ran3s second for males and fifth for females in
New Zealand -"rden of *isease estimates.
1#
5. 0"ng cancer is the most common ca"se of cancer death in men and more
recently women. The direct costs associated with l"ng cancer management in
New Zealand range from @1? to @1C million and will increase s"bstantially if
international g"idelines on the "se of chemotherapy in non small cell l"ng cancer
are endorsed.
11
0"ng cancer ran3s fifth in New Zealand males in New Zealand
-"rden of *isease estimates and 11th in females, b"t is rising rapidly and sho"ld
ran3 ahead of breast cancer, +c"rrently ran3ed fo"rth,, within 1& years.
15
1;
$. )ne"monia and lower respiratory tract infections are a maor ca"se of death in
middle2aged and elderly persons and the most common ca"se of hospital
admission. Respiratory tract infections ran3 third for males in New Zealand
-"rden of *isease estimates.
1?
;. Serio"s sleep related breathing disorders occ"r in 5 percent of middle2aged
ad"lt males and one to 1 percent of females, and may contrib"te to "pwards of
11 percent of serio"s road traffic crashes +RTCs,.
1#
To date, ins"fficient data is
available to estimate the costs +direct and indirect, associated with these
conditions and so no b"rden of disease estimates have been form"lated
+tho"gh a New Zealand st"dy has recently been commissioned,. However,
given the li3ely prevalence of the disorder and its association with a n"mber of
common conditions +RTCs, hypertension, cardiac fail"re, CG.,, the associated
costs are li3ely to be high.
>. !n 1C?5 the 'H( declared p"lmonary t"berc"losis a worldwide emergency.
Together with an increasing incidence in 'estern co"ntries, the development of
m"lti2dr"g resistant disease T- will provide a maor medical challenge for the
f"t"re. T- presently ran3s si<th in the world in global b"rden of disease
estimates.
1>
Respiratory illness is a partic"lar problem among Aaori and )acific people of all
ages, with considerable premat"re deaths attrib"table to bronchiectasis.
15
.
s"bstantial proportion of the total b"rden of respiratory illness % specifically that
related to cigarette smo3ing,
1$
occ"pational health
1;
and lac3 of imm"nisation
1>,1?
% is
theoretically preventable.
*H-s sho"ld ens"re that services are available to effectively meet the needs of
people with the above disorders, and sho"ld s"pport all meas"res, incl"ding
prevention and ade8"ate access to primary health care, that help avoid s"ch
diseases and red"ce their impact in the comm"nity. Respiratory services need to be
easily accessible to all individ"als. (rganisational and financial barriers to health
care have a more immediate impact on patients with respiratory disease than those
with most other medical conditions, and remain the maor and most preventable
component of escalating admission rates for a variety of respiratory disorders.
1C
/inancial barriers to primary care have an e<aggerated effect on respiratory
disorders partly beca"se respiratory illness is more common and more severe in
lower socioeconomic gro"ps +as well as in Aaori and )acific pop"lations,.
Respiratory disorders are also inclined to worsen ac"tely, often demanding the need
for after ho"rs care and f"rther costs to the patient. The )rimary Health Care
Strategy has, as a 3ey foc"s, the red"ction of financial barriers to health care, which
may go some way towards improving this sit"ation.
7arly diagnosis and treatment of the maority of respiratory illnesses co"ld be
e<pected to red"ce morbidity and mortality. )artic"lar emphasis sho"ld be placed on
the needs of Nat ris3= gro"ps in the comm"nity, s"ch as children of smo3ing parents,
#&

children of atopic parents, immigrants at high ris3 of t"berc"losis,
#1,#1,##
smo3ers
#5
and
overweight snorers. . well2organised m"ltidisciplinary approach will be re8"ired to
identify individ"al needs and to implement effective management plans.
1>
)>1 7or! nd Pc!f!c he$th
Aaori have a "ni8"e place in New Zealand society, being an indigeno"s minority with
special needs d"e to a significant disparity in their health stat"s compared to the
whole pop"lation. The Treaty of 'aitangi and Crown obectives for the health of
Aaori provide a framewor3 for planning and actions to address these disparities.
Aaori comprise abo"t 1$ percent of the pop"lation c"rrently, b"t li3e the )acific
pop"lation have a greater rate of growth and a significantly lower health stat"s
compared to the remainder of the New Zealand pop"lation.
#$
The b"rden of chronic disease on Aaori and )acific pop"lations has been well
described b"t is only e<plained in part by poverty. /or e<ample, Aarwic3 et al
#;
in
their analysis of the 1CC;:C> New Zealand Health S"rvey concl"ded, with regard to
primary care services, that there are other barriers for Aaori besides income and all
the identified variables. /"rthermore, it is apparent that Aaori with chronic disease
do not achieve the same health o"tcomes, even when attending general practice, as
often as non2Aaori. Having a health care provider who is empathetic and
comm"nicates well with
#>
the patient has consistently been shown to achieve patient
satisfaction and raise the acceptability of treatment.
#?,#C
This is e8"ally tr"e for
Aaori.
5&
However, the lac3 of c"lt"ral agreement7rror6 Reference so"rce not fo"nd
,51
between Aaori patients and many non2Aaori health providers s"ggests that a 3ey
factor in improving access to care,7rror6 Reference so"rce not fo"nd adherence to
treatment
51
and o"tcomes wo"ld be to develop the c"lt"ral competence of health
care providers.
Consistent and acc"rate collection of patient ethnicity data from Aaori, )acific and
other disadvantaged comm"nities is a priority.
)>; Ser-!ce h!#tor"
The great maority of respiratory illness has been and contin"es to be managed at
the primary health care level. Hospital2based respiratory medical and s"rgical
services were originally concerned with treatment and prevention of t"berc"losis,
severe C()*, severe asthma and l"ng cancer. .s the prevalence of t"berc"losis
declined in New Zealand, Respiratory Services became increasingly involved in
detection, diagnosis and management of diseases of airways obstr"ction +asthma,
C()*, bronchiectasis, cystic fibrosis, bronchiolitis,, l"ng infections +incl"ding
pne"monia, and malignancies.
1?
However, t"berc"losis is again on the increase, and certain conditions, s"ch as
bronchiectasis, (S. and asthma, are clearly more prevalent than initially recognised.
*iagnostic and management strategies for pne"monia have advanced, partic"larly in
the last decade.
5#,55
New technology has led to recognition, diagnosis, and th"s
treatment of new conditions s"ch as sleep related breathing disorders, opport"nistic
infection and a variety of interstitial l"ng disorders. Technologic advances in other
areas of medicine and new diseases +eg, H!G,
5$
and new therapies have led to new
challenges, eg dr"g ind"ced l"ng disease, p"lmonary infection in the imm"ne
compromised host, and p"lmonary manifestations of organ reection in
transplantation +bone marrow and l"ng,. !mproved management and "nderstanding
of certain paediatric conditions, incl"ding cystic fibrosis, -)*, and conditions s"ch as
bronchiectasis, has meant improved s"rvival and led to transfer of patients to ad"lt
services for care. *evelopment of facilities and e<pertise in s"pport services has
also occ"rred for aspects of respiratory disease s"ch as respiratory physiology, chest
radiology, p"lmonary allergy and imm"nology, *N. based diagnosis and molec"lar
epidemiology, cytopathology, bronchoscopy and bronchoscopic techni8"es, thoracic
s"rgery and non2invasive ventilation.
This newer technology has contrib"ted to improved management of patients in
secondary and tertiary health care instit"tes. Non2invasive ventilation, for e<ample,
has enabled closer relationships between respiratory physicians and intensive care
"nits. This technology has also helped with the investigation of imm"no2
compromised patients, enabling closer ties between patients and physicians
managing lymphoproliferative disorders, .!*S and transplantation services. The
development of recombinant *N. based therapies, s"ch as r *N=ase
5;
and alpha 1
antitrypsin replacement,
5>
as well as monoclonal antibody therapies targeting cancer
cells or !g7 will add to the need for highly specialised respiratory services.
)>. Future d!rect!on# for re#p!rtor" #er-!ce#
There are strong indications of a pending rise in the need for respiratory services.
Aany respiratory illnesses are increasing in prevalence or severity. These incl"de
asthma, C()*, bronchiectasis, p"lmonary malignancy, interstitial l"ng disorders,
occ"pational l"ng disease, p"lmonary t"berc"losis and p"lmonary problems in the
imm"no2s"ppressed. The prevalence of some diseases are infl"enced by
environmental factors, especially cigarette smo3ing,7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd
and it is li3ely that smo3ing2related l"ng diseases will not
pea3 for another 1& years. /"rther, passive smo3ing e<pos"re increases childhood
admission rates in several disease categories and has many other negative health
effects.7rror6 Reference so"rce not fo"nd
The increased longevity of children with cystic fibrosis means that most children born
now will s"rvive to ad"lthood, which in t"rn will re8"ire increasing "se of specialist
ad"lt respiratory services.7rror6 Reference so"rce not fo"nd
,5?,5C
!n addition,
improved neonatal care will res"lt in larger n"mbers of children and hence ad"lts with
bronchop"lmonary dysplasia +-)*, d"e to premat"rity and its complications.
1C
The increasing diagnostic capabilities within respiratory medicine, incl"ding radiology
+p"lmonary angiography, CT scanning, bronchial arteriography, and other modalities
of organ imaging +magnetic resonance imaging +AR!,, isotope scanning,, physiology,
sleep st"dy, bronchoscopy, imm"nology and investigation of infection in imm"no2
compromised hosts +for transplant patients, le"3aemia and lymphoma, and H!G for
e<ample, have increased specialist referrals for assessment.
The effect of the ageing pop"lation has also increased the prevalence of respiratory
illness, and raised the n"mbers of patients admitted to hospital with pne"monia and
C()*. Th"s, not only have the n"mbers of respiratory patients increased, b"t also
the increased comple<ity of disease and associated co2morbidity will place increasing
demands on respiratory services.
.ppendi< ! ill"strates changes in hospital admissions for vario"s types of respiratory
illness across all age gro"ps at five yearly intervals from 1C>& to 1CC?. +These data
need to be interpreted in the conte<t of mar3edly red"ced admissions +ie, heightened
threshold, for certain conditions +eg, T- and l"ng cancer, and the mar3edly red"ced
d"ration of admission for other conditions +eg, asthma, C()*,. .dmissions for
t"berc"losis are again increasing, predominantly beca"se of immigration from
developing co"ntries where this disease is epidemic. There are increasing n"mbers
of patients with m"lti2dr"g resistant T-. There has also been a s"bstantial increase
+#$& percent, in admissions for diseases of airways obstr"ction +asthma, C()*, and
a do"bling in the n"mber of admissions with l"ng malignancy over the past 1& years.
The n"mbers of admissions d"e to p"lmonary infection grad"ally red"ced "p to
1C?$, b"t have increased again mainly beca"se of increasing rates of antibiotic
resistance. +)ne"mococcal infections were fo"nd to be resistant to penicillins in
C percent of cases in 1CC;, compared with & percent in 1C?&., (verall, d"ring a
1#2year period, there has been a 1$& percent increase in admissions for all
respiratory ca"ses. .dmissions in 1&&$ are predicted to increase by 1; percent, with
the greatest increase occ"rring in patients with C()*.
These fig"res ma3e for sober reading. Respiratory admissions are increasing at a
disproportionate rate to other medical conditions. 'inter admissions d"e to
respiratory disorders paralyse hospitals, with respiratory patients displacing elective
s"rgical patients, ca"sing cancellation of s"rgical lists, and lengthening s"rgical
waiting lists. New, more integrated approaches to respiratory health care delivery
are clearly needed if we are to reverse this trend.
1&
)>@ Pred!ct!on#
(n the basis of recent trends and c"rrent practices, it is predicted that6
the incidence of t"berc"losis will grad"ally increase even with more ade8"ate
screening of immigrants than e<ists presently. Aanagement will remain
predominantly an o"tpatient:comm"nity service, b"t patients who are aged or infirm,
are recent immigrants, or have co2e<istent H!G infection will need initial inpatient
therapy. Those who have dr"g resistant T-, who are infectio"s or who are li3ely to
be non2compliant with therapy will need in2patient treatment for at least a month and
directly observed o"tpatient therapy for at least si< months.#1
,$&,$1
'ell co2ordinated
approaches to care, characterised by close wor3ing relationships between )"blic
Health and hospital based services, are therefore re8"ired. These need to be
"nderpinned by "p2to2date national g"idelines on T- management
http6::www.moh.govt.n9:moh.nsf:&:5>;&*/#$?&.;/$-$CC1$;C?;&&;7*#C5:@/ile:
T-ControlB"idelines&#.pdf
there will contin"e to be a steady increase in the prevalence of diseases
associated with smo3ing, specifically C()* and l"ng cancer. These will re8"ire
greater comm"nity and hospital2based facilities for diagnosis and management.
Smo3ing2related p"lmonary disease is predicted to pea3 aro"nd the year 1&1&.
!ntegration of primary and secondary care services, with "se of hospital o"treach
programmes and comm"nity services, will be an essential re8"irement. 7arly
discharge at either the 7* or ward level, with management by a hospital o"treach
team +case management,, or the provision of f"nding to the primary care sector to
s"pport follow2"p or achieve more comprehensive intervention in the comm"nity
d"ring ac"te e<acerbations, has been shown to be effective in the Co"nties
Aan"3a" *H-.
C1
.ssisted ventilation given to selected patients with C()*, who
were admitted in respiratory fail"re, has been shown to be effective and to red"ce
!CD admissions and mortality rates
the prevalence of asthma appears to be grad"ally increasing. . #&%$& percent
red"ction in hospital admissions co"ld be achieved7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd,$1,$#,$5,$$
,
$;
if6
comm"nity and o"tpatient management programmes are "pgraded and
implemented more effectively
inhaled steroids and long acting inhaled beta agonists are more appropriately
prescribed
patient self2management ed"cation is made more available
factors that impair the ac8"isition of 3nowledge and the development of
appropriate self2management behavio"r are addressed, and
financial barriers to primary health care are red"ced
there will be a steady increase in p"lmonary infections in the imm"ne s"ppressed,
which will place considerable demands on time and reso"rces. Comm"nity
ac8"ired infections re8"iring hospitalisation, partic"larly pne"monia, are also
increasing and may reflect +along with asthma admissions, the ageing pop"lation
and poor access to primary health care by people living in disadvantaged
comm"nities.7rror6 Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,$>,$?

Strategies to manage patients with less severe comm"nity2ac8"ired pne"monia
+perhaps, grades one thro"gh three in severity, in the comm"nity co"ld be
eval"ated
11
as a larger pool of patients with cystic fibrosis and bronchiectasis with moderately
severe or severe disease evolve, there will be a f"rther increase in admission
rates for s"pport d"ring infective e<acerbations. S"ch patients are more li3ely to
develop infection resistant to commonly employed antibiotics, re8"iring e<pensive
antibiotic regimens and, on occasions, assisted ventilation. These patients co"ld
often be managed in the comm"nity, if home !G programmes were in place, along
with visits from the hospital o"treach team7rror6 Reference so"rce not fo"nd
,7rror6
Reference so"rce not fo"nd
sleep related breathing disorders are common
$C
and the screening and appropriate
management of people in New Zealand with this range of illnesses is poorly co2
ordinated and inade8"ately f"nded. No b"dget has been agreed to nationally, for
either st"dying the condition or providing therapy +nasal C).), -i).),. 'e fall
far below accepted international standards of care for managing this disorder,
which has important p"blic health implications d"e to its 3nown association with
fatal RTCs and occ"pational in"ries. !n addition, (S. is at least twice as
common in Aaori and )acific people
;&
non2invasive ventilation for m"sc"lar dystrophy, m"sc"los3eletal disorders, and
other ca"ses of respiratory fail"re, need to be introd"ced and appropriate f"nding
ens"red. .ssisted ventilation for !CD patients coming off mechanical ventilation,
and ventilatory s"pport for C()* e<acerbations +for which there are five
randomised controlled trials demonstrating benefit,
;1,;1,;#,;5
will place added
demands on hospital services, b"t will lead to earlier discharge of patients with
these disorders as well as patients with C()*, (S. and bronchiectasis.
The maor impact of these changes in prevalence and severity will initially be at the
primary health care level, where provision of services in respiratory diagnosis and
management will need to be increased, made more sophisticated and also more
accessible. *H-s will need to develop strategies to ens"re that the increased
respiratory wor3load in both primary and hospital2based services is met. However,
development of strategies to "se e<isting services more intelligently may lead to a
need to increase reso"rces at a secondary and tertiary care level in the f"t"re. This
need sho"ld be red"ced over time if the benefits from better 8"ality secondary and
tertiary health care evolve into the comm"nity.
)>+ Ne% techno$o3!e#
*H-s will need to consider the relative priorities and cost:effectiveness of the
following services, and will need to give consideration as to how these sho"ld be
developed within their own regions to ens"re ade8"ate access and 8"ality.
1. *omiciliary o<ygen therapy is increasingly "sed for children with
bronchop"lmonary dysplasia and cystic fibrosis, and ad"lts with interstitial l"ng
disorders, C()*, bronchiectasis, p"lmonary hypertension and terminal
malignant disease.
;$,;;
. review of the domiciliary o<ygen service in ."c3land
showed it was often "sed too late in the co"rse of C()* treatment.
;>
Targeting
the "se of o<ygen in patients with less severe disease may not only lead to
greater improvement in s"rvival, b"t to greater improvements in 8"ality of life
and red"ced need for hospitalisation. !nternational g"idelines on domiciliary
o<ygen,
;?
if f"lly adopted in New Zealand, will have important reso"rce
implications +for e<ample, in ."c3land the rate of prescription was 15:1&&,&&&
11
compared with $1:1&&,&&& in ."stralia, ;&:1&&,&&& in Canada and 15&:1&&,&&&
in the DS.,. C"rrently, portable o<ygen therapy, the most efficacio"s form of
o<ygen therapy, is "nf"nded and the amo"nt spent on o<ygen in New Zealand
is $& percent of that spent in ."stralia and 7ngland and five percent of the
spend in the DS.. 'e are "nable to apply international g"idelines on (<ygen
therapy beca"se of this lac3 of f"nding +see also .ppendi< F!,.
1. Cancer treatments s"ch as chemotherapy are c"rrently standard treatment for
small cell l"ng cancers. 0aser therapy, airway stenting and brachytherapy
;C

sho"ld be "sed for palliation in a greater n"mber of selected cancer patients.
Chemotherapy for non small cell l"ng cancer is being "sed increasingly
internationally, and presently cons"mes more than $& percent of the total
chemotherapy b"dget in the DS.. However, it is not ro"tinely available in New
Zealand. B"idelines for the "se of chemotherapy in non small cell l"ng cancer
patients have been developed in ."stralia
>&,>1
and have been endorsed by the
TS.NZ. Since chemotherapy for non small cell l"ng cancer is more cost
effective than mammography in women over the age of $$ or chemotherapy for
breast cancer +two presently f"nded initiatives,,
>1
this iss"e needs to be "rgently
addressed in New Zealand as we are "nable to implement these g"idelines.
#. Replacement therapies s"ch as alpha 1 antiprotease +for ad"lts with hereditary
emphysema,,7rror6 Reference so"rce not fo"nd and gamma2glob"lin +for
children and ad"lts with imm"ne deficiencies, can now be administered to
individ"als with these life2threatening deficiencies.
5. )rophyla<is and treatment of opport"nistic infections related to imm"ne
deficiency will increase, partic"larly if the incidence of .!*S rises along with the
proected increase in patients with organ transplants +heart, bone marrow, l"ng,
3idney and liver,.
$. (rgan imaging technologies, specifically comp"terised tomography +CT,
scanning, +an e<isting service, and n"clear magnetic resonance imaging +AR!,
will enhance the 8"ality of diagnostic services b"t at moderate cost. High
resol"tion CT scanning of the l"ng and CT). have only been developed in the
last 1& years and have revol"tionised the way patients with a wide spectr"m of
respiratory disorders are eval"ated. However, CT scanners will need to be
"pgraded and respiratory radiologists trained at regional centres to ens"re
scans are acc"rately reported. )7T scanning is a newer form of scanner, which
is partic"larly "sef"l in eval"ating the chest wall and mediastin"m, and will have
a small b"t important part to play in the investigation of l"ng cancer and chest
wall and mediastinal disorders.
;. (rgan transplantation +see .ppendi< !F, incl"ding single l"ng, bilateral
se8"ential l"ng and heart2l"ng transplantation is appropriate for a selected
gro"p of patients.
>#
. national l"ng transplant service has been established at
."c3land City Hospital. This programme is limited by a lac3 of donor organs,
which allows only 1& patients to "ndergo l"ng transplantation ann"ally, b"t
co"ld be revol"tionised by advances in <enografting. The present standardised
l"ng transplant rate is $& percent that of ."stralia. Reection is noted more
commonly in l"ng transplantation than in other solid organ transplant
programmes and more e<pensive imm"nos"ppressants will need to be 8"ic3ly
accommodated into the programme, as has already occ"rred for liver
transplantation in New Zealand.
1#
>. Sleep related breathing disorders are common and vario"sly reported as
affecting between 1 and 5 percent of the pop"lation.7rror6 Reference so"rce not
fo"nd 'hilst criteria abo"t who sho"ld be prescribed nasal C).) therapy still
need to be acc"rately defined, there is clear symptomatic and probable s"rvival
benefit with this treatment in those with moderate and severe disease.
Treatment is not "niformly available in New Zealand and there is no f"nding for
investigation of paediatric patients. However, the .RHT.C Report on the
effectiveness of nasal C).), which was commissioned, by the H/. and the
Ainistry of Health +see .ppendi< F!!, concl"ded that nasal C).) is an effective
treatment for (S.. The Report also defined specific patient gro"ps who sho"ld
receive therapy.
?. Non2invasive ventilation
>5
is becoming increasingly "tilised and has led to a
closer wor3ing relationship with !ntensive Care Dnits, with shared care:step2
down care of selected patients with primary respiratory fail"re. 0evel two data
now e<ists showing s"rvival benefit with "se of noct"rnal ventilatory s"pport or
non2invasive ventilation therapy in patients with a wide variety of ne"rom"sc"lar
disorders.
>$,>;
S"ch treatment is not f"nded in New Zealand.
C. )"lmonary hypertension is an increasingly recognised condition, which can
complicate a n"mber of disorders. )"lmonary endarterectomy
>>
can be offered
to a small s"bset of patients with central thromb"s complicating p"lmonary
emboli that has not resolved on anticoag"lant therapy. This proced"re can be
performed at ."c3land City Hospital. !n patients with primary p"lmonary
hypertension "nable to be controlled on calci"m antagonists, prostacyclines
have a proven role in management, b"t only limited f"nding e<ists for this care
in New Zealand.
1&. 0"ng vol"me red"ction s"rgery +.ppendi< F, is ro"tinely available in most
'estern co"ntries to a highly selected gro"p of patients with emphysema. !t is
not ro"tinely available in New Zealand, tho"gh 11 cases have been performed
at ."c3land City Hospital with no post2 operative deaths and #& percent
improvement +on average, in l"ng f"nction and e<ercise capacity. *ata has
been forwarded to the ."stralasian database.
>?
The rate of 0GRS in ."stralia is
five per million per year and in New Zealand one per million per year.
11. Neb"lised antibiotics have an established role in the management of cystic
fibrosis and evidence s"ggests benefit in bronchiectasis.
>C
They are available in
New Zealand for "se in cystic fibrosis patients only. )reservative free
tobramycin is not listed on the pharmace"tical sched"le and therefore not
available free to most patients.
New dr"g therapies are abo"t to be made available. !/N gamma is li3ely to be
confirmed as the only pharmacologic agent benefiting C/. +alone or associated with
connective tiss"e disorders,.
?&
(ther therapies incl"de anti !g7 therapy for asthma,
?1

monoclonal antibody therapy for ac"te severe pne"monia and long2acting inhaled
anticholinergic therapy in C()*.
?1
15
/ 6u!de$!ne# for De-e$opment of Re#p!rtor" Ser-!ce#
/>) Pre-ent!on of d!#e#e
To help detect early disease and prevent disease occ"rrence, attention sho"ld be
directed to6
the primary prevention of l"ng disease of pre2term infants
genetic co"nselling in cystic fibrosis families
"niversal newborn screening
screening and replacement therapy for alpha21 antiprotease deficiency
prevention or cessation of smo3ing
prevention of occ"pational l"ng disease
s"rveillance of contacts of patients with t"berc"losis.
)reventive strategies sho"ld also incl"de6
comm"nity health ed"cation programmes
avoidance of wor3 related p"lmonary in"ry
vaccination programmes, especially for those at highest ris3
screening of children with fre8"ent lower respiratory tract infections in infancy
earlier referral to respiratory specialists of patients with chronic respiratory
symptoms not easily classifiable or which do not respond satisfactorily to available
therapies, especially when certain specific conditions are s"spected.
!t is e<pected that the National Respiratory Committee wo"ld wor3 closely with the
Ainistry of Health, and Regional )"blic Health Dnits +thro"gh *H-s, and *istrict
Health -oards New Zealand +*H-NZ, to develop effective, evidence based
strategies to help prevent respiratory illness.
/>/ 7or! nd Pc!f!c he$th
Aaori and )acific people have a considerably yo"nger age str"ct"re compared with
the whole New Zealand pop"lation. Certain respiratory conditions +pne"monia, (S.,
t"berc"losis, and bronchiectasis, are both more common and more severe in Aaori
and )acific people, contrib"ting to premat"re mortality.
$>
!n addition, Aaori and
)acific people have higher hospital admission rates for C()*, asthma,
bronchiectasis, ac"te lower respiratory infections, t"berc"losis and sleep related
breathing disorders. Aaori and )acific people also "tilise services differently from
the 7"ropean:)a3eha pop"lation +for e<ample, there is greater "se of the emergency
department by )acific people in partic"lar,
51
and they have additional barriers to
primary care that are not e<plained by deprivation.7rror6 Reference so"rce not fo"nd
1$
!n contrast to the red"ction in smo3ing prevalence seen in 7"ropean:)a3eha
pop"lations over the last decade, there has been no decrease in smo3ing prevalence
in Aaori or )acific pop"lations.
?#,?5
Together these data confirm the greater b"rden of
illness s"ffered by Aaori and )acific people d"e to respiratory illnesses compared to
the 7"ropean:)a3eha pop"lation. !n order to address this significant disparity,
attention m"st be foc"sed on providing care and preventive services that are
c"lt"rally acceptable.
/>? Cu$tur$$" ccept4$e cre
)atients are more satisfied with care provided by services that are a part of, or in
t"ne with, their c"lt"re.7rror6 Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd
'hen
there is agreement between the different c"lt"ral beliefs, and there is greater
"nderstanding between the provider and the patient, access is improved and
adherence to treatment is enhanced.7rror6 Reference so"rce not fo"nd /or
e<ample, Aaori and )acific patients are m"ch less li3ely to 8"estion treatment plans
than )a3eha. !n large part this is beca"se )a3eha health professionals are seen to
have a position of a"thority, and sho"ld not be 8"estioned, as that wo"ld be
disrespectf"l. Clinicians therefore need to chec3 on the "nderstanding of Aaori and
)acific patients in different ways, s"ch as thro"gh indirect 8"estioning, the "se of
family members, and by "sing Aaori or )acific health wor3ers. 'hile initiatives to
increase the n"mbers of Aaori and )acific providers are "nderway,
?$
there remains a
need to increase the c"lt"ral competency of all providers in order to improve access
and health o"tcomes for Aaori and )acific people.7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not
fo"nd,$C
C"lt"rally acceptable care
$C
begins with comm"nity involvement. This may re8"ire
Aaori and )acific !sland and other ethnic gro"ps to become incl"ded at all stages of
service development, incl"ding6
staff training
policy and reso"rce materials development
complaints processes
assessments of patient satisfaction
relationships with Aaori and )acific providers
eval"ations and planning for service improvements.
.ssistance with these matters can also be so"ght from the Aaori and )acific
comm"nity, Aaori and )acific health professional gro"ps, 8"alified Aaori and )acific
cons"ltants, Aaori and )acific patient advocacy gro"ps, Aaori and )acific staff of
hospitals, *H-s, the Ainistry of Health, Te Iete Ha"ora and others. .ppropriate
recompense and s"pport for these gro"ps sho"ld be considered.
1;
/>1 Ethn!c!t" dt
.ll of these activities sho"ld be s"pported by reliable ethnicity information. Services
m"st ens"re that the self2identified ethnicity +incl"ding all iwi and hap" that are
relevant to the individ"al, is incl"ded in the patient information management systems
as well as any patient records "sed by provider staff. This data sho"ld be collected
in an approved and consistent manner, so that individ"al patients can be offered
c"lt"rally acceptable and safe care and so that their care o"tcomes can be
appropriately eval"ated. Collecting and reporting demographic, epidemiological and
clinical o"tcome data bro3en down by ethnicity is the first step to ma3ing
improvements to services for Aaori, )acific and other disadvantaged gro"ps.
/>; Pr!mr" nd commun!t" cre
The maority of respiratory problems sho"ld be managed in the comm"nity. These
incl"de most respiratory infections and most cases of asthma, bronchiectasis, and
C()*.
?;
Contin"ing care sho"ld also be available in the comm"nity for patients with
l"ng cancer or sleep related breathing disorders. S"ch primary and comm"nity
health care needs to involve general practitioners and practice n"rses,
physiotherapists, n"rses from health development "nits and vol"ntary agencies,
s"pported and reso"rced if necessary by the base hospital facilities.
*H-s now have the opport"nity to direct their attention to the comm"nity, and
provide planning for integrated services by, for e<ample, wor3ing with general
practitioners, local .sthma Societies and the .sthma and Respiratory /o"ndation of
New Zealand, TS.NZ, Cancer Society, local Hospices, Cystic /ibrosis .ssociation,
Sleep .ssociation, T"berc"losis and Chest *iseases .ssociation, Health )romotion
Services and (cc"pational Safety and Health Dnit, as well as local iwi and )acific
comm"nities.
The integration of comm"nity, professional and hospital2based services sho"ld
red"ce the c"rrent press"re on hospital2based services, incl"ding the "se of 7*s for
management of ac"te asthma, C()* and ac"te respiratory infection, and red"ce
morbidity from respiratory diseases in the comm"nity. 'e recommend that health
providers involved in comm"nity care be directly involved in the planning and
management of these services.
7<citing possibilities e<ist for respiratory specialists to be made more available to the
comm"nity, for e<ample thro"gh lin3s with )H(s and "se of s"per clinics.
?>

/"rthermore, the potential for disease2specific f"nding co"ld be e<plored. However,
these initiatives sho"ld be closely monitored, and the *H- may need to consider
apportioning money to eval"ate health o"tcomes as a res"lt of these endeavo"rs so
that they can be improved over time.
1>
/>. 5e$th educt!on nd #e$fAmn3ement of re#p!rtor" d!#order#
There is a growing recognition of the need to provide patients with greater
information and hence deliver them greater responsibility for preservation of their
health and for management of illness. The ed"cational material sho"ld be prod"ced
in m"ltiple lang"ages and be c"lt"rally appropriate.
The development of asthma services in several centres over the last 1& years is one
e<ample of the envisaged ed"cation services. These services sho"ld be available
thro"gh m"ltiple referral ro"tes % s"ch as general practice, patient self2referral, or
hospitals. They will need to be developed and f"nded to the appropriate referral level.
.de8"ate reso"rces will also allow6
home visits by respiratory n"rse practitioners
gro"p sessions in individ"al practices
comm"nity centres
employment gro"ps and gro"ps li3e this
training of other patients and their families
ed"cation of colleag"es and other health professionals
liaison with practice n"rses and general practitioners and
provision of advice and assistance with treatments +eg, "se of inhalation devices,
monitoring of l"ng f"nction, and "se of prescribed management plans,.
!n addition, ed"cators and specialist respiratory n"rses m"st have roles in the
development of p"blic awareness programmes, and co2ordination with other lay and
s"pport gro"ps, Aaori health wor3ers, asthma societies, etc.
Dnder new legislative arrangements, respiratory n"rse practitioners sho"ld be in a
position to case manage and co2ordinate care +within their defined scope of practice
eg, C()*,, whilst maintaining close liaison with general practitioners or
physicians:paediatricians. The B) and physician sho"ld maintain primary
responsibility for the management programmes and for the prescription and "se of
treatments, b"t in certain instances repeat prescriptions co"ld be carried o"t by n"rse
practitioners. Respiratory n"rse practitioners sho"ld also cons"lt other n"rsing
services, s"ch as district n"rsing services in asthma, p"blic health n"rses in T- and
Cancer Society and hospice n"rses in l"ng cancer.
/>@ Secondr" nd tert!r" he$th cre
The e<tent of respiratory hospital services will vary according to the si9e of the
region. !n general, in2patient beds sho"ld be available for investigation and
management of ac"te and chronic ad"lt respiratory illnesses. 7* services and
intensive care sho"ld be available in each region. 7<tensive s"pport services,
incl"ding organ imaging, physiology, pathology and associated medical, and s"rgical
disciplines +incl"ding cardiology, thoracic s"rgery, otorhinolaryngology, imm"nology,
oncology and radiotherapy, sleep clinics and polysomnography, sho"ld be available
in larger centres +see Table 1,.
1?
Hospital o"tpatient departments and private specialists sho"ld provide clinics for
ad"lt respiratory diseases, while day patient facilities co"ld provide an increasingly
"sed alternative to inpatient stay for specialised investigations and proced"res +for
e<ample, administration of chemotherapy, imm"noglob"lin transf"sions, early
management of C()* e<acerbations and investigation of respiratory disorders
re8"iring m"ltiple investigations s"ch as l"ng f"nction, perc"taneo"s needle biopsy,
CT scanning and bronchoscopy,.
)resently, there is too m"ch emphasis on the "se of e<pensive ac"te secondary
health care services, partic"larly for the management of respiratory disorders. !n o"r
opinion, the red"ction of hospital admissions will not occ"r simply by diverting f"nds
from secondary to primary services. !t is o"r view that this co"ld be achieved
thro"gh6
better integration of primary and secondary services
improved comm"nication +electronic, between primary and secondary services
improved trac3ing of patients discharged from hospital, with improved follow2"p in
o"tpatient clinics
definition of at2ris3 patients for m"ltidisciplinary respiratory o"treach team follow2
"p, and s"bse8"ent transfer to comm"nity based gro"ps
increased availability of specialist advice
implementation of evidence based g"idelines in primary:secondary care sectors
agreed to criteria as to when and how to discharge patients from o"tpatient clinic
follow2"p.
Respiratory n"rse practitioners and electronic information systems can both
contrib"te to contin"ity of care between the primary, secondary and tertiary sectors.
/>+ Bu$!t" ##urnce nd peer re-!e%
M"ality needs to be assessed by clinical a"dit, credentialing, clinical pathways,
g"idelines, clinical indicators, 8"ality feedbac3 processes and meas"rement of
clinical o"tcomes +incl"ding morbidity, mortality and 8"ality of life meas"res,.
??

These assessments sho"ld be monitored nationally with the assistance of an
epidemiologist or specialist in comm"nity medicine.
Health providers responsible for patient care at all levels sho"ld maintain acc"rate,
f"ll and confidential records which sho"ld be available to a"thorised personal for the
p"rposes of a"dit, assessment of o"tcomes, st"dy of trends in prevalence, referral
patterns, and standards of care. . 8"ality ass"rance programme incorporating peer
review sho"ld be maintained by the *H-.
*H-s sho"ld also ma3e data available for within2region, inter2regional and
international comparisons with respect to access to health care, standards of health
care and effect of preventative meas"res. 7<amples of how the limited data c"rrently
available for l"ng cancer and asthma can be "sed are given in .ppendi< !!.
1C
The following will re8"ire more specific eval"ation6
rates of attendance for asthma at 7*s
patterns of admission for asthma and C()*
the length of time from B) referral to s"rgery:radiotherapy for l"ng cancer
the proportion of patients referred for s"rgery, radiotherapy or chemotherapy
the proportion of patients staged with N1 disease post s"rgery and
five year s"rvival fig"res.
#&
? Re#p!rtor" Ser-!ce# !n 6ener$ Prct!ce
The general practitioner is, in most instances, the primary caregiver for patients with
respiratory disorders, providing assessment, treatment, referral, ed"cation and
ongoing s"rveillance. 78"ipment available to )H(s sho"ld incl"de spirometers and
p"lse o<imeters +both of which re8"ire calibration and reg"lar maintenance,, mobile
neb"lising "nits +both vent"ri and "ltrasonic, and each of a s"itable standard, with
reg"lar maintenance chec3s,, o<ygen for neb"lisation and appropriate ed"cation
material.
Beneral practitioner services sho"ld be of the highest standard possible, and be
available 15 ho"rs a day for ac"te assessment and treatment of all respiratory
problems, or there sho"ld be an appropriate bac32"p service available to patients
over 15 ho"rs.
'e recommend that strategies be developed to red"ce financial barriers to primary
health care for selective patients with chronic respiratory disorders.
?>) Educt!on
The general practitioner and the practice n"rse sho"ld "nderta3e basic and
contin"ing ed"cation. 7d"cation sho"ld6
be fle<ible eno"gh to fit all disorders and age gro"ps
be socially and c"lt"rally appropriate
occ"r over time as patient re8"irement varies.
!n comm"nities with high incidences of morbidity:mortality from respiratory disorders
the concept of a comm"nity based ed"cation centre or of a m"ltidisciplinary and
possibly m"ltic"lt"ral respiratory health team may need to be e<plored. This
approach may re8"ire comm"nication and co2ordination with lay societies s"ch as
the Cancer Society, .sthma Society, Cystic /ibrosis Society and others.
?>/ Referr$ to #econdr" nd tert!r" cre
The services described in the secondary and tertiary g"idelines, especially the
cons"ltative services, sho"ld be readily available to patients "nder the care of
general practitioners. B"idelines for appropriate referral and for the information to be
s"pplied to patients need to be developed. There is also a need to f"rther develop
the national access and priority assessment criteria prepared by the TS.NZ and H/.
+see .ppendi< !!!,. Comm"nication between services m"st be rapid and effect"al,
and f"rther investigation of modern sec"re electronic systems +email, is needed.
Specialist advice and services s"ch as respiratory physiotherapy:rehabilitation, and
l"ng f"nction laboratories sho"ld be made more available and receive more sec"re
f"nding, as sho"ld specialist o"tpatient care. 'e believe that hospital admission
rates will decline with improved f"nding and access to primary and amb"latory care.
#1
?>? Bu$!t" contro$
Aaintenance of professional standards of general practitioner services sho"ld be
"nder the a"spices of the Royal New Zealand College of Beneral )ractitioners
+RNZCB),, which sho"ld set standards for medical care in the comm"nity. .s part
of an ongoing 8"ality ass"rance programme, the RNZCB) sho"ld assess the
re8"irements of a general practitioner who is caring for patients with respiratory
diseases and establish g"idelines for these, in con"nction with the *H-s, )H(S, the
Thoracic Society of ."stralia and New Zealand, the Cochrane Collaboration and the
New Zealand Ainistry of Health B"idelines Committee.
!nternational g"idelines for management of asthma,7rror6 Reference so"rce not
fo"nd
,?C,C&,C1
C()*,
C1,C#
comm"nity ac8"ired pne"monia,7rror6 Reference so"rce not
fo"nd l"ng cancer,
C5
o<ygen therapy7rror6 Reference so"rce not fo"nd and cystic
fibrosis
C$,C;
and the investigation of s"spected sleep breathing disorder have been
developed and sho"ld be adopted for "se in New Zealand, with any necessary
adaptations. 7val"ations sho"ld be "nderta3en to ens"re they are implemented at
primary, secondary and tertiary healthcare levels. C"rrently, there is no mandate for
any of the *H-s to implement g"idelines, whether developed in New Zealand or
."stralasia +ie, developed by TS.NZ,.
National evidence2based g"idelines for the management of interstitial l"ng disorders,
sleep related breathing disorders and bronchiectasis still need to be developed in
New Zealand. These need to be along the same lines as those for asthma, C()*
and t"berc"losis.#1
?>1 P$nn!n3 #er-!ce#
Beneral practitioners, wor3ing at the divide between health and disease and caring
for people over time, clearly see the need for health services planning to be based on
primary care. Secondary and tertiary services sho"ld be complementary to primary
care, and act in a s"pportive, ed"cational and bac3"p role. The general practitioner
sho"ld also wor3 with patients in the same way, to help with independence,
enco"rage self2reliance and avoid over medication.
?>; Inte3rted e$ectron!c !nformt!on #"#tem#
!mproved electronic information systems are "rgently re8"ired to6
help develop an integrated health wor3 force
improve comm"nication between hospital and comm"nity based health care
providers
improve comm"nication between the five regional respiratory centres and
secondary health care providers.
#1
1 Spec!$!#t Re#p!rtor" Ser-!ce#
1>) Re#p!rtor" #er-!ce# t nt!on$ $e-e$
!n view of the relatively small si9e of New Zealand=s pop"lation, certain low vol"me
and highly technical proced"res sho"ld only be developed at one centre. This co"ld
be reviewed ann"ally so that, if vol"mes did increase, some proced"res co"ld be
developed in regional centres.
)resently, l"ng transplantation, l"ng vol"me red"ction s"rgery, and p"lmonary
thromboendarterectomy are available only at ."c3land City Hospital. This "nit also
has two bronchoscopists trained in laser therapy and stenting of airways. Strong
consideration sho"ld be given to the development of a brachytherapy "nit to
s"pplement the programme c"rrently being offered.
Regional T- reference laboratories and diagnostic laboratories offering molec"lar
biology techni8"es
C>
sho"ld be co2ordinated to develop new techni8"es and ma3e
these increasingly available internationally, and also to monitor the 8"ality of the
techni8"es already developed. /or e<ample, 8"ality ass"rance programmes
s"rro"nding respiratory histopathology and cytology are of paramo"nt importance, as
is the iss"e of 8"ality ass"rance in relation to thoracic radiology +see .ppendi< G,.
1>/ Re#p!rtor" #er-!ce# t re3!on$ $e-e$
Regional respiratory "nits sho"ld provide a high standard for the maority of services
in respiratory medicine, and sho"ld ta3e patient referrals from neighbo"ring *H-s
where highly specialised staff and facilities are not available. These regional
respiratory "nits sho"ld be training centres in respiratory medicine +see .ppendices
!G and G,, and sho"ld provide reso"rce and ed"cational facilities to adacent *H-s.
They sho"ld also provide regional oversight to management of conditions s"ch as
l"ng cancer, T-, interstitial l"ng disorders, sleep related breathing disorders,
p"lmonary vasc"lar diseases and cystic fibrosis.
Aore comprehensive training in ad"lt respiratory medicine is c"rrently available at
seven respiratory "nits in New Zealand, which have been approved by the Royal
."stralasian College of )hysicians. These "nits are in ."c3land, Hamilton,
'ellington, Christch"rch, *"nedin, )almerston North and Hastings. The TS.NZ
e<ec"tive in association with the New Zealand and ."stralian Aedical Co"ncils are in
the process of determining what minimal reso"rces are re8"ired for departments of
respiratory medicine to be accredited to contin"e training in postgrad"ate respiratory
medicine. !t is li3ely, as a res"lt, that the n"mber of training sites will be red"ced in
New Zealand.
'ith the e<ception of *"nedin, )almerston North and Hastings, these "nits serve
regions with pop"lations in e<cess of 1$&,&&& people. !t is recommended that five
centres serve as the regional reso"rce centres for New Zealand +vi9 ."c3land,
Hamilton, 'ellington, Christch"rch and *"nedin,. The regional "nits will set and
maintain standards and act as centres of e<cellence for the practice of respiratory
medicine.
C?,CC,1&&
How this is achieved will depend on the geography of the region, the
##
socio2demographic characteristics of the pop"lations served and e<isting clinical
services. /or e<ample, 'ellington, altho"gh servicing a large geographic area, has
two other hospitals within its region, which can provide good 8"ality tertiary services
+)almerston North and Hastings Hospitals,.
So 'ellington will re8"ire a different organisation than ."c3land. This is beca"se
."c3land has a more specialised tertiary centre located centrally at ."c3land City
Hospital and two other maor hospitals +Aiddlemore, 'aitemata,, which serve
pop"lations greater than #$&,&&& and which also provide a n"mber of tertiary
services. /"rthermore, ."c3land has only one geographically remote hospital
+Northland,.
!t is envisaged that the regional committees will offer most of the respiratory services
to their region. This will re8"ire a n"mber of changes in practice, or an e<tension of
what is already available. These changes might incl"de o"treach clinics performed
away from the regional tertiary hospital by a m"ltidisciplinary team. The regional
committees may s"pport respiratory physicians who have s"b specialised in certain
areas +for e<ample, sleep or transplantation, to be employed by more than one *H-.
The first step is to credential each hospital=s ability to provide reasonable standards
of care for patients with respiratory illness +see .ppendi< F!G,. This will involve
assessment by a committee appointed by the TS.NZ +or National Respiratory
Committee,, Ainistry of Health and with possible Aedical Co"ncil representation.
The aim of s"ch a process is to eval"ate the respiratory physician=s training with
respect to the 1& maor areas of respiratory disease they might be e<pected to
manage, which are "nderpinned by this doc"ment. .n assessment will also be made
as to whether physicians have appropriate s"pport in areas s"ch as histopathology,
radiology, physiology and e8"ipment to care for the needs of the pop"lation they
serve.
.n assessment will also be needed to ens"re appropriate proced"re man"als and
g"idelines are in place and that appropriate 8"ality ass"rance programmes are
available. The assessments sho"ld be designed to complement the present directive
of the Ainistry of Health.
1&1
These assessments have been s"ccessf"lly performed at
Aiddlemore, ."c3land City, 'ai3ato and Christch"rch hospitals. This will ens"re
that all patients with respiratory disorders have available to them the f"ll range of
respiratory services and are overseen by physicians with the appropriate mi< of s3ills
and training. This process will also ens"re that physicians have the appropriate
range of reso"rces and other health personnel to s"pport them in their practice. !t
will also infl"ence wor3force development, contin"ing medical ed"cation +CA7, for
respiratory physicians, n"rses and allied health professionals, and the way
respiratory health care is managed regionally and nationally.
Planning indicators
*H-s will plan their services incl"ding comm"nity and hospital care on a regional
basis, drawing on local estimates of disease prevalence, to ens"re that6
primary services are commens"rate with the act"al or anticipated need
detection, diagnosis, investigation, assessment and management of respiratory
system disorders are co2ordinated
#5
referral systems are established in a formalised manner to ens"re that specific
respiratory conditions needing specialist care are referred to the most appropriate
treatment facility, and that appropriately ed"cated and trained staff are available at
these regional centres and are available for cons"ltation to the comm"nity and to
smaller hospitals7rror6 Reference so"rce not fo"nd
integrated care systems are developed to better s"pport a wide variety of
respiratory disorders
morbidity and mortality rates are e8"al to or better than those achieved in
comparable services in highly developed co"ntries7rror6 Reference so"rce not
fo"nd
both the referring agent and the patient are f"lly satisfied with the service offered
and received
planning ac3nowledges the Treaty of 'aitangi.
Access indicators
/or most respiratory diseases, incidence rates and o"tcomes sho"ld be similar for all
races, socioeconomic gro"ps and for "rban and r"ral dwellers. However, it is
ac3nowledged that even in health care systems where there are no financial barriers
to primary health care d"ring ac"te illness +as opposed to New Zealand,, respiratory
diseases s"ch as asthma, bronchiectasis, pne"monia, C()*, (S., T- and l"ng
cancer are either more prevalent or more severe in wor3ing class neighbo"rhoods
+as well as in ethnic minority gro"ps,.
)rimary care m"st be available 15 ho"rs a day for ac"te problems, with secondary
and tertiary cons"ltations available immediately by telephone, and emergency
hospital admission facilities available with transfer provided if needed.
)atients referred by primary care physicians for "rgent specialist assessment of
management of their serio"s illness +s"ch as l"ng cancer, sho"ld be seen within two
wee3s of referral, either by a r"ral or "rban domicile.
/or life2threatening illnesses, s"ch as respiratory fail"re, massive haemoptysis or
severe asthma, ad"lt specialist services, together with essential bac3"p services,
m"st be immediately available 15 ho"rs daily for cons"ltation and +if necessary,
referral and admission +see .ppendi< !!!,.
)atients with s"spected active infectio"s t"berc"losis or pne"monia or empyema
sho"ld be seen within 15 ho"rs. /or "rgent cases % for e<ample, assessment:
cons"ltation for diffic"lt asthma, C()*, interstitial l"ng disease, diagnosis of
occ"pational l"ng disease, s"spected severe (S., "ne<plained dyspnoea or chest
pain % cons"ltation within one month is desirable. *elay of over si< wee3s in seeing
s"ch patients sho"ld prompt an e<amination of service load, staffing levels, and
priorities within the services +see National .ccess Criteria for /irst .ssessment and
National Clinical )riority .ssessment Criteria developed in 1&&& by TS.NZ:Ainistry
of Health .ppendi< !!!,.
Consideration sho"ld also be given to accessibility of primary care and o"tpatient
services o"tside "s"al wor3ing ho"rs to cater for employed persons re8"iring reg"lar
reviews. ("tpatient clinics cond"cted by respiratory specialists from large regional
#$
centres sho"ld be available in smaller centres on a reg"lar +1%# monthly, basis.
Aarae2based respiratory programmes, hospital in the home and ref"gee
programmes need e<ploration.
.s an e<ample of a simple access indicator that co"ld be readily monitored, the time
from initial presentation with l"ng cancer to the start of treatment co"ld be compared
in city and r"ral areas, and also against international standards.
1&1
Impact indicators
'ith appropriate emphasis on preventive meas"res and greater patient self2
management, primary health care attendance and, hospital admissions sho"ld
grad"ally decrease for conditions s"ch as asthma, C()* and bronchiectasis. These
conditions are amenable to good control by self2management, and as a res"lt of
greater "se of o"tpatient and ancillary services s"ch as rehabilitation and ed"cation.
7ffective "se of s"ch facilities sho"ld red"ce the n"mber of follow2"p visits, beca"se
greater reliance on good primary care, when integrated into a total respiratory
service, will res"lt in decreasing morbidity and mortality. There are li3ely to be
increased o"tpatient visits for diagnosis, assessment and management of C()*
over the ne<t 1$ years and contin"ed stable mortality or only a slight decrease.
Outcome indicators
("tcomes sho"ld be reg"larly assessed and compared with other regions nationally
and internationally +for e<ample, see .ppendi< !!,. 7<pected o"tcomes from a better
8"ality respiratory service will incl"de6
a red"ction in prevalence and severity of preventable t"berc"losis
1&#
+if immigration
screening and contact tracing of friends, wor3mates and relatives of infectio"s
cases is properly performed,
red"ced morbidity from C()*
increased s"rvival of patients with l"ng cancer and C()*
red"ced morbidity and mortality from asthma
red"ced prevalence of smo3ing
decreased e<pos"re to poll"tants and occ"pational sensitisers red"cing the
prevalence of occ"pational asthma
red"ced fatal RTCs, wor3 related accidents, from earlier and acc"rate diagnosis of
sleep related breathing disorders.
!nfl"en9a vaccination also red"ces the ris3 of infective e<acerbation of C()* by
abo"t $& percent and wo"ld therefore be e<pected to red"ce hospitalisation.7rror6
Reference so"rce not fo"nd
/or these reasons, a national and regional data2monitoring programme needs to be
established "sing the National Health Statistics Centre as a core repository. The
collection of certain data wo"ld be made comp"lsory. This sho"ld incl"de, for
e<ample, 7* asthma :C()* attendances +re2attendances,, ro"te of admission to
hospital +B) vers"s self referral vers"s o"tpatient,, time from referral to first
#;
appointment, to diagnosis, to first treatment +chemotherapy:s"rgery:radiotherapy, for
l"ng cancer patients etc.
)harmac contin"es to ma3e decisions on behalf of the Bovernment as to which
registered medications receive government s"bsidy. The recently re2created
respiratory s"b2committee of the )harmacology and Therape"tics .dvisory
Committee +)T.C, sho"ld provide advice on rationalising e<isting dr"g therapies and
the appropriate application of new dr"g therapies. /or e<ample, inhaled steroids
confer benefit to only 1&%1$ percent of the C()* pop"lation, yet are prescribed to
as many as ;& percent. No collaborative effort has been "nderta3en to attempt to
red"ce prescribing rates. /"rther, the decision, in the 1CC&s,to s"bstantially restrict
access to inhaled long acting beta agonists +0.-.s, in the management of asthma,
together with the p"blication of non evidence based criteria for their "se led to over2
prescribing of inhaled steroids at a dose well above that considered cost effective.
C"rrently, combined inhaled steroids and 0.-.s are "tilised in a way that is more
infl"enced by the pharmace"tical ind"stry than by )harmac, AedSafe or )T.C. Non
C/C inhaled steroid A*!s +eg, MG.R, have been available since 1CC? with an
efficacy 1.$ times that of C/C A*!s, "sing the same form"lation and with an
improved safety profile. These have not been s"bsidised in New Zealand. MG.R
inhalers ma3e "p 5& percent of sales in ."stralia and the DI where they are
considered an important advance in asthma care. *espite their 3nown adverse
effect on the environment, C/C inhalers are only "st being phased o"t in New
Zealand despite non2C/C alternatives being available since 1CC?. . National
Respiratory Committee wo"ld envisage a closer wor3ing relationship with )harmac,
and with the respiratory s"bcommittee of )T.C.
7lectronic capt"re of prescribing information on a National *atabase thro"gh the "se
of NH! n"mbers lin3ed to each prescription wo"ld ma3e doctors more acco"ntable for
their prescribing habits and wo"ld allow post mar3eting s"rveillance and
pharmacoepidemiology st"dies to be performed. These co"ld be e<pected to impact
positively on the pharmace"tical b"dget and on 8"ality of care.
. health intranet wo"ld also allow better comm"nication between health
professionals and improved self2 and patient2directed ed"cation.
Recommended structures of regional respiratory services
The comprehensive services o"tlined later in this doc"ment sho"ld be provided and
organised by the five regional respiratory committees. To enable this to happen,
strategic plans will need to be developed along with g"idelines for management of
referral strategies. The pop"lation served by each will range from aro"nd #&&,&&& to
1.$ million. These regional respiratory services wo"ld be the responsibility of the
respiratory advisors for each *H- in each region.
1&5
The advisors wo"ld report bac3
to the f"nding and planning arm of their *H-s as well as to the provider arm, and the
National Respiratory Committee, who in t"rn wo"ld advise the Ainistry of Health, and
report directly to the *irector Beneral of Health, the Ainister of Health and *H-NZ
+/ig"re 1,. The regional respiratory services wo"ld be organised to accommodate
regional variations in pop"lation, geography, ethnic mi< etc.
#>
Respiratory services at a district level (between 50,00050,000 population!
Gol"ntary organisations s"ch as local asthma societies, the .sthma and Respiratory
/o"ndation of New Zealand, the Cystic /ibrosis Society and the New Zealand T-
/o"ndation co"ld be involved in p"blic ed"cation and health promotion and s"pport
for patients with respiratory disease. .t a district level, specialist respiratory n"rses
may be employed by two different agencies % for e<ample, )H( and .sthma Society
or hospital % and th"s be capable of combining their roles.
.ll district hospitals provide care for patients with ac"te respiratory illness b"t the
level of care varies. However, all hospitals serving pop"lations of O$&,&&& sho"ld
have an intensive care "nit and ventilatory and non2invasive ventilatory s"pport +eg,
-i).) therapy,.
Beneral physicians "s"ally provide medical care. /or pop"lations of $&%1$&,&&&,
one or two of the physicians employed need to have a special interest in respiratory
disease. /or pop"lations of between 1$&%1$&,&&&, ideally 1%# specialist respiratory
physicians sho"ld be employed. Thoracic s"rgical services are generally not
available or warranted at district level. However, some general s"rgeons have
training in thoracic s"rgery and sho"ld be allowed to contin"e to deliver this service
as long as the n"mber of thoracic s"rgical cases is s"fficient to maintain e<pertise
and the case2mi< and standards meet R.CS criteria +see .ppendi< G,.
Access indicators
*H-s sho"ld ens"re that provision is made for detection, diagnosis and
management of disorders of the respiratory system, and that referral systems are
established to ens"re that, when necessary, specific respiratory conditions are
referred to the most appropriate regional treatment facilities. *elays in diagnosis and
treatment, or access to screening, sho"ld be no greater or less than for patients living
close to a regional centre.
The district hospital may operate a retrieval service to treat and stabilise patients in
smaller +local, "nits before transfer to the district level facility.
/or certain conditions s"ch as sleep related breathing disorders, tro"blesome
bronchiectasis or asthma,
1&$,1&;,1&>
cystic fibrosis,7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd
and certain interstitial l"ng disorders, an occasional review
by a regional centre or a visiting respiratory physician and respiratory n"rse specialist
from a regional centre sho"ld be mandatory. There is doc"mented evidence of
s"rvival benefit from review of cystic fibrosis patients in tertiary centres7rror6
Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd
and the Calman recommendations
and -ritish Thoracic Society
1&?
arg"e strongly for regional care co2ordination of l"ng
cancer patients. This allows respiratory physicians wor3ing o"t of centralised tertiary
"nits to maintain e<pertise in s"bspecialty areas, which in t"rn lifts the level of care
offered in that s"bspecialty, both regionally and nationally. !n this way, patients with
these conditions have access to care which sho"ld be of world standard 8"ality.
#?
)atients accessing the regional service wo"ld have access to the m"ltidisciplinary
team wor3ing o"t of the regional centre % for e<ample, a cystic fibrosis n"rse, an
oncology n"rse, an o<ygen therapy n"rse, a respiratory physiotherapist, a thoracic
radiologist:histopathologist and a physiologist,. Aembers of the m"ltidisciplinary
team may also travel to geographically isolated places from time to time. Respiratory
n"rse practitioners sho"ld be trained thro"gh regional centres for deployment in
geographically remote areas to allow more sophisticated and better 8"ality of care to
be delivered to s"ch regions.
Impact and outcome indicators
The same impact and o"tcome indicators that are "sed for a regional service are
appropriate, with the data generated from these services being incorporated into both
the regional and national database.
Inpatient services
.dmissions to the district hospital may incl"de all types of respiratory illness for
which the patient can be ade8"ately treated with the medical:n"rsing staff available,
and for which the o"tcome is as good at this level as at a regional level. 'here
possible, a specialist physician with an interest in respiratory disorders sho"ld
manage more complicated respiratory patients. The beds in which these patients are
n"rsed sho"ld be e8"ipped with piped o<ygen and s"ction, with s"itable monitoring
e8"ipment available. The services available at district level will depend on staff and
facilities, and may incl"de some or most of those provided at the regional level.
Transbronchial biopsies sho"ld not be "nderta3en at this level "nless the
bronchoscopist performs at least 1& per year,
1&C
and has o<ygen and 7CB monitoring
and res"scitation e8"ipment. The bronchoscopist m"st also have formal lin3s with
reference pathology services for review of cytology and histology. The TS.NZ +and
.merican Thoracic Society,7rror6 Reference so"rce not fo"nd
,11&,111
recommends
bronchoscopists perform at least $& bronchoscopies per year to maintain e<pertise
+see .ppendi< G!,. /ine needle l"ng biopsies of nod"les less than 1 cm in si9e
sho"ld only be "nderta3en with biplanar or CT screening by appropriately trained
persons with ade8"ate res"scitation e8"ipment and e<pertise +see .ppendi< G,.
*iffic"lt biopsies, or in sit"ations where patients are at partic"lar ris3 of complications
from biopsy, sho"ld be "nderta3en in a regional centre. )atients with respiratory
disorders re8"iring specialised investigation may re8"ire transfer to a regional centre
with a respiratory service +for e<ample, polysomnography, p"lmonary angiography,
cardio2p"lmonary testing, level !! intensive care "nit facilities,. Cons"ltation sho"ld
be immediately available thro"gh the regional service to allow transfer of these
patients when necessary.
#C
"pecial facilities
. radiology service providing chest radiographs m"st be available on a 152ho"r
basis, and other radiological investigations sho"ld be available on site or at the
regional centre +see .ppendi< G,. The district hospital will need to have an intensive
care "nit, facilities to perform partial sleep st"dies, a basic respiratory laboratory
+capable of performing spirometry and *0C(,, CT scanner and ancillary medical and
paramedical services +Table 1, as in a regional hospital. The e<ception will be
thoracic s"rgery +apart from straightforward cases "nderta3en by a s"rgeon with
approved thoracic s"rgical training, +see .ppendi< G,. The general laboratory
service sho"ld be comprehensive, b"t samples may be referred to a regional hospital
laboratory for some specialised tests.
Outpatient facilities
Resident or visiting respiratory specialists will provide o"tpatient clinics, altho"gh
some patients will re8"ire referral to a regional o"tpatient clinic for more detailed
investigations or assessments.
"taffing
Hospitals at a district level sho"ld endeavo"r to appoint at least one physician with
specialist training in respiratory medicine, whose responsibilities may also incl"de
general medicine. The proportion of physician time given to respiratory services
sho"ld be e8"ivalent to the recommended level of 1 /T7 respiratory specialist per
>$%1&&,&&& people, after allowing for the level of service e<tended to the district
hospital from the regional centre. The remainder of the staff re8"ired for services at
this level can be calc"lated pro rata "sing the recommendations for regional centres.
1>? Re#p!rtor" #er-!ce# t rur$ $e-e$ &4e$o% ;0,000(
Beneral practitioners and practice n"rses provide primary health care. Gol"ntary
organisations, partic"larly the .sthma Society, are also involved in ed"cation and
health promotion and s"pport for patients with respiratory disease. Aost smaller
hospitals provide care for patients with ac"te respiratory illness b"t the level of care
varies widely. Beneral practitioners often provide medical care, some of who have
developed a special interest in respiratory disease.
Access indicators
.reas with pop"lations "nder $&,&&&, which are not within a reasonable travelling
time from a district service, will need to ma3e special provisions for secondary health
care. *H-s sho"ld ens"re that provision is made for detection, diagnosis and initial
management of respiratory system disorders and that referral systems are
established to ens"re specific respiratory conditions are directed to the most
appropriate treatment facilities. The local hospital needs to establish an appropriate
arrangement with the district and regional hospital to facilitate prompt and safe
transfer of ill patients. The regional:base hospital may also need to operate a
retrieval service to treat and stabilise patients prior to transport. S"ch a system will
ens"re that patients can be established on ventilatory or non2invasive ventilatory
5&
s"pport prior to transfer. *elays in diagnosis and treatment, or access to screening,
sho"ld be not s"bstantially greater than those occ"rring at a regional or district level.
Inpatient services
.dmission to the local hospital sho"ld be limited to cases of relatively minor illness
with clear2c"t diagnosis, where the patient can be ade8"ately treated with the
medical:n"rsing staff available. )atients with respiratory disorders re8"iring
investigation sho"ld be referred to a district or regional hospital service where there
is ready access to a respiratory service. Cons"ltation sho"ld be formalised with a
regional service to allow transfer of these patients when necessary. .t a local level,
general practitioners may be the only medical staff available to loo3 after these
patients, b"t where possible a specialist physician with an interest in respiratory
disorders sho"ld ta3e over patient management. The beds in which these patients
are n"rsed sho"ld be e8"ipped with piped o<ygen and s"ction, and there need to be
ade8"ate monitoring facilities. The services available at local level may incl"de
some or all of these provided at the district level, depending on the si9e.
There sho"ld be ade8"ate facilities for the res"scitation and stabilisation of critically
ill patients prior to transfer to district or regional services.
"pecial facilities
. radiology service providing chest radiographs m"st be available on a 152ho"r
basis. The general laboratory service may not always be available at a local level b"t
where possible sho"ld provide basic haematology and biochemistry incl"ding blood
gas analysis.
Outpatient facilities
Gisiting specialists will provide o"tpatient clinics, or patients will be referred to a
district or regional clinic.
"taffing
/or a pop"lation of $&,&&&, there will not generally be a resident specialist respiratory
physician, b"t specialist services will be provided from the appropriate district or
regional centre.
51
; Support Fc!$!t!e# for Inpt!ent Re#p!rtor" Ser-!ce# t
Re3!on$ Le-e$
1. !ntensive care with facilities for artificial ventilation, in which the ad"lt or
paediatric respiratory physician can retain clinical involvement with his or her
patients. The intensive care "nit sho"ld be in the same hospital as the ordinary
inpatient facilities, and sho"ld be co2ordinated with respiratory services.
N.ssisted ventilation= +see g"idelines, allows for step2down treatment in
appropriate facilities overseen by respiratory physicians.
1. Radiology services which, in addition to standard radiology, provide biplane
screening, "ltraso"nd, comp"terised tomography, bronchial arteriography and
embolisation, and p"lmonary angiography. CT scanning, bronchial
arteriography and p"lmonary angiography, along with ro"tine radiology, m"st be
available 15 ho"rs daily, with a radiologist available at all times. .n ade8"ately
trained radiologist+s, with a respiratory interest is essential +see .ppendi< G,.
-edside radiology facilities are essential. . n"clear medicine department will
provide ventilation and perf"sion l"ng scans, galli"m scans and JgatedK
ventric"lograms, s"pervised by a physician e<perienced in interpretation of
n"clear imaging.
#. . respiratory physiology laboratory with facilities for spirometry,
111
incl"ding
bronchodilator response testing, meas"rement of l"ng vol"mes by body
plethysmography, heli"m dil"tion or nitrogen washo"t techni8"es, flow vol"me
loops, meas"rement of gas transfer, cardiop"lmonary e<ercise testing,
bronchial challenge testing pharmacological +methacholine or histamine, and
physical +e<ercise and: or hyper2tonic saline and:or hyperventilation,,
respiratory m"scle strength, blood gas and acid base sampling and analysis,
co2o<imetry, monitoring of o<ygen sat"ration with p"lse o<imetry, p"lmonary
sh"nt estimation, polysomnography d"ring sleep, and chemo2sensitivity
st"dies.
11#
.ll res"lts not re8"ested by a respiratory physician sho"ld incl"de an
interpretation in the report.
5. . sleep laboratory r"n by an accredited thoracic:sleep physician. The
laboratory sho"ld adhere to the standards o"tlined in the .ccreditation of Sleep
*isorders Services doc"ment prepared by the TS.NZ and ."stralasian Sleep
.ssociation +.S., 1&&& +see .ppendi< F!!,.
$. Beneral laboratory services, incl"ding cytopathology, histopathology,
imm"nohaematology, biochemistry and microbiology, with 152ho"r availability of
blood gas analysis and other essential biochemistry and haematology, dr"g
assays and microbiology. .ccess to a national reference T- laboratory7rror6
Reference so"rce not fo"nd and molec"lar biology diagnostic laboratory is
essential. .t least one pathologist sho"ld have a special interest in p"lmonary
diseases and have access to electron microscopy. )aediatric facilities will need
to incl"de microsampling and microanalysis of blood specimens.
51
;. -ronchoscopy facilities with several fle<ible fibreoptic bronchoscopes as well as
facilities for rigid bronchoscopy m"st be available 15 ho"rs daily. . f"ll range of
si9es of both rigid and fibreoptic bronchoscopes from #.& mm "pwards sho"ld
be incl"ded with accessories. The minim"m team for performing fibreoptic
bronchoscopy is a respiratory physician, and two trained assistants.7rror6
Reference so"rce not fo"nd -ronchoscopy theatres sho"ld have <2ray
screening facilities available if re8"ired.
0aser and endobronchial stenting e8"ipment sho"ld be available nationally
since there is inade8"ate demand to ma3e this a regional service. This service
presently e<ists at ."c3land City Hospital. . teaching e<tension or preferably a
videoscope is necessary for training. )aediatric bronchoscopies sho"ld only be
carried o"t where there are s"rgeons trained in paediatric thoracic s"rgery.
>. .ccess to oncology and radiotherapy services. There sho"ld be ready access
to oncologists and radiotherapists for cons"ltation and, if desired, referral of
patients with p"lmonary malignancies. Terminal care for s"ch patients may be
a oint responsibility. Reg"lar liaison is preferable % for e<ample, thro"gh
wee3ly meetings % combined with the thoracic s"rgical service, radiology and
oncology and radiotherapy services.
?. )atient ed"cation facilities. (ne or more health ed"cators trained in respiratory
medicine and partic"larly asthma, cystic fibrosis, bronchiectasis, t"berc"losis,
C()* and rehabilitation need to be based in the respiratory "nit, with
responsibilities for inpatients and o"tpatients. They will also act as reso"rce
persons to smaller "nits.
C. 0iaison with other clinical departments, incl"ding !CD, thoracic s"rgery,
cardiology, clinical imm"nology:allergy, (R0 and liaison psychiatry and
anaesthesia incl"ding pain clinic, sho"ld be readily available. Respiratory
medical proced"res have become more sophisticated +for e<ample, stenting,
laser therapy, brachial artery embolisation, and have increased the need to
have immediate thoracic s"rgical bac32"p. Thoracic s"rgery intervention needs
to be critically timed to increase the li3elihood of s"ccess and red"ce post2
operative morbidity +for e<ample, thro"gh s"rgical management of empyema
and pne"mothora<,.
1&. Special services
+a, )alliative care teams to help in the management of patients with end stage
respiratory disease sho"ld be available. The team sho"ld be made "p of
a palliative care n"rse, physiotherapist, social wor3er and respiratory
physician, and have strong liaison with the oncologists, radiotherapists,
pain clinic and hospices in view of the large n"mber of patients with
terminal l"ng cancer managed by respiratory services.
+b, (<ygen service. 7ach region sho"ld have a centralised o<ygen service to
ens"re o<ygen concentrators and portable o<ygen are delivered to
patients satisfying the international criteria for long term o<ygen therapy,
+0T(T, as defined by the TS.NZ7rror6 Reference so"rce not fo"nd.
B"idelines are more li3ely to be acc"rately implemented and follow2"p
maintained if a respiratory physician oversees the service.7rror6
Reference so"rce not fo"nd !deally, the service sho"ld maintain close
professional contacts with the rehabilitation service and with comm"nity
5#
s"pport services, and maintain a database of all patients in the *H- on
0T(T +.ppendi< F!,.
+c, Cystic fibrosis team. 7ach region sho"ld have a centralised cystic fibrosis
team made "p of a respiratory physician, respiratory paediatrician,
dietician, cystic fibrosis n"rse, physiotherapist, clinical psychologist, social
wor3er and psychiatrist. S"ch reso"rcing ac3nowledges the specialised
re8"irements of s"ccessf"lly managing cystic fibrosis.7rror6 Reference
so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd
+d, Rehabilitation services for chronically ill patients with respiratory
conditions, partic"larly bronchop"lmonary dysplasia, C()*, severe
asthma, cystic fibrosis and bronchiectasis, rehabilitation services sho"ld
be available.
115
)hysiotherapists, occ"pational therapists, dieticians,
social wor3ers and psychologists sho"ld develop a m"ltidisciplinary
approach to rehabilitation with close liaison with physicians thro"gh the
o"tpatient department.
11. (ther services. To maintain good levels of care the following services are
essential6
+a, appropriate levels of clerical:secretarial s"pport
+b, information services with appropriate comp"ter facilities
+c, translation service, to accommodate the increasing pop"lation of
immigrants. This service sho"ld also loo3 to help develop ed"cational
material that is c"lt"rally appropriate and available in a variety of
lang"ages.
55
. Re9u!rement# for Outpt!ent Re#p!rtor" Ser-!ce# t Re3!on$
Le-e$
1. The respiratory clinic sho"ld be identifiable and separate from general medical
o"tpatient clinics, and m"st have ade8"ate clinic space, n"rsing staff,
appropriately trained secretarial and clerical staff and a satisfactory
appointments system. Aedical records and <2rays, whether maintained as a
separate file or part of the hospital records, m"st always be readily available,
and the clerical:secretarial system set "p so that relevant information is rapidly
comm"nicated bac3 to the referring practitioner, preferably within 5? ho"rs of
cons"ltation.
1. Standard o"tpatient e8"ipment sho"ld be available, with the addition of
spirometry, pea3 flow monitoring, p"lse o<imetry, blood gas analysis,
neb"lisers, electrocardiography, and facilities for allergy and t"berc"lin s3in
testing.
#. There sho"ld be good access to plain chest radiology and CT scanning. This
sho"ld be either immediately available or within a si<2wee3 waiting time,
depending on clinical circ"mstances.
5. There sho"ld be ready access to a f"lly e8"ipped respiratory physiology
laboratory.
$. Ro"tine o"tpatient cyto2pathology services sho"ld be readily accessible +for
e<ample, diagnostic /N.,.
;. There sho"ld be ready access to non2invasive cardiological tests,
echocardiography, and n"clear medicine investigations.
>. Space and reso"rces for patient and family ed"cation sho"ld be provided.
?. The opport"nity to f"lly investigate patients with interstitial l"ng disorders,
opport"nistic infection, )T-, and l"ng cancer, as day patients sho"ld be
e<plored. +This wo"ld re8"ire readily available microbiology, CT scanning,
perc"taneo"s needle biopsy, cytology, bronchoscopy and respiratory
physiology., 'ith good planning, this co"ld be performed in a day stay facility
with s"bse8"ent red"ction in hospital admissions and follow2"p o"tpatient
attendances.
5$
@ 7!n!mum Re9u!rement for Stff!n3 t Re3!on$ nd D!#tr!ct
Le-e$
@>) Sen!or con#u$tnt #tff
!n 1C?;, the -ritish Thoracic Society7rror6 Reference so"rce not fo"nd reviewed
respiratory specialist staffing in Breat -ritain. !ncl"ding f"ll2time +/T7, cons"ltants,
senior registrars, research fellows and lect"rers, and associate specialists, senior
registrars, research fellows and lect"rers, and associate specialists of hospital
practitioner grade or clinical assistant, Breat -ritain had &.?$ respiratory specialists
/T7 per 1&&,&&& pop"lation. This fig"re is greater than that c"rrently in New
Zealand +&.?:1&&.&&&,, yet the -ritish Thoracic Society and the Royal College of
)hysicians
1$
regarded staffing in -ritain as inade8"ate.
!n ."stralia the n"mber of respiratory physicians varies depending on the state +from
1.$:1&&,&&& in NS' to &.?$:1&&,&&& in Gictoria, with all states apart from Gictoria
having O1.&:1&&,&&& respiratory physicians.
1;
Biven the severity of respiratory
illness, partic"larly asthma, C()*, bronchiectasis and (S. in New Zealand, it is
recommended that *H-s move to a minim"m respiratory physician staffing of not
less than one /T7 per >$%1&&,&&& people as a matter of "rgency. !n determining
cons"ltant levels, consideration needs to be given to ens"ring ade8"ate time for
patient investigations, inpatient and o"tpatient service needs, administrative d"ties,
a"dit, research, teaching and contin"ing ed"cation, together with provision for time
off2call and coverage while absent.
.n appropriately trained and credentialed respiratory sleep physician +minim"m one
/T7 per region, sho"ld be available for all regional services. !n addition, respiratory
physicians with appropriate e<perience in the diagnosis and management of sleep
disorders sho"ld be available to provide a clinical service to s"pport the needs of the
local pop"lation.
The Royal College of )hysicians in the Dnited Iingdom have s"ggested that, given
c"rrent demand, one cons"ltant physician is re8"ired for between $& and 1&&,&&&
pop"lation in each of the following specialities6 cardiologyE diabetes and
endocrinologyE gastroenterologyE nephrologyE ne"rologyE respiratory medicineE and
rhe"matology.
1$
. review of New Zealand=s clinical wor3force s"ggests that, of these
specialities, only ne"rology +1:1&;,1#&, and respiratory medicine +1:11&,&&&,
+Table 1,
1$
fall below the g"idelines s"ggested by the Royal College of )hysicians,
+which recommends1:$&%1&&,&&& people not 1:>$%1&&,&&&,. The ratio we propose
for New Zealand can th"s be seen as reasonable.
5;
@>/ Re#!dent med!c$ #tff
Two registrars and two ho"se physicians will be re8"ired per 15%#; bed ward "nit.
This ac3nowledges that registrars have other responsibilities s"ch as providing
o"tpatient and day patient care. .dditional staff will be re8"ired for o"tpatient and
day patient facilities. Consideration m"st be given to training needs, partic"larly for
registrars. Aedical registrars need to f"lfil training re8"irements to satisfy the Royal
."stralasian College of )hysicians7rror6 Reference so"rce not fo"nd and TS.NZ
+see .ppendi< !G,. Respiratory registrars m"st "nderta3e training in bronchoscopy,
l"ng f"nction testing, sleep st"dy interpretation, and so on, and complete research
proects to satisfy the re8"irements of the TS.NZ. )lanning needs to be "nderta3en
to ens"re ade8"ately trained Respiratory )hysicians are available to maintain and
advance standards in respiratory medicine in the f"t"re.
)resently seven centres in New Zealand +."c3land, Hamilton, )almerston North,
Hastings, 'ellington, Christch"rch and *"nedin, are recognised by the TS.NZ for
training, altho"gh ."c3land is the only centre that presently offers comprehensive
training in all aspects of respiratory medicine. Hamilton, 'ellington, Christch"rch
and *"nedin=s services need to be improved to provide more comprehensive
training, as well as services to the regions they serve, and to comply with the TS.NZ
standards for respiratory training that are c"rrently "nder review.
@>? Nur#!n3 #tff
N"rses sho"ld have had specific training in the care of patients with respiratory
illness, incl"ding intensive care n"rsing.7rror6 Reference so"rce not fo"nd .
registered n"rse sho"ld be responsible and acco"ntable for the care of inpatients in a
respiratory "nit 15 ho"rs a day. The n"mber of n"rses and their 8"alifications will be
determined by the wor3load at any one time. !f separate intensive care facilities are
not readily available, there will be a need for trained registered n"rses to "nderta3e
individ"alised patient care as part of a step2down "nit from the !CD.
There is a need to develop national and regional respiratory n"rse training
programmes to improve standards amongst respiratory n"rses and specialist s3ills.
S"ch a programme wo"ld incl"de training in6
cystic fibrosis
asthma
bronchiectasis
C()*
T-
sleep related breathing disorders
assisted ventilation
intensive care and palliative care for respiratory patients with a terminal illness
+partic"larly l"ng cancer,.
5>
N"rses with these s3ills can also immensely benefit the o"tpatient clinic, where their
role wo"ld e<tend into ed"cation of patients and families. !n smaller centres, there
may be a need to combine the roles of a general or comm"nity n"rse with that of a
specialist respiratory n"rse.
@>1 Re#p!rtor" nur#e prct!t!oner
N"rse practitioners with wide e<perience in respiratory medicine and proven
comm"nication s3ills can increase the awareness, 3nowledge, practical s3ills and
confidence of their patients and their families. This approach sho"ld assist in red"cing
morbidity:mortality associated with respiratory illness. The respiratory n"rse
practitioner, in cons"ltation with the medical team, sho"ld help implement a consistent
team approach along with dieticians, other n"rses +incl"ding p"blic health n"rses,
district n"rses, staff n"rses and practice n"rses,, occ"pational therapists, pharmacists,
physiotherapists, rehabilitation officers, social wor3ers, teachers and psychologists.
Their role co"ld also e<pand to help develop ed"cation programmes for other health
professionals. They m"st maintain their own 3nowledge by reading, attending and
contrib"ting to seminars and conferences in respiratory medicine. These n"rse
practitioners sho"ld be accredited as their role and n"mber increases. !t is
recommended that one /T7 respiratory n"rse practitioner per $&%1&&,&&& people be
employed, and that consideration be given to employing n"rses with specific
responsibilities, for e<ample T-, asthma, cystic fibrosis, and palliative care n"rses.
To a large e<tent this will depend on the vol"mes of patients with these disorders
being managed by any given service.
@>; Re#p!rtor" ph"#!otherp!#t#
Respiratory physiotherapists will have had specific training in respiratory care
proced"res and specialised 3nowledge and s3ill in managing breathlessness,
decreased e<ercise tolerance, sp"t"m removal techni8"es, and breathing pattern
disorders. They will have an important role in managing hyperventilation syndrome
and will ma3e "p part of the m"ltidisciplinary team in C()*, cystic fibrosis and
bronchiectasis. They have an increasing role in patient rehabilitation and ed"cation.
!t is recommended that one /T7 respiratory physiotherapist per $&%1&&,&&&
pop"lation be employed.
@>. Secretr!$, c$er!c$ nd dm!n!#trt!-e #tff
There sho"ld be eno"gh staff to meet the needs of each "nit and its Clinical *irector.
Ta3ing into acco"nt the move towards comp"terised patient and other record
information, these people will need comp"ter s3ills for entry and retrieval of
information for clinical and statistical p"rposes. .t least one staff person sho"ld be
permanently attached to the respiratory "nit in smaller "nits serving less than
1$&,&&& people. (ne 8"ality ass"rance person sho"ld be employed for each
regional respiratory "nit. They in t"rn sho"ld report to the regional committee and
sho"ld also be available to smaller centres within the region.
5?
@>@ Re#p!rtor" ph"#!o$o3" #c!ent!#t# C techno$o3!#t# C techn!c!n#
.ppropriately trained laboratory staff7rror6 Reference so"rce not fo"nd will help raise
the 8"ality of physiological services. 0aboratory staff perform l"ng f"nction
assessments and are responsible for the calibration, maintenance and 8"ality control
of e8"ipment. Staff sho"ld meet standards for accreditation as o"tlined by the
TS.NZ.
@>+ Stff def!n!t!on#
));,)).
Techn!c!n or techno$o3!#t> Technical staff perform a limited range of respiratory
f"nction tests and associated d"ties "nder the s"pervision of senior laboratory staff.
Sc!ent!#t> Scientific staff are involved in all aspects of respiratory f"nction
assessment incl"ding patient testing, e8"ipment maintenance, developing:eval"ating
new methods and 8"ality ass"rance.
5ed #c!ent!#t> !n addition to their role as a scientist, the head scientist is involved
in staff s"pervision and training and has immediate responsibility for the operation of
the service. The head scientist may have significant involvement in research and
teaching o"tside the ro"tine operation of the laboratory.
@>* Recommendt!on#
The following 8"alifications are recommended for scientific and:or technical staff
employed in the assessment of respiratory f"nction in New Zealand.
7!n!mum entr"
9u$!f!ct!on#
Form$ tr!n!n3 !n
re#p!rtor" #c!ence
CRFS credent!$ L4ortor"
eDper!ence
Technician:
technologist
*iploma or technical
certificate
Recommended Recommended
Respiratory
scientist
*egree )ostgrad"ate
training
recommended
Recommended
Head scientist *egree )ostgrad"ate
training strongly
recommended
Strongly
recommended
#%$ years
Technicians or technologists sho"ld have at least two years tertiary training in
biological or physical science. Scientists and the head scientist sho"ld possess at
least a -achelor of Science.
!t is recommended that scientific and or technical staff witho"t s"bstantial practical or
theoretical e<perience in respiratory f"nction meas"rement, partic"larly staff
commencing their career, obtain formal, relevant professional training. This training
sho"ld preferably be thro"gh a tertiary co"rse of st"dy, s"ch as Charles St"art
Dniversity )ostgrad"ate Certificate, or the )ostgrad"ate *iploma in Respiratory
Science from ."c3land Technical !nstit"te.
5C
!t is recommended that scientific and or technical staff ac8"ire the certified
respiratory f"nction scientist credential, based on e<amination by the .NZSRS. This
credential is strongly recommended for head scientists beca"se of their training
responsibilities.
The head scientist sho"ld have a minim"m of three years e<perience in the
meas"rement of respiratory f"nction at the time of appointment to the position. Aore
e<perience may be appropriate depending on the nat"re of previo"s e<perience,
range of tests performed in the laboratory and any other associated d"ties. !n all
sit"ations, head scientists m"st demonstrate e<perience in solving e8"ipment
problems, analysing test protocols and the implementation of rigoro"s 8"ality
ass"rance programme. Head scientists may re8"ire greater e<perience and tertiary
8"alifications +eg, ASc, )h*, if teaching and research, o"tside of ro"tine operation of
the laboratory, forms a significant part of their d"ties.
Contin"ing professional ed"cation is essential for all scientific and or technical staff.
This may be thro"gh involvement in professional associations, attendance and or
presentations at meetings, attendance of post2grad"ate co"rses. /"nds sho"ld be
available in the b"dget for ed"cation and attendance at ann"al scientific meetings.
$&
+ Re#p!rtor" Ser-!ce# t Su4#pec!$t" Le-e$
+>) Tu4ercu$o#!#
#urrent situation and future directions
The new case notification rate of t"berc"losis +T-, reached its lowest point in 1C??,
and since then there has been a small b"t persistent increase.
The halt in decline in the incidence of T-, and rise since the mid2late 1C?&s has
occ"rred in .merica, -ritain, Canada and ."stralia, as well as New Zealand. The
increased rate of T- in "nder2developed co"ntries and proected fig"res for T-
infection, disease and death after the year 1&&& led the 'H( to declare T- a global
emergency in 1CC5. Not only is the increasing incidence a maor concern, b"t the
incidence of m"lti2dr"g resistant T- is also increasing. !ncreased financial reso"rces
and disciplined adherence to g"idelines are needed if these two aspects of T- are to
be overcome both in New Zealand and overseas.
There are five districts in New Zealand where the incidence of t"berc"losis +T-, is
s"bstantially greater than the national average. The main factors responsible for this
are6
migration and visitation from overseas
the higher than average incidence of t"berc"losis amongst Aaori
poverty and s"bse8"ent ho"sing and n"tritional deficiencies.
The highest incidence of t"berc"losis in New Zealand occ"rs in non2New Zealand
born, followed by Aaori and the elderly. .ltho"gh H!G is an important ris3 factor for
development of t"berc"losis, to date H!G has not had a significant impact on
t"berc"losis notification rates in New Zealand.
)re2e<isting resistance to anti2t"berc"lo"s dr"gs is an important consideration in
non2New Zealand born individ"als. The development of dr"g resistance in this
co"ntry is li3ely to occ"r if treatment is incorrectly prescribed or ta3en, or if
immigrants with m"lti2dr"g resistant T- are not caref"lly screened at the borders and
then either treated comprehensively or ref"sed entry.
!n order to improve the 8"ality of patient care and red"ce the national t"berc"losis
rates, we need to foc"s on "nifying the services provided by hospitals and
comm"nity health services. . cohesive team approach is re8"ired, not only for
individ"al cases, b"t also in oint planning, a"diting and the review of systems s"ch
as comm"nication needed to carry o"t a cohesive t"berc"losis policy. Aedical and
n"rsing staff involved with managing t"berc"losis in hospitals and in the comm"nity
health services thro"gho"t New Zealand need to hold reg"lar regional meetings.
Close liaison between these gro"ps is an e<pected activity in regional t"berc"losis
control, and sho"ld be monitored by *H-s to ens"re 8"ality of care is maintained
and enco"raged.
$1
Revised B"idelines for T"berc"losis Control in New Zealand are now available
http6::www.moh.govt.n9:moh.nsf:&:5>;&*/#$?&.;/$-$CC1$;C?;&&;7*#C5:@/ile:
T-ControlB"idelines&#.pdf #1 and have been "pdated. These sho"ld provide the
basis for any t"berc"losis service.
$uidelines for referral to secondary and tertiary %ealt% care
!nitiation of anti2t"berc"lo"s treatment and s"bse8"ent s"pervision of management is
a f"nction of secondary and tertiary healthcare services. There are a n"mber of
factors that necessitate this approach6
1. A"ltiple T- dr"g regimens e<ist and selection of a correct regimen re8"ires
e<perience and training.
1 There is a ris3 of enco"raging dr"g resistance if an incorrect treatment is
prescribed, or if patient non2compliance occ"rs.
#. Close monitoring and ed"cation is re8"ired in order to ens"re compliance.
5. There is a relatively high incidence of dr"g side effects, which re8"ire
management by an e<perienced clinician so that optimal and effective treatment
is contin"ed.
Referral to a tertiary healthcare centre is re8"ired for6
1. cases with e<tensive disease
1. cases with m"lti2dr"g resistant t"berc"losis +or where m"lti2dr"g resistance is
s"spected,.
Clinicians with only occasional e<perience of this condition sho"ld not manage cases
of t"berc"losis. . comprehensive management term involving e<perienced n"rsing
staff is an important component of s"ccessf"l clinical t"berc"losis management.
&ational ' regional ' local practice
1. )op"lation $&,&&&6 straightforward cases will be managed "nder the care of a
respiratory physician.
1. $&%1$&,&&& pop"lation6 as per a,.
#. National t"berc"losis centres. Cases with e<tensive disease and or m"lti dr"g
resistant t"berc"losis sho"ld be referred to a regional tertiary care instit"tion for
isolation and s"pervision by a t"berc"losis specialist. Highly infectio"s cases
m"st be referred to a centre with facilities for isolation in a negative press"re
environment. National t"berc"losis centres sho"ld be associated with national
T- reference laboratories and sho"ld also be responsible for the provision of
the second and third2line antit"berc"lo"s dr"gs, which are otherwise
"navailable to hospital and other pharmacies.
(uality assurance measures
0ocal compared with national incidence of t"berc"losis.
)ercentage of confirmed +namely T- c"lt"re positive, cases % local compared with
national.
$1
)ercentage of cases s"ccessf"lly treated. These sho"ld be s"bdivided as to
cases where treatment was self2administered and those where directly observed
treatment +*(T, was ta3en.
Time between onset of symptoms and +1, diagnosis of T-, +1, notification,
+#, initiation of treatment.
Compliance with visits and adherence to the treatment regimen.
Contact s"rveillance statistics6 the n"mber of contacts s"ccessf"lly investigatedE
the percentage needing chemoprophyla<isE the percentage needing treatment.
Rates for dr"g resistant organisms.
0aboratory standards6 This s"bect is dealt with in the NZ National T"berc"losis
B"idelines 1CC;.#1 -riefly, technical aspects of performing smear and c"lt"re
tests on specimens need to be followed, and safety standards "pheld.
0aboratories performing smear tests sho"ld be able to report smears within
15 ho"rs for "rgent cases. 0aboratories, which do not "se li8"id c"lt"re, sho"ld
send specimens to a reference laboratory immediately when t"berc"losis is
s"spected, partic"larly if there is a ris3 of dr"g resistance.
*H-s sho"ld re8"ire an ann"al report to be prepared by Aedical (fficers of
Health, laboratories and the principal clinician involved with t"berc"losis, dealing
with the above meas"res.
Regional b"dgets6 The b"dget for managing T- sho"ld either be held by the
tertiary referral centre, the Aedical (fficer of Health involved with managing T-, or
shared between the two. This will ens"re standards of care are maintained and
appropriate b"dgets defined to meet the needs of the oint +hospital and
comm"nity, services managing a condition with increasing incidence. Since an
important ca"se of the increase in )T- in New Zealand is as a conse8"ence of
immigration, specific efforts need to be "nderta3en to screen o"r borders more
effectively. Screening of immigrants is considered s"boptimal by the TS.NZ.
Therefore, specific information needs to be collected on all T- patients not born in
New Zealand. The !mmigration *epartment sho"ld also store <2rays and medical
records on s"ccessf"l applicants from co"ntries where the incidence of T- is
O #&:1&&,&&&:year.
+>/ C"#t!c f!4ro#!#
)ac*ground
Cystic fibrosis +C/, is the most common lethal genetic disorder in New Zealand,
occ"rring in one in #1&& non2)olynesian births and c"rrently affecting appro<imately
#&& children and yo"ng ad"lts in this co"ntry.
.ltho"gh a m"lti2system disease, affecting the respiratory tract, pancreas, hepato2
biliary system and t"b"lar g"t, most C/ morbidity and mortality in ad"lts is d"e to
cardio2respiratory complications. The s"rvival rate of patients with C/ has risen
dramatically in the last two decades and in Gictoria ?& percent of new patients will
reach the age of twenty years and ;& percent will s"rvive to the age of thirty.
+Recent evidence s"ggests that New Zealand s"rvival fig"res are very similar to
those of Gictoria,. Aedian s"rvival in some North .merican centres is 1&%1$ years in
$#
females and #&%#$ years in males. This improvement in s"rvival is d"e most li3ely to
the improvement in overall care s"pplied by the m"ltidisciplinary team approach.
. n"mber of potentially important advances in the area of cystic fibrosis have
occ"rred in recent years. The most important of these has been the discovery of the
C/ gene and el"cidation of the str"ct"re and f"nction of the gene prod"ct +C/TR %
cystic fibrosis transmembrane reg"lator,. 0arge scale m"lti2centre trials have proven
the efficacy of certain treatments.
High dose ib"profen slows decline in l"ng f"nction and maintains weight when
"sed long2term, in comparison with placebo.
*N=ase +neb"lised, has been shown to decrease the rate of decline in /7G1 and
to decrease Ninfective= e<acerbations in comparison to placebo.
(ther treatments showing promise incl"de P
1
anti2protease s"pplementation,
neb"lised amiloride and neb"lised hypertonic saline.
0"ng transplantation is a viable option for a proportion of C/ patients. !n the f"t"re,
there is the definite prospect of gene replacement therapy. Clinical trials are
c"rrently ta3ing place.
Criteria for the management of paediatric C/ patients in New Zealand have been
developed7rror6 Reference so"rce not fo"nd and the TS.NZ has p"blished
g"idelines on management.
11>
The o"tcome for patients with C/ is better if they are managed by m"ltidisciplinary
teams in a secondary or tertiary instit"tion, JThe need for cystic fibrosis centres is
virt"ally indisp"tableK.
1>,1?
These centres sho"ld manage a minim"m of 1& C/
patients. Centres with Q 1& patients sho"ld establish lin3s with Nregional= centres and
patients sho"ld be reviewed by these centres at least si< monthly.
The m"ltidisciplinary team sho"ld consist of6
paediatricians:physician+s, e<perienced in the management of patients with C/
C/ charge n"rse co2ordinator
respiratory physiotherapist
dietician
social wor3er
liaison psychiatrist:clinical psychologist.
C/ regional centres also re8"ire access to services s"ch as6
porta cath insertion
gastrostomy t"be insertion
gastroenterology:diabetes:growth and n"trition:rhe"matology:(R0 cons"ltation
domiciliary o<ygen
provision of neb"lisers
provision of special medications
thoracic s"rgery
f"ll l"ng f"nction testing facilities
$5
microbiology laboratory
dr"g monitoring facilities.
. close relationship with a l"ng transplant "nit sho"ld be established, with agreed
g"idelines as to who and when to refer +these e<ist at ."c3land City Hospital,.
!npatient re8"irements incl"de6
s"itably trained n"rsing staff
separate room accommodation
preca"tions to prevent or minimise transmissions of infection
physiotherapy or e<ercise facilities
3itchen and recreation facilities
ongoing involvement of the C/ team, d"ring admission.
(uality assurance measurements
1. *ata on individ"al patients is contrib"ted ann"ally to the national database.
1. !ndivid"al centre databases.
#. .ltho"gh C/ is c"rrently an inevitably fatal condition, o"tcomes s"ch as6
median s"rvival
l"ng f"nction
growth parameters,
co"ld be compared with those obtained in overseas centres.
5. Comparison of management with international g"idelines.7rror6 Reference
so"rce not fo"nd
+>? 'ronch!ect#!#
)ac*ground
-ronchiectasis remains a maor so"rce of mortality and morbidity in New Zealand,
with admission rates of 1;:1&&,&&& and mortality rates of 1.$:1&&,&&& in 1CC1.7rror6
Reference so"rce not fo"nd Aortality rates now e<ceed that of asthma, with no
decline between 1C?; and 1CC#. Aortality per "nit pop"lation is s"bstantially higher
in Aaori +1;:1&&,&&&, and )acific !slanders +11:1&&,&&&, than in 7"ropeans +Q
1:1&&,&&&, in those O $& years and is paralleled by a higher rate of hospital
admissions. *espite the high prevalence of the disease, there is no overall
consens"s as to how best to ma<imise the "tility of comm"nity and hospital
reso"rces in investigation and management.
.n improvement in short2term morbidity is an obvio"s and worthwhile aim, b"t does
not, in isolation, meet the needs of patients with bronchiectasis. Aortality and
morbidity rates may be red"ced if there were a systematic approach in place, which
aimed at preventing progression of disease. )revention of disease progression is
partially or wholly attainable in most patients, b"t re8"ires early diagnosis and
optim"m management. Since the disorder often declares itself for the first time in
childhood, then a combined approach to management "tilising paediatric and ad"lt
$$
respiratory physicians is essential. The introd"ction of antibiotics in the 1C$&s
res"lted in a maor red"ction in mortalityE there is little do"bt that the improved "se of
antibiotics, inhaled corticosteroids, physiotherapy and rehabilitation wo"ld bring
abo"t a f"rther red"ction in morbidity and mortality.
The first step in management is to ma3e a confident diagnosis of bronchiectasis,
"sing thin section CT scanning, which has now s"pplanted bronchography and
sho"ld be performed in all patients with "ne<plained chronic p"r"lent sp"t"m
prod"ction. .cc"rate diagnosis re8"ires not only CT technology b"t also, cr"cially,
radiological e<pertise in the interpretation of CT abnormalities. However, CT
technology is new and e<pertise in New Zealand is "neven and lac3ing in some
regions. Aoreover, the grey area between normal and abnormal is a matter of
perspective and can only be ac8"ired with e<perience, even by the most s3illed
radiologists. The ne<t decade sho"ld see the dissemination of CT e<pertise to
secondary centres. !n the meantime, regional centres with a large CT e<perience
have a central role to play in diagnosis. The widespread development of digital
telemedicine facilities sho"ld allow CT images to be transmitted for review by
e<perienced practitioners.
(nce the diagnosis of bronchiectasis has been sec"red, the best site of initial
investigation and management depends "pon disease severity. Aild, non2
progressive disease with minimal morbidity can be reasonably managed by
collaboration between smaller centres +pop"lation Q 1&&,&&&, and comm"nity
services. -y contrast, moderate to severe disease may be best managed initially in
regional centres. Aild disease, which is progressive, despite the prompt "se of
antibiotics for infective e<acerbations, sho"ld be referred regionally, before
irreversible deterioration has occ"rred. (ptimal management sho"ld incl"de6
the identification of "nderlying ca"ses of bronchiectasis +incl"ding e<cl"sion of
imm"nodeficiency states and cystic fibrosis variant,
the e<cl"sion and treatment of conc"rrent rhinosin"sitis and gastro2oesophageal
refl"<
physiotherapist g"ided training in p"lmonary clearance techni8"es with rigoro"s
follow2"p
the development of an individ"alised management strategy +incorporating the best
"se of antibiotics and anti2inflammatory treatments,
the consideration of s"rgery in selected cases.
The management of bronchiectasis re8"ires a cohesive approach, incorporating
physician diagnostic and management s3ills, the definitive staging of disease severity
+to allow s"bse8"ent assessment of progression,, physiotherape"tic e<pertise, ready
access to (R0 services and, ideally, the inp"t of a bronchiectasis n"rse practitioner.
The maor arg"ment for the regional management of bronchiectasis is that s"ch an
approach allows a concentration of reso"rces and e<pertise to a larger gro"p of
patients. However, patients with mild disease sho"ld be monitored at reg"lar
intervals with spirometry and if there is a loss of l"ng f"nction of O $& mls per year
over three years, then referral to a regional centre for assessment sho"ld be
mandatory.
$;
-ronchiectasis is seen most commonly in lower socioeconomic gro"ps and it is
essential that e<pertise in management by general practitioners and general
physicians be increased d"ring the ne<t decade. /or this to be effective,
bronchiectasis needs to be given a higher profile in district hospitals, with the
designation of physicians and physiotherapists who have a partic"lar interest in the
disease. B)s and comm"nity services need to be more proactive in following
patients and, as with other respiratory disorders, there is a strong case for spirometry
to be ro"tinely available in general practice.
Dltimately, bronchiectasis sho"ld be managed at s"bregional centres, with close
comm"nity liaison. However, this approach is at least a decade awayE the present
recommendations for the best "se of reso"rces are geared to the early 11st cent"ry.
$uidelines for referral to secondary and sub+regional'district services
.ll patients s"spected of having bronchiectasis +chronic prod"ctive co"gh, fre8"ent
chest infections, sho"ld be referred initially to regional or s"b2regional or district
"nits. The reasons for this recommendation are6
CT scanning is re8"ired for diagnosis
definitive staging of disease severity and monitoring for progressive disease
sho"ld incl"de detailed l"ng f"nction tests
initial eval"ation to define specific ca"ses or complications re8"ires a stereotyped
list of investigations, incl"ding imm"noglob"lin levels, sweat testing and cystic
fibrosis genotyping and aspergill"s serology in selected cases, along with the
e<cl"sion or treatment of rhinosin"sitis, atypical T- and gastro2oesophageal refl"<
specialist physiotherapist instr"ction and follow2"p
specialist medical e<pertise and e<perience is re8"ired for comple< management
iss"es
access to imm"nology, infectio"s diseases and thoracic s"rgical services.
&ational ' regional ' local practice
1. )op"lation $&,&&&. Aild disease sho"ld be managed initially by a physician
with access to a CT scanner and s"bse8"ently by comm"nity services +with
stated indications for re2referral,. !t is essential that progression of disease is
monitored by spirometry and chest <2ray and possibly CT scanning in selected
cases and progressive disease be referred to a regional centre. /ollow2"p of
moderate and severe disease will be "nderta3en by a respiratory physician,
with reg"lar physiotherape"tic eval"ation. There sho"ld be a low threshold for
re2referral to a regional centre if disease is progressive +eg, O $& ml decline in
/7G
1
per year over three years, or morbidity "nacceptable despite treatment.
1. )op"lation $&21$&,&&&. !n general, e<actly as for a,. The best division in
management and follow2"p between a, and b, will depend "pon the severity of
disease, socioeconomic constraints, and the availability of medical and
physiotherape"tic e<pertise in +a,. !deally, most ro"tine follow2"p sho"ld be
"nderta3en in +b, b"t if local facilities are "ne8"al to this aim, patients sho"ld be
offered reg"lar review in larger "nits.
$>
#. )op"lation O 1$&,&&&. Regional centres remain a vital reso"rce that sho"ld be
available to all patients with advanced or progressive bronchiectasis. !n time,
m"ch of the radiologic, microbiologic, medical, physiotherape"tic and
rehabilitation e<pertise will be distrib"ted to smaller centres, b"t even in the
distant f"t"re, there will still be an important role filled by regional centres in
managing diffic"lt cases or in those where there is disease progression.
!ndependent of the need for specialist s"pervision, the maority of patients with
bronchiectasis will be managed in the comm"nity by B)s. Recognising that
both Aaori and )acific !sland pop"lations have a higher prevalence of
bronchiectasis and more severe disease than 7"ropeans, a case may e<ist for
respiratory physicians and respiratory physiotherapists to wor3 in close
association with Aaori and )acific !sland comm"nity health centres.
(uality assurance measures
There are diffic"lties in instit"ting short2term 8"ality ass"rance +M., meas"res. The
prevention of progression of disease is essential, b"t by definition, this aim will be
s"ccessf"lly met if disease severity is "naltered. . red"ction in disease severity is
attainable in some b"t not all patients. Th"s, the overall s"ccess of definitive
management in preventing decline can only be eval"ated over the co"rse of
decades. Short2term M. meas"res m"st therefore be directed towards red"ctions in
admission and mortality rates, improved 8"ality of life and patient compliance +to
o"tpatient visits and medical management, and to preventing f"rther decline in l"ng
f"nction.
$?
+>1 Occupt!on$ $un3 d!#e#e
&umbers
.s in other 'estern nations
11?
it is diffic"lt to be s"re of the tr"e incidence of
occ"pational l"ng disease in New Zealand. However, the National .sbestos and
(cc"pational .sthma Aedical .dvisory )anels report the following incidence for the
period 1CC1%C56
(cc"pational asthma +>C validated by panel, 1C1
.sbestos ple"ral disease 11C
.sbestosis ?1
Aesothelioma ;C
0"ng cancer #?
C()* 15
The incidence of asbestos related ple"ro2p"lmonary disease is not e<pected to
diminish "ntil after 1&1& beca"se of the lag between e<pos"re and manifestation of
disease.
11C,11&
$uidelines for referral
+1, .ll patients s"spected of having occ"pational l"ng disease incl"ding
asymptomatic impairment considered d"e to environmental e<pos"res.
+1, .ll patients considered to have asbestos related l"ng disease independent of
whether there is f"nctional impairment.7rror6 Reference so"rce not fo"nd
+#, .ll patients tho"ght to have occ"pational asthma.
111
&ational vs regional vs local
(cc"pational l"ng disease sho"ld be managed at s"b regional level only if there are
specialist occ"pational and respiratory services. -eca"se of the need for detailed
l"ng f"nction testing, interpretation and CT scanning, referral to a regional centre
may be necessary. Rare disorders, for e<ample hard metal l"ng disease and
cadmi"m ind"ced emphysema, may re8"ire regional referral, with access to a
specialised laboratory with pathology and:or biochemistry laboratory facilities. !n
addition, whenever l"ng biopsy or medical thoracoscopy is re8"ired, referral to a
regional centre is indicated. The maority of patients referred who are tho"ght to
have an occ"pational l"ng disease sho"ld also be eval"ated by an occ"pational
physician who sho"ld maintain a close liaison with respiratory physicians. 'hatever
the pattern of referral, acc"rate notification to (SH sho"ld be mandatory so that
trends in disease incidence can be monitored. +This is not c"rrently happening and
there is anecdotal evidence that asbestos related l"ng disorders are only being
reported to (SH in 1$R of instances., /"rther, c"rrent .CC policies mitigate against
fair rem"neration for patients with occ"pational l"ng disorders where there is a long
latency period between e<pos"re and manifestation of disease.
$C
(uality assurance measures
1. .cc"rate disease incidences need to be recorded. This sho"ld be co2ordinated
by (SH and sho"ld be mandatory.
1. Aorbidity and mortality statistics sho"ld be monitored by (SH and trends
notified to occ"pational and respiratory physicians.
#. Respiratory physicians with an interest in occ"pational l"ng disease sho"ld
have contin"ing ed"cation in this area. Close liaison with an occ"pational
physician and occ"pational health n"rses is essential.
5. Radiologists reporting <2rays and CT films on patients with occ"pational l"ng
disease sho"ld have partic"lar e<pertise in this area. !nter2observer variability
in reporting the e<tent of interstitial disease sho"ld be determined. Dntil this is
achieved ideally a thoracic radiologist at a regional centre sho"ld chec3 all plain
radiographs or CT scans.
+>; S$eep d!#ordered 4reth!n3 #er-!ce &du$t#(
)ac*ground
Sleep relating breathing disorders are common. (f these, obstr"ctive sleep apnoea
+(S., is the most widespread. .ltho"gh it is diffic"lt to determine prevalence
acc"rately, 1%5 percent of the ad"lt pop"lation in New Zealand will s"ffer from
(S..
111
-etween &.$ and 1.& percent have moderate to severe (S., and are at ris3
of e<cessive daytime sleepiness and severe end2organ damage +respiratory fail"re,
cardiomyopathy, hypertension, ischaemic heart disease and cardiovasc"lar disease,.
The confo"nding factor in diagnosis is that the symptoms of (S., snoring and
sleepiness, are common in the general pop"lation.
This disease carries a maor socioeconomic and health b"rden lin3ed to the
cardiovasc"lar morbidity, incl"ding hypertension. (S. patients have a high
incidence of road traffic crashes +RTCs,,7rror6 Reference so"rce not fo"nd
,11#

occ"pationally related accidents, "nder2performance at wor3 and "nemployment and
divorce rates. /rom data collected at ."c3land City Hospital, (S. appears both
more prevalent and more severe in Aaori and )acific !sland pop"lations.
?&
7arly
intervention in this disease has been shown to dramatically decrease mortality, and
to a lesser e<tent morbidity, with considerable savings to the health service achieved
thro"gh avoiding the need to treat res"ltant end2organ fail"re.
115
,iagnosis
)atients "nder investigation of (S. or e<cessive daytime somnolence have
e<cessive daytime sleepiness, witnessed apnoeas or snoring and fre8"ently a
combination of all three. Since these symptoms are not specific, clinical diagnosis is
not possible witho"t detailed respiratory monitoring d"ring sleep. )olysomnography
remains the gold standard for the diagnosis of sleep related breathing disorders and
other conditions that can prod"ce e<cessive daytime somnolence s"ch as periodic
limb movements of sleep and narcolepsy. !n an effort to improve cost2effectiveness
and the long waiting lists for st"dy which e<ist in New Zealand, patients with a high
pre2test clinical probability of (S. can receive split polysomnography, where nasal
;&
C).) treatment is initiated d"ring the second half of the st"dy on confirmation of
(S.. There is also increasing evidence that polysomnography can be "sed in the
home environment.
Simple overnight o<imetry is the least sophisticated monitoring available b"t, whilst
capable of confirming the diagnosis in most patients with severe (S., it lac3s
sensitivity and to a lesser e<tent specificity. Dpdated g"idelines regarding the
provision of polysomnography in a hospital, and home environment, will need to be
provided. There is evidence that some patients can be effectively eval"ated "tilising
a comprehensive respiratory sleep st"dy. 7ns"ring ade8"acy of treatment with
contin"o"s positive airway press"re +C).), is diffic"lt. Nonetheless, simple
o<imetry may have a limited role at either end of the spectr"m6 that is, in severe
disease to confirm diagnosis, or to e<cl"de the diagnosis in lo"d snorers with no
other feat"res of (S. +that is low pre2test probability where normal o<imetry wo"ld
e<cl"de significant (S. if the patient slept well,.
0imited respiratory monitoring systems are now available at reasonable cost, which
meas"re o<ygen sat"ration, airflow, and in most cases chest wall and abdominal
movements. 'hilst many of these devices have not been ade8"ately validated, they
are the most practical, cost effective system c"rrently available, and sho"ld be
ac8"ired in hospitals servicing pop"lations between 1&&,&&& and 1$&,&&& if a more
comprehensive service is not geographically available. They are capable of
confirming the diagnosis and monitoring s"ccess of therapy in the maority
+>&%?& percent, of patients. They are relatively simple to "se and the res"lts easy to
interpret in most cases, tho"gh they sho"ld only be "sed "nder the s"pervision of a
trained respiratory or sleep physician who is able to recognise the limitations of the
e8"ipment. St"dies sho"ld be carried o"t in a medical ward +preferably in a
dedicated, 8"iet so"nd2proofed room,. /"rther eval"ation of treatment strategies
based on home diagnosis and treatment is re8"ired before it can be recommended.
!nteraction with (R0 services for "pper airway assessment and when re8"ired,
s"rgery, is mandatory.
!n a significant proportion of patients +1& percent,, a diagnosis will not be able to be
made, or the diagnosis of (S. cannot be satisfactorily e<cl"ded. These patients,
along with those where there is diffic"lty in establishing effective therapy, sho"ld be
referred to a regional sleep laboratory with f"ll polysomnography.7rror6 Reference
so"rce not fo"nd !deally the district and regional service sho"ld develop protocols for
diagnosis, treatment and referral for polysomnography to ens"re e8"ity of access to
a regional specialist service when re8"ired.
Regional sleep laboratory service
The regional sleep laboratory sho"ld be staffed by a minim"m of one /T7 sleep
physician, with dedicated s"pport staff and a f"ll polysomnography facility. !t sho"ld
have close lin3s with (R0 and with psychology or psychiatric and ne"rology services.
!t sho"ld act as a tertiary referral centre for the district services and have a maor role
in ed"cation and reso"rce s"pport of the district services. Regional sleep
laboratories sho"ld serve a pop"lation of greater than &.$ million to ens"re efficient
"tilisation of reso"rces, and sho"ld be f"nded accordingly. The 8"ality of the
regional sleep laboratories and of its personnel sho"ld comply with the .S.:TS.NZ
;1
paper J.ccreditation of Sleep 0aboratoriesK +see .ppendi< F!G,, and all sho"ld be
accredited.
"upport staff
.t a district and regional level it is essential to have clearly identified s"pport staff
+respiratory n"rse or physiotherapist or physiology technician, trained in mas3 fitting,
machine maintenance etc. These personnel are cr"cial to achieving patient
confidence and compliance.
(uality assurance
7ach regional centre sho"ld be responsible for standards of sleep disordered
breathing services, and sho"ld report ann"ally on the n"mber of patients tested in
the region and the proportion conforming to g"idelines for nasal C).) therapy. .s a
res"lt, each *H- within a region can be assessed to ens"re that sleep services are
being applied evenly across the region and rates of testing can be compared with
international rates. To allow more specific information to be recorded, specific
g"idelines for diagnosis and definition of severity m"st be agreed "pon. This will
allow patient s"bgro"ps to be treated with C).) or splints to be defined. 7ach
district hospital will therefore be as3ed to maintain a database which will record
information on patients who have been st"died in relationship to follow2"p, o"tcome,
compliance with therapy, and so on.
)resently, sleep related breathing disorders have not been appropriately recognised
by the H/., and s"bse8"ently the Ainistry of Health and *H-s, and only patients
with severe disease are allowed access to C).) therapy. *"e to the restricted
facilities available, waiting lists are rapidly increasing. /or these reasons, access
criteria to the sleep laboratory need to be defined and patients categorised on an
"rgent, semi2"rgent or ro"tine basis. )rioritisation criteria are o"tlined below. )atient
n"mbers sho"ld be recorded in each category and, if waiting times for the vario"s
categories cannot be maintained, this sho"ld be reported to the Ainistry of Health
and Regional Respiratory Service Committee.
Obstructive sleep apnoea
Cte3or" def!n!t!on#
1. 7mergency Sleep st"dy or review within one wee3
1. Drgent Sleep st"dy or clinic review within two wee3s +TS.NZ B"idelines,
#. Ro"tine Sleep st"dy or clinic review within three months +TS.NZ B"idelines,
Cte3or" Cr!ter! EDmp$e# &not eDhu#t!-e $!#t(
1. 7mergency Hospitalisation for complications of (S.
which are life2threatening
Resistant respiratory fail"re of Cor
)"lmonale where no other aetiology 3nown
and high inde< of s"spicion of (S..
.dmission to *CC:!CD with "ne<plained
respiratory fail"re.
1. Drgent Recent admission with life2threatening
illness or ac"te respiratory fail"re.
7pisode of respiratory fail"re in absence or
evidence of infection or airways.
Complication of (S. and for which no
other aetiology 3nown.
(verwhelming daytime sleepiness leading
to maor problems coping with daily
activitiesE not "st diffic"lty with driving,
/alling asleep eating and tal3ing.
Aotor vehicle accidents or Nnear misses= in
;1
especially6
if occ"pation p"ts patient and others at
ris3 of accidental in"ry
maor co2e<istent medical problems
which co"ld be e<acerbated by (S. or
be the res"lt of (S..
reg"lar or commercial drivers or accidents
at wor3 in those wor3ing with machines.
Repeated attac3s of "nstable angina.
Severe and diffic"lt to control hypertension.
#. Ro"tine 7<cessive daytime sleepiness. /alling asleep when not active or on long
o"rneys.
0o"d snoring with or witho"t 7*S. Snoring that is a problem to other
ho"sehold members or a threat to
marriage.
0ow probability in s"bects with other
illness which co"ld be lin3ed with (S..
!ntermittent snoring and mild daytime
sleepiness in a patient with intermittent
angina.
+>. Lun3 cncer
Introduction
0"ng cancer is a significant ca"se of morbidity and mortality in New Zealand with
hospital admissions totalling over #&&& per year. 0"ng cancer contin"es to be the
main ca"se of cancer death in men and an increasing ca"se among women, d"e to
the increasing n"mbers of women smo3ing. /actors associated with an increased
ris3 of l"ng cancer incl"de tobacco smo3e, inhalation of environmental tobacco
smo3e, medical radiation, previo"s l"ng disease and asbestos e<pos"re.
11$
The
strongest ris3 factor is tobacco smo3ing and the "se of effective interventions
incl"ding advice from doctors, str"ct"red interventions from n"rses and individ"al
and or gro"p co"nselling sho"ld be employed.
11;,11>
,iagnosis of lung cancer
.ll individ"als with s"spected l"ng cancer sho"ld be referred to a respiratory
physician for an opinion.
11?
*iagnostic techni8"es employed incl"de sp"t"m
cytology, bronchoscopy and perc"taneo"s needle biopsy. . diagnosis can and
sho"ld "s"ally be made witho"t having to proceed to thoracotomy, for e<ample by
bronchoscopy or /N.. )re2operative staging of non small cell l"ng cancer may
re8"ire a n"mber of proced"res6 plain chest radiograph, CT +to more acc"rately
stage and to assess whether mediastinal nodes are enlarged,, and trans2tracheal
aspiration via bronchofibroscope or rigid bronchoscope, mediastinoscopy or
mediastinotomy if mediastinal lymph nodes are O 1 centimetre in si9e.
-reatment of non+small cell lung cancer
Surgery
)atients are considered potentially operable if, on history and e<amination, the
patient is fit and deemed to have ade8"ate respiratory reserve to withstand s"rgery
and l"ng resection, and there is no evidence of local +T5,, regional +N1%#, or
metastatic disease +A1,. )rognosis based on the TNA classification +T S si9e of
t"mo"r, N S nodal station and A S metastases, shows that early stage one l"ng
cancer T1%1 No Ao has a ;$%C& percent five2year s"rvival which declines to 1&%;$
percent as staging increases.
11C
.ll s"rgical resections sho"ld be performed with
;#
mediastinal node sampling to more acc"rately stage patients. Radical mediastinal
lymph node resection confers no benefit.
1#&
Chemotherapy
Recent st"dies s"ggest that perioperative chemotherapy sho"ld be considered in
locally invasive cases +Stage !!!.,,
1#1
which may render these previo"sly "ntreatable
t"mo"rs resectable. !mproved s"rvival can be achieved with this combined
treatment. However, f"rther st"dies are re8"ired before ind"ction chemotherapy
becomes standard practice. /or "nresectable l"ng cancer +Stage !!!- and !G,,
treatment has been mainly palliative with radiotherapy, however a n"mber of recent
st"dies have shown that modern platin"m based chemotherape"tic regimens alone
or combined with radiotherapy sho"ld be considered in patients with good
performance stat"s. These treatments have achieved response rates of #&%5&
percent and modest s"rvival advantage.
1#1
C"rrently chemotherapy for advanced carcinomas of the breast is considered
standard despite only modest improvement in s"rvival. Therefore, chemotherapy for
advanced l"ng cancer also needs consideration, partic"larly since it has been shown
to be more cost effective than chemotherapy for disseminated breast cancer. Recent
st"dies have shown that palliative chemotherapy can not only improve symptom
control, b"t also red"ce days spent in hospital, and th"s cost.
Radiotherapy
Radical radiotherapy may be helpf"l in small t"mo"rs where the patient=s l"ng
f"nction or co2e<isting medical problems do not allow resection. This yields variable
res"lts of between ; and 51 percent five2year s"rvival rates for stage one disease.
However, s"rvival of patients with s"rgical resection is s"perior to radical
radiotherapy. )alliative e<ternal beam radiotherapy presently remains the mainstay
of treatment for e<tensive non small cell l"ng cancer. -rachytherapy appears e8"ally
effective at controlling symptoms and has the benefit of being administered in one
day compared with five to eight days for e<ternal beam radiotherapy. S"ch therapy
e<ists in Hamilton only. Res"lts are at least as good as e<ternal beam irradiation and
less e<pensive.
1##
"mall cell lung cancer
Small cell l"ng cancer is the second maor gro"p of l"ng cancers acco"nting for 1$%1$
percent of all l"ng t"mo"rs. 7arly t"mo"r dissemination is the r"le and s"rgery even in
limited stage disease has not been shown to increase s"rvival. Small cell l"ng cancer
is chemosensitive and prognosis is determined by the e<tent of t"mo"r at diagnosis.
0imited stage small cell l"ng cancer +confined to one hemithora<,, treated with
combined chemotherapy has been shown to have a response rate of ?&%C& percent
and complete response rate of "p to $& percent with a median s"rvival of 1;%1&
months compared with ?%11 wee3s if "ntreated. Small n"mbers of patients with
limited disease live beyond two years +$%1& percent, following chemotherapy.
1#5,1#$
!n advanced disease, prognosis is worse with no long2term s"rvivors following
chemotherapy. However, chemotherapy does have a role in symptom control and
improves median s"rvival from ; to11 wee3s. The addition of thoracic radiotherapy
to a chemotherape"tic regimen for limited stage small cell carcinoma has also been
shown to improve s"rvival by appro<imately $ percent and sho"ld be considered part
;5
of standard treatment for limited stage small cell carcinoma, especially in patients
who have had a complete response. !n addition, prophylactic cranial radiotherapy
has been shown by meta2analysis to red"ce the incidence of cerebral metastases
and improve s"rvival by a f"rther $ percent.
1#;
"ummary
("r recommendation to *H-s in terms of reso"rcing, investigation and management
of l"ng cancer is that every patient considered to have a l"ng cancer sho"ld be
referred to a respiratory physician for an opinion. .ll necessary investigations
re8"ired to ma3e a therape"tic decision sho"ld have been completed within si<
wee3s of referral, regardless of where patients live.
.c3nowledging that New Zealand has variable and relatively limited access to
chemotherapy +and therefore cannot conform with international evidence based
g"idelines,, the development of New Zealand B"idelines for l"ng cancer
management sho"ld be an "rgent priority. These g"idelines sho"ld be developed
with inp"t from the Ainistry of Health, NZ B"idelines Bro"p, TS.NZ and the New
Zealand Society of Radiotherapists and (ncologists, along with representation from
)alliative Care )hysicians and Cancer Societies. Biven the variable access to both
radiotherapy +"nacceptably long waiting times in some regions, and chemotherapy
and the lac3 of a national database on s"rgical o"tcomes +post operative mortality
rates and five year s"rvival fig"res,, each region sho"ld develop strategies to ens"re
care is optimised and well co2ordinated and collect data for national and international
comparisons. The data sho"ld be collected in s"ch a manner that comparisons as
reported in .ppendi< !! can be made.
/"ndamental to these re8"irements are6
good access to a respiratory physician trained in bronchoscopy to obtain biopsy
material for diagnosis, and to assess whether the t"mo"r is potentially resectable
radiological s"pport with radiologists s3illed in the techni8"es of fine needle
aspiration and biopsy, thoracic CT scanning
e<ercise testing and ventilation:perf"sion scanning for pre2operative assessment
in those patients perceived to have borderline l"ng f"nction
a s"rgeon trained in thoracic s"rgery, who sho"ld have the ability to perform
thoracotomy, mediastinal dissection, mediastinoscopy and mediastinotomy. Aore
recently there has been a trend to perform thorascopic s"rgery and each region
needs to give consideration to enco"raging training in this techni8"e. M"ality
ass"rance mar3ers sho"ld be maintained by all Thoracic S"rgical Dnits and by all
s"rgeons "nderta3ing thoracic s"rgery and which m"st be performed to accepted
standards and "sing .TS B"idelines +see .ppendi< G,
associated with the Thoracic S"rgical Dnit there sho"ld be an intensive care "nit
able to manage post2thoracotomy patients where appropriate
each region sho"ld have a radiotherapy "nit and treatment sho"ld not be delayed
for O 1 wee3s, whether it be c"rative or palliative. There sho"ld be a national
brachytherapy "nit "sing an H*R Selectron and a national bronchoscopy theatre
with facilities for endobronchial laser and stent placement
;$
small cell l"ng cancer sho"ld be managed either by an oncologist or a respiratory
physician with a partic"lar interest in oncology +preferably patients sho"ld be
co2managed,
there is an "rgent need to address new developments in l"ng cancer and which
have important reso"rce implications, that is6
the "se of chemotherapy in non small cell l"ng cancer +regionally,
the "se of brachytherapy as opposed to e<ternal beam radiotherapy in the
palliation of respiratory symptoms in non small cell l"ng cancer +national "nit,.
+>@ Inter#t!t!$ $un3 d!#e#e#
#urrent situation and future directions
There are over 1&& interstitial l"ng diseases +!0*s, comprising abo"t 1$ percent of
respiratory practice.
1#>
They encompass a very wide spectr"m of pathologies,
presentations and o"tcomes. There is concern that !0*s may be poorly recognised
and it is considered that respiratory physicians are the only gro"p with appropriate
training and s3ills to deal with the comple<ity of the diagnosis and management of
these conditions. There is, however, evidence of wide variation in the management
of !0*s amongst respiratory physicians.
1#?,1#C
/or that reason, the -ritish Thoracic
Society has form"lated recommendations on management beginning with the
statement that patients with !0* or s"spected !0* sho"ld be "nder the direct or oint
care of a respiratory physician.
15&
The investigation of !0* has been simplified enormo"sly with the development of
High2Resol"tion Comp"terised Tomography +HRCT,.
151
'ithin respiratory
departments there is growing dependence on high 8"ality reporting +refer to the
radiology standards in .ppendi< G, and less referral to s"rgeons for open l"ng
biopsy. There are very few therape"tic options for the treatment of !0*s b"t the
f"t"re promises novel +and, probably e<pensive new therapies.
151
!t is envisaged that
these will be offered on a case2by2case basis or in the conte<t of a clinical trial. !n
view of the above factors it is recommended that all patients with !0* be referred to a
secondary centre for eval"ation by a respiratory physician and that comple<, rare or
diffic"lt cases be disc"ssed at, or referred to, a tertiary centre.
$uidelines for referral to secondary %ealt% care
)rimary health services or general physicians with no designated respiratory interest
sho"ld not manage patients with !0*. Th"s referral to secondary or tertiary services
is mandatory.
$uidelines for referral to tertiary %ealt% care
The following indications for tertiary eval"ation can be form"lated6
!nitial eval"ation. Cases in whom the secondary physician is insec"re abo"t the
diagnosis or management or where comple< diagnostic proced"res are re8"ired
for e<ample open l"ng biopsy.
Aonitoring disease progression where comple< l"ng f"nction or s"perior HRCT
reporting is re8"ired.
;;
'hen the patient is receiving a novel or e<perimental dr"g for the treatment of
!0*.
'here facilities e<ist for m"ltidisciplinary care of comple< patients for e<ample
rhe"matology and respiratory in the case of !0* associated with connective tiss"e
disorder.
Referral for consideration of l"ng transplantation.
&ational'regional practice
1. )op"lation $&,&&&6 Straightforward cases and ro"tine follow2"p to be managed
locally by a respiratory physician or general physician with a respiratory interest.
There sho"ld be regional access to bronchoscopy +-.0 and transbronchial
biopsy,, cyto2pathology, HRCT and l"ng f"nction testing +plethysmography and
*0C(,.
1. )op"lation $&,&&&%1$&,&&&6 as for a,.
#. National centre6 Cases meeting the above tertiary criteria sho"ld be referred to
regional or national centres. Those centres sho"ld ideally have a clinician+s,
with post fellowship training in and an academic interest in !0*, high level of
competency in HRCT interpretation access to respiratory s"bspecialty cyto2
pathology e<pertise and a f"lly e8"ipped l"ng f"nction laboratory +e<ercise,
*0C(, compliance and body plethysmography, and thoracic s"rgical services.
+>+ Pu$monr" -#cu$r d!#order#
Geno"s thromboembolism remains a significant ca"se of morbidity.
15#
.ppro<imately
1& percent of patients with deep veno"s thrombosis will develop a p"lmonary
embolism, 1& percent of them will die. Chronic p"lmonary embolism with s"bse8"ent
p"lmonary hypertension is rare +abo"t &.1 percent of those that s"ffer embolism,.
'ith the e<ception of s"perior vena caval obstr"ction, most commonly d"e to
thoracic malignancy, other p"lmonary vasc"lar disorders are rare +primary p"lmonary
hypertension, veno2occl"sive disease, arterio:veno"s malformations,
hepatop"lmonary syndrome,.
&ational'regional'local practice
a, )op"lation $&,&&&6 )eripheral veno"s thrombosis sho"ld be diagnosed and
treated by local physicians. !f p"lmonary embol"s is s"spected and imaging
facilities are available for diagnosis, management sho"ld also be by a local
physician. There sho"ld be facilities for basic res"scitation, arterial blood gas
and meas"rement of blood coag"lation profile.
155
b, )op"lation $&,&&&%1$&,&&&6 /acilities for the diagnosis of thromboembolism, for
e<ample scintigraphy, "ltrasonography, T:2 angiography sho"ld e<ist.
.ppropriate laboratory facilities for the diagnosis of inheritable coag"lopathy
sho"ld be available. There sho"ld be intensive care facilities for the
management of maor p"lmonary embol"s with hemodynamic compromise.
c, )op"lation O1$&,&&&6 Radiologic facilities sho"ld incl"de digital s"btraction
angiography, spiral CT, intravasc"lar stenting, placement of !GC filters and
intravasc"lar occl"sion devices. There sho"ld also be appropriate facilities for
;>
right and left cardiac catheterisation and trans2oesophageal cardiac "ltraso"nd.
Thoracic s"rgery and intensive care sho"ld be available.
#riteria for referral to a tertiary centre
a, Comple< p"lmonary vasc"lar disease re8"iring6
sophisticated imaging
vasc"lar stenting, coil or filter placement
vasc"lar s"rgery +p"lmonary endarterectomy % ."c3land City Hospital,.
b, Rare p"lmonary vasc"lar disorders incl"de6
p"lmonary veno2occl"sive disease
p"lmonary .G malformations
hepatop"lmonary syndrome.
(uality assurance measures
/"lly trained staff.
Reg"lar contin"ing ed"cation and peer review with participation in e<ternal
accreditation programmes where appropriate.
Safe well maintained e8"ipment and facilities.
+>* A#thm
)ac*ground
!n New Zealand, hospital admissions and deaths from asthma have fallen between
1C?C and 1CC5, altho"gh the reasons for this are not entirely clear. /rom this it might
be hoped that the morbidity of the disease in the pop"lation is decreasing. However,
there is no data to s"pport thisE in fact, sales of inhaled -2agonists contin"e to rise
and asthma admissions increased by #$ percent between 1CC5 and 1CC;, indicating
that morbidity may be increasing. The incidence and prevalence of the disease has
contin"ed to rise both locally and internationally tho"gh there appears to have been a
platea" over the past five years. There is no information on whether c"rrent asthma
therapy is improving the nat"ral history of the disorder, altho"gh the red"ction in
asthma admissions and mortality, which coincided with increasing "se of inhaled
steroids in the late 1C?&s, s"ggests that inhaled steroids may s"bstantially modify the
co"rse of the disorder.7rror6 Reference so"rce not fo"nd
Consens"s g"idelines for the diagnosis and management of asthma have been
prod"ced by a n"mber of gro"ps and are generally very similar in their
recommendations.7rror6 Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference
so"rce not fo"nd
!n New Zealand comprehensive consens"s g"idelines were developed in 1&&& b"t
there has been no mandate for *H-s to introd"ce these into practice and ta3e2"p
has conse8"ently been variable.
15$
;?
Re.uirements for diagnosis of ast%ma
.sthma is a symptomatic disease. The possibility of asthma is fre8"ently first
identified by the patient or patient=s family. )"blic ed"cation abo"t how to
recognise the disorder is therefore an essential initial part of any local or national
strategy.
*iagnosis is "s"ally made within the primary care setting by a general practitioner.
!n addition to the "s"al s3ills of history ta3ing and e<amination, the general
practitioner will need ready access to, and "nderstanding of6
pea3 e<piratory flow meters and recordings
simple spirometry
s3in pric3 testing
ro"tine laboratory blood testing
chest radiology.
Cases where the diagnosis is "ncertain, where occ"pational asthma is considered,
or where good control is diffic"lt to achieve, sho"ld be referred to a respiratory
physician. .lso6
more comple< respiratory laboratory testing, incl"ding static l"ng vol"mes, flow
loops, simple e<ercise challenge testing or bronchial provocation testing
CT chest scanning +either locally or on referral to another centre,, e<pired nitric
o<ide and ind"ced sp"t"m testing.
(ccasional referral to a tertiary centre may be necessary, partic"larly in cases
where asthma or bronchial hyperactivity is associated with other p"lmonary
conditions s"ch as bronchiolitis. S"ch a centre will have access as needed to6
TS.NZ Category # respiratory laboratory
open l"ng:thoracoscopic l"ng biopsy.
Re.uirements for treatment
The patient
.sthma is a condition that re8"ires active ongoing self2management in order to
achieve a s"ccessf"l o"tcome. This will re8"ire ade8"ate motivation, ed"cation
and access to medical care for the patient and family.
Primary care
.ppropriately s3illed general practitioner.
.ppropriately s3illed practice n"rse.
These to incl"de % therape"tics, ed"cation, management plans and access for
"rgent advice and treatment.
7mergency services and after ho"rs clinics need trained staff and ade8"ate
e8"ipment, incl"ding o<ygen, neb"lisers, o<imetry and spirometry.
Secondary care
Specialist o"tpatient clinics and general medical inpatient care facilities.
;C
Specialist asthma ed"cators available for patient, healthcare professional and
comm"nity ed"cation.
Tertiary
.s above.
*evelopment of treatment g"idelines, research, and so on.
The community
.ccess to local asthma societies and other comm"nity ed"cation gro"ps.
The role of schools, sports cl"bs and other comm"nity gro"ps needs to be
considered.
The image of asthma in the comm"nity is li3ely to significantly affect treatment.
The research community
!mprovement in the treatment of asthma needs ongoing investment in all areas of
research that translate thro"gh to the assessment and improvement of care of
asthma generally.
-%e need for a national consensus
The National .sthma Campaign

in ."stralia7rror6 Reference so"rce not fo"nd has
been developed in co2operation with a n"mber of gro"ps. New Zealand does not
have a similar programme, altho"gh there has been co2operation between the Royal
College of Beneral )ractitioners, the .sthma and Respiratory /o"ndation of New
Zealand, the Royal ."stralasian College of )hysicians, the Thoracic Society of
."stralia and New Zealand +New Zealand branch, and the government in prod"cing
a n"mber of asthma self2management plans.
!t may be appropriate to develop a local programme b"ilding on the e<perience in
."stralia and other co"ntries. This co"ld follow on the recent development of New
Zealand g"idelines for the diagnosis and treatment of asthma, along with the
introd"ction of strategies for prevention, directions for local research, initiatives for
ed"cation and related topics.
-%e need for a co+ordinated approac% to service delivery
The recent health reforms have dramatically changed the way in which the gro"ps
involved with the treatment of people with asthma can interact with each other.
*ialog"e is needed between secondary and primary health care providers +thro"gh
)H(s, and the Royal College of Beneral )ractitioners, specialists +thro"gh the
TS.NZ, and the Royal ."stralasian College of )hysicians, and comm"nity and
national organisations s"ch as the .sthma and Respiratory /o"ndation of New
Zealand. !ss"es to consider incl"de how the c"rrent environment sho"ld be applied
to prod"ce the best o"tcomes for the patients with asthma, and to point o"t areas
where improvements are needed.
>&
+>)0 Chron!c o4#truct!-e pu$monr" d!#e#e &COPD(Error8 Reference #ource
not found
,Error8 Reference #ource not found
C()* is a significant health problem. !n New Zealand it is the third most common
ca"se of death +? percent of male and 5 percent of female deaths,. Dsing New
Zealand hospital discharge data from 1CCC as a mar3er of morbidity, it ran3s second
for males +first for Aaori, and si<th for females +fo"rth for Aaori,. . cross2sectional
st"dy in New Zealand in 1C?C estimated that the total health care costs attrib"table to
smo3ing were @1?$ million +> percent of the total State e<pendit"re on health,. (f
the @11? million spent on hospital costs, @11 million was for C()* admissions.
These are li3ely to be s"bstantially higher in 1&&5, partic"larly if one incl"des the
costs associated with C()* when it is defined as a secondary diagnosis and
contrib"tes to the length of hospital stay. *epending on the prevalence of C()* a
recent review in 1&&# estimated that between @11& million and @1#$ million is spent
on the direct costs of health services.
22
*"e to the ageing pop"lation, C()* is
ma3ing a significant contrib"tion to the rising incidence of ac"te hospital admissions.
!t is now the commonest ca"se of respiratory admission.
!n spite of the fre8"ency of admission and cost associated with managing C()*,
service development has lagged behind other medical conditions. There is an "rgent
need for the development of a comprehensive vertically integrated service.
Ro"tine management sho"ld be devolved for the most part to general practitioners,
other primary care providers and both general and respiratory physicians. The maor
role for respiratory physicians is6
to provide a cons"ltation service regarding diagnosis and management,
partic"larly of those with severe disability
lead the development of m"ltidisciplinary management and rehabilitation
programmes
assist in the development and implementation of standards and best practice

g"idelines
assist in a"dit and 8"ality ass"rance processes
develop new treatment modalities, for e<ample vol"me red"ction s"rgery, portable
o<ygen, l"ng transplantation, and assisted ventilation d"ring ac"te e<acerbations
when indicated
research.
The devol"tion of ro"tine management to primary care will re8"ire the development
of an integrated service across the primary:secondary health care interface. This will
re8"ire disc"ssions with general practice gro"ps, )H(s and p"rchasing health
a"thorities. Aodels s"ccessf"lly developed in the Co"nties Aan"3a" *H- and
Canterb"ry *H- co"ld be f"rther e<plored.
"econdary care services
!n these sit"ations there sho"ld be a specialist respiratory physician or a general
physician with an interest in respiratory disease who closely associates with the
regional respiratory department in the tertiary centre. Services that sho"ld be
provided incl"de6
>1
physiological assessment incl"ding spirometry, flow vol"me loops, transfer factor,
arterial blood gas analysis and p"lse o<imetry
clinical management incl"ding ac"te e<acerbations based on TS.NZ g"idelines
1CC$7rror6 Reference so"rce not fo"nd
intensive care facilities with the capability of ventilating selected cases. High
dependency "nits +H*Ds, or allocated areas in respiratory wards with appropriate
training and g"ideline development can provide assisted ventilation +bi).), d"ring
an e<acerbation
a service for long term domiciliary o<ygen therapy and, in selected cases,
amb"latory o<ygen therapy
a limited level three sleep diagnostic and treatment service for C()* cases with
associated (S. or noct"rnal hypoventilation
a m"ltidisciplinary ed"cation and rehabilitation programme emphasising self2care,
action plan, rehabilitation programme, activities of daily living, medication and
neb"liser "se, n"trition and psychosocial s"pport
an o"treach programme assisting integration with primary health care services
a str"ct"red smo3ing cessation programme, s"ch as the Smo3escreen
programme for the 1CC&s +Dniversity of New So"th 'ales,.
15;
This co"ld be a
combined service with general practice and other primary health care providers.
-ertiary care services
The five tertiary centres sho"ld have well developed secondary care services as
o"tlined above and sho"ld facilitate and s"pport the development of secondary care
services, s"ch as ed"cation, rehabilitation, smo3ing cessation and o<ygen therapy
services, within the region.
!n addition to those secondary services, the regional centre sho"ld be able to provide
the following6
additional respiratory f"nction assessments s"ch as l"ng vol"me estimations and
e<ercise testing
a regional centre for the development of a home ventilation service for selected
patients
a f"ll sleep assessment and management service
a regional thoracic s"rgical service for the operative and thoracoscopic
management of selected cases of pne"mothora< associated with C()*
a physician with responsibility for preliminary assessment and follow "p of C()*
cases selected for transplantation or l"ng vol"me red"ction s"rgery.
&ational service
There sho"ld be one centre in the co"ntry responsible for6
l"ng transplantation, l"ng vol"me red"ction s"rgery and complicated s"rgery for
maor b"llo"s disease
>1
a national centre +Canterb"ry, has been established for the registration of cases of
alpha 1 antitriptysin deficiency. This centre is endeavo"ring to co2ordinate a st"dy
into replacement therapy thro"gh a worldwide m"lticentre trial, which involves
."c3land as the other principal st"dy centre.
Prevention
C()* has a long pre2symptomatic phase with symptoms often not developing "ntil
the /7G
1
red"ces to aro"nd $& percent of predicted. C()* is an ideal case for
secondary prevention. Spirometry is a simple, reliable and ine<pensive test for pre2
symptomatic identification of this disease b"t needs to be introd"ced caref"lly to
ens"re that good 8"ality recordings are achieved. This co"ld be "sed for screening
of smo3ers to identify the 1$ percent or 1& percent who are developing C()*.
Those e<hibiting a red"ction in /7G
1
to less than ;$ percent of predicted co"ld be
s"bected to more intensive smo3ing cessation efforts, with "tilisation of newer
programmes that, in the c"rrent non2smo3ing social environment, are becoming
increasingly s"ccessf"l. Spirometric recordings have also been shown to increase
the li3elihood of smo3e cessation. /or those who are "nable to 8"it, close follow "p
wo"ld allow other timely interventions and revisiting of the smo3ing iss"e. There
needs to be a maor service development in the field of C()* prevention. . f"t"re
prevention programme co"ld incl"de6
spirometric screening of all smo3ers over the age of #&, preferably in the general
practice or other comm"nity settings, b"t also d"ring admission to other hospital
departments, for e<ample pre2operative assessment
the provision of intensified smo3ing cessation services integrated across the
primary 2secondary care interface
active disco"ragement of smo3ing by older children with asthma or rec"rrent
bronchitis by paediatricians and general practitioners
environmental meas"res s"ch as red"ction in air poll"tion and occ"pational
e<pos"re to l"ng irritants
a screening programme for families of cases identified with alpha 1 antitriptysin
deficiency.
(uality assurance
The absence of strong evidence based s"pport for m"ch of contemporary C()*
management ma3es it diffic"lt to apply 8"ality ass"rance meas"res. Nevertheless,
standards and c"rrent best practice g"idelines sho"ld be developed and
implemented as part of service development. These sho"ld be "sed as a benchmar3
to a"dit the process, o"tcome and cost effectiveness of care, incl"ding improving the
8"ality of life for those who live with this progressive disease.
>#
Inte3rt!on of 7ed!c$ Ser-!ce# %!th Commun!t" 6roup#
*H-s will be responsible for liaison with general practitioners, practice n"rses, health
development staff, and lay comm"nity gro"ps +eg, .sthma Societies, Cancer Society,
Hospice Society, .!*S /o"ndation, Cystic /ibrosis .ssociation, T"berc"losis and
Chest *iseases .ssociation, with regard to provision of primary medical care,
preventive programmes, screening services, ed"cational initiatives, contin"ing
medical ed"cation and 8"ality control. (ther government bodies s"ch as the
(cc"pational Safety and Health Committee and National .dvisory Committee on
Health and *isability need to have a closer relationship with regional respiratory
services development. The board sho"ld enco"rage the wor3 of vol"ntary
organisations, and s"ch gro"ps sho"ld, where appropriate, be represented on
decision2ma3ing committees.
>5
5e$th Ser-!ce Dt Re9u!rement#
*H-s m"st ens"re that ade8"ate records are 3ept of patient cons"ltations at all
levels, admissions, follow2"p and other activities, so that regional data are available
for a"dit and cost analysis and for comparisons of services, o"tcomes, and other
epidemiologic and service2related p"rposes.
>$
Re#erch nd Educt!on Re9u!rement#
*H-s have responsibility to enco"rage research appropriate to identified local and
regional needs incl"ding health service needs, and to facilitate research f"nded by
other independent so"rces, for e<ample Health Research Co"ncil, 0ottery Health
Research, local Aedical Research /o"ndations, and lay organisations. .ll research
m"st be approved by an appropriately constit"ted ethics committee, and s"bect to
peer scientific review.
*H-s and the Ainistry of Health need to "rgently review systems to s"pport
postgrad"ate ed"cation as well as research. 7volving better 8"ality of care from
hospital settings into the comm"nity will re8"ire "ps3illing of staff at all levels.
Regional centres of e<pertise sho"ld wor3 with local "niversities or technical
instit"tes to ens"re postgrad"ate training of respiratory physicians
15>
+see also
.ppendi< F!!, "pdating of general physicians and general practitioners, postgrad"ate
training of respiratory scientists, training of respiratory n"rse practitioners,7rror6
Reference so"rce not fo"nd respiratory physiotherapists and of p"blic health and
practice n"rses +see .ppendi< F!!!,. These endeavo"rs need to be overseen by the
respective *H-s and the regional gro"ps to ens"re the moneys are being distrib"ted
appropriately and that those entr"sted with administering f"nds are made
acco"ntable. National meetings sho"ld also be held to review respective *H-=s
progress and to prevent d"plication of effort.
>;
Append!D I8 Nt!on$ ho#p!t$ dm!##!on# for re#p!rtor" d!#e#e#
)*@0<*+, nd proEect!on# for /00;
Reported dm!##!on#
Yer )*@0 )*@; )*+0 )*+; )**0 )**1 )**+ /00;F
T"berc"losis #;C ;>C $;& #$> #C; #?1 5$; 5?&
C()* and allied conditions
incl"ding asthma
;##? >,?;? 11,C&? 1;,1#5 1;,555 1>,$$5 11,?&1 1$,&&&
0"ng malignancies 1,;$5 1,1?$ 1,;$5 1,>51 #,115 #,;1C #11& #,1&&
0"ng infection >,?;$ >,&$; ;,;5> ;,C?1 ?,511 ?,??$ 11,C#? 1$,&&&
Total 1;,11; 1>,>>? 11,>;C 1;,115 1?,#;$ #&,55& #>,#&; 5#,;?&
L 1&&$ predictions based on growth over #& years. Note most other medical conditions have platea" or
red"ced over past 1& years apart from an increased rate in the elderly.
So"rce6 New Zealand Health !nformation Service +NZH!S,, 'ellington
>>
Append!D II8 7e#urement of performnce nd outcome !nd!ctor#
Aeas"rement is essential for 8"ality ass"rance and m"st be co2ordinated on a
national basis. Respiratory medicine statistics m"st be collected in all regions to
allow within2region, inter2regional and international comparison. *ata collection and
interpretation is a highly s3illed process and m"st be done by people with
epidemiological, respiratory and comm"nity medicine training.
The following ill"strations of a"dit data for l"ng cancer and asthma relate to 8"ality
ass"rance and may allow some assessment of the effect of preventive meas"res,
access to health care and standards of health care delivery. These ill"strations also
highlight the need for caref"l interpretation of the data and the importance of local
3nowledge abo"t o"r facilities and practices.
)> Lun3 cncer
T4$e I
A3eAdEu#ted mort$!t" rteC)00,000 popu$t!on &)*+0+)(
7$e Fem$e
New Zealand ;$.C 1>.1
DS. >1.; 11.5
."stralia ;$.1 11.1
Canada ;?.5 1;.;
7ngland and 'ales C1.$ 11.C
T4$e /
F!-eA"er #ur-!-$ rte# for $un3 cncer
)*.0<.?
&G(
)*@0<@?
&G(
)*@@<+?
&G(
/00)<0?
&G(
DS. +whites, ? 1& 1# 1C
)*;;<.;
&G(
)*.+
&G(
)*@+<@*
&G(
/00)<0?
&G(
New Zealand 5.# ;.5 ; ;.#
The res"lts of every component of care at Breen 0ane Hospital,
15?
when p"blished,
compare favo"rably with !nternational p"blished reports +s"rgery, radiotherapy,
chemotherapy,. However, New Zealand=s five2year s"rvival rates +Table 1, lag well
behind those of the DS. and the differences in o"tcome have increased over the
past 1& years. The difference in five2year s"rvival rates in the 1C>&s is tho"ght to
relate to poor access to primary care in New Zealand +or delays in diagnosis,. !t is
tho"ght that the recent f"rther divergence in five2year s"rvival fig"res, relates to
"navailability of chemotherapy for non2small cell l"ng cancer in New Zealand. /ive2
year s"rvival fig"res for l"ng cancer in New Zealand are c"rrently the worst in the
'estern world.
>?
T4$e ?
Compr!#on# of outcome# !n d!fferent re3!on# of Ne% Ze$nd
Auc2$nd
&)*@+<@*(
Cnter4ur"
&)*@/<@.(
Pneumonectom" &n( 1> #1
)ost2op mortality >.5R 11.$R
/ive2year s"rvival ##R 1$.;R
Lo4ectom" &n( 5> $#
)ost2op mortality &R >.$R
/ive2year s"rvival 5>R #C.;R
Inoper4$e t thorcotom" &n( ? +1&R, 1> +15R,
Rd!otherp" &curt!-e( &n( ;C 1>?
/ive2year s"rvival >.1R 5.$R
Note6 n S n"mber of cases.
Concl"sions from comparative data as in Table # m"st be drawn with ca"tion
beca"se of the large n"mber of potentially "ncontrolled infl"ences, for e<ample age,
histological type, acc"racy of diagnosis, and most importantly the staging of the
cancer at the time of treatment, and the time the st"dy was carried o"t. The Nbetter=
res"lts in ."c3land are li3ely to be d"e to better pre2operative staging and therefore
better selection of patients not only for thoracotomy b"t also radiotherapy, which in
t"rn reflects the earlier introd"ction of CT scanning in ."c3land. !t is, however, clear
that if attempts to collect s"ch data are not made, then it will be impossible to monitor
effectiveness or to form"late hypotheses abo"t the 8"ality of the service.
Comprehensive reports covering each of the maor respiratory diseases, li3e that
prod"ced by -orrie et al in 1C>#
15C
sho"ld periodically be "nderta3en. Ar -orrie=s
report reviewed trends in deaths and cases reported, and e<amined patterns in
diagnosis, treatment and s"rvival. These data enabled recommendations abo"t care
and prevention to be made. -eca"se there was no professional body established +as
is envisaged in these g"idelines, no effort was made to assess whether these
recommendations were ever endorsed and introd"ced.
/> A#thm
Introduction
Aortality from asthma in New Zealand increased mar3edly in the late 1C>&s, pea3ing
in 1C>C before steadily declining d"ring the 1C?&s to a level of &.C$:1&&,&&& in the
;%$52year2old pop"lation in 1CC# +/ig"re 1,.7rror6 Reference so"rce not fo"nd
!ndices of asthma morbidity6 intensive care "nit +!CD, admissions, hospital
admissions and emergency department +7*, visits increased along with asthma
mortality in the late 1C>&s, b"t, whilst mortality fell, !CD admissions, first admissions
+as opposed to readmissions, and 7* visits contin"ed to increase d"ring the 1C?&s
"ntil 1C?C. However, after 1CC& there was a s"bstantial red"ction in all
meas"rements of asthma morbidity as reflected in hospital admission rates "ntil they
began to increase again in 1CC; +/ig"re 1,.
>C
Aany reasons were cited for the increase in both mortality and admission rates in the
late 1C>&s incl"ding6
an increase in the prevalence or severity of asthma
changes in the provision of and access to primary health care against a
bac3gro"nd of social and economic decline
direct dr"g to<icity d"e either to individ"al dr"gs +fenoterol, or a combination of
dr"gs
management error by patient, relatives or doctor d"ring the ac"te attac3.
*espite an analysis of the wealth of epidemiological data now available to "s7rror6
Reference so"rce not fo"nd we are still "nable to specifically differentiate between
the relative contrib"tions each of these factors may have had on either admission or
mortality rates. 'hilst debate contin"es abo"t the contrib"tion fenoterol A*!s may
have had on the increase in mortality rates, there is agreement that over"se of
inhaled - agonists as a class and "nder"se of inhaled steroids were maor
contrib"ting factors. 'ithdrawal of fenoterol +a poorly selective and relatively high
dose - agonist, and warnings abo"t the potential dangers of over"se of inhaled -
agonists in association with the release of high dose inhaled steroids "ndo"btedly
contrib"ted to the red"ction in both mortality and morbidity in the late 1C?&s.
'hile decreases in asthma mortality s"ggest that c"rrent asthma strategies are
effective, it is important to contin"e to monitor these trends as they may change
8"ic3ly as happened in the late 1C>&s. !ndeed, hospital admissions have again risen
by #$ percent since 1CC$.
(ther 8"ality care meas"rements sho"ld incl"de6
intensive care "nit admission rates
readmission ratios
emergency department visits and relapses and corticosteroid to U agonist inhaler
prescription ratios.
/ortality rates
'hilst death occ"rs in only a very small proportion of the asthmatic pop"lation, most
deaths are considered preventable, and many asthmatics who have died had
previo"sly declared themselves to be at high ris3 of e<periencing severe attac3s.
The 1CC# mortality rate for $%$52year2olds was &.C# per 1&&,&&& and reflects the
trend towards falling mortality over the last 1& years.
.n important goal sho"ld be to 3eep mortality rates below an Nacceptable= level and
below the c"rrent rate as has contin"ed to happen. -eca"se the total n"mber of
asthmatics dying within *H-s is relatively small there can be considerable yearly
variation +see Table 1,. !t is therefore s"ggested that regional mortality rates be
eval"ated over a period of at least three years +see Table 1,, and to incl"de $%$52
year2olds rather than $2#5 year olds since the acc"racy of diagnosis in #$%$52year2
olds is C& percent +ie, acceptable, and wo"ld allow larger n"mbers of asthmatics to
be incorporated.
?&
Admission rates
0oo3ed "pon as a form of treatment, the decision to admit a patient with asthma to
hospital is s"bect to three factors6
the organisation of the medical care system
asthma management
illness behavio"r.
7ach of these factors may be diffic"lt to change. /or e<ample, the distrib"tion of the
pop"lation aro"nd a hospital will infl"ence how that pop"lation "se the reso"rce. !f
the pop"lation residing in close pro<imity to the hospital is poor and carries a high
n"mber of patients belonging to ethnic minority gro"ps then the "se of the
emergency department for ac"te asthma may be high beca"se patients will "se the
emergency department in preference to the comm"nity based medical care. 'hilst
three separate a"dits have shown that the 8"ality of care available in New Zealand
"rban emergency departments is as good or better than e8"ivalent si9ed overseas
centres, New Zealand patients tend to "se the reso"rce later in an attac3 than they
wo"ld a comm"nity2based centre and s"bse8"ently are more li3ely to be admitted.
(ver the past three years there has been a general downward trend in hospital
admission rates within most districts in New Zealand b"t there are still two2fold
differences between *H-s.
Readmission ratios
This is defined as the n"mber of readmissions divided by total admissions within a
calendar year +tho"gh readmissions within one or three months of first admission
may be a better meas"re,. .ltho"gh it is a relatively cr"de method of meas"ring
readmissions +patients admitted in the latter half of the year and who are readmitted
in the early stages of the following year wo"ld not be incl"ded as a readmission,,
s"ch meas"rements are easily calc"lated from information available from the New
Zealand Health !nformation Services or Ainistry of Health, and can be compared
from year to year and between regions +see Table 1,.
.sthmatics who re8"ire readmission are ac3nowledged to be a high2ris3 gro"p and
sho"ld be targeted for specialist o"tpatient care. Readmission ratios began to drop
in New Zealand in 1C?; +see /ig"re 1,, coinciding with the la"nching of high dose
inhaled steroids which were available on specialist only prescription and which may
have e<aggerated the positive effect of hospital based asthma clinics which were
being established on a larger scale in New Zealand at the time. . red"ction in
readmissions is the aim of any o"tpatient clinic, +along with rationalisation of therapy,
improvement of asthma control and the teaching of self management s3ills,.
Therefore, readmission rates are a good indicator of the 8"ality of follow2"p care after
discharge.
?1
Intensive care unit admissions (I#0!
!ntensive care "nit +!CD, admissions are relatively easy to monitor in those areas that
have s"ch a reso"rce. .ltho"gh !CDs may have different criteria for admission, the
acc"racy of this information may be improved by only incl"ding those patients who
either re8"ire ventilation or who have a pH of less than >.1 or a )aC(
1
of greater
than ;.> 3)a +or 5$ mmHg, at the time of their admission to hospital.
.ll patients admitted with these criteria sho"ld spend at least some time in an !CD.
.sthmatics who have re8"ired !CD admission are at very high ris3 of mortality and
morbidity and sho"ld be targeted for close s"pervision in asthma clinics. 7ffective
intervention in this gro"p is li3ely to red"ce mortality and also impact on admission
rates. !n ."c3land red"ctions in !CD admissions paralleled red"ctions in hospital
admissions +see /ig"re 1,.
1mergency department (1,! use
!n the past, information on emergency department +7*, "se has been diffic"lt to
obtain d"e to inade8"ate data collection, b"t this sho"ld improve as 7*s incorporate
electronic information systems. !t wo"ld be of "se to *H-s to compare 7* rates with
other centres, since 7* rates correlate well with hospital admission and which in t"rn
may e<plain variations in admission rates between centres. )atients re8"iring
re2attendance at the 7* within one wee3 of assessment e<pressed as a percentage
of the total n"mber of asthmatics "sing the 7* is a "sef"l meas"re of 8"ality of care
within the 7* and sho"ld be Q $ percent.
In%aled preventers'in%aled bronc%odilator ratio
!nformation on the 8"ality of asthma care o"tside of the hospital environment is
diffic"lt to define "nless cross sectional 8"estionnaire based st"dies on asthmatics in
the comm"nity are "nderta3en. However, data relating to prescription of medications
is available. !t is generally accepted that adoption of appropriate doses of inhaled
steroids and to a lesser e<tent long acting inhaled - agonists wo"ld red"ce asthma
morbidity rates. The "se of reg"lar inhaled steroids instead of reliance on
bronchodilator medication is a widely accepted principle in asthma management.
. ratio of inhaled corticosteroid prescription rates to inhaled bronchodilator
prescription rates for asthma might be a "sef"l meas"rement of 8"ality of care +see
Table 1, tho"gh others have fo"nd as we did that this was a relatively cr"de meas"re
of 8"ality of care and in part is as a conse8"ence of o"r inability to differentiate
between C()* and asthma with prescriptions filled +appro<imately ;& percent of
prescriptions +based on !AS +!ntercontinental Aedical Statistics, fig"res, are for
asthma,.
Converting all corticosteroid therapy to 1&& Vg per p"ff e8"ivalent and all U agonists
to 1&& Vg e8"ivalent per p"ff then total sales nationally are ro"ghly e8"ivalent.
-ased on an estimation of cost then inhaled steroid to inhaled U agonist ratio sho"ld
be greater than 161. The 8"ality of this information wo"ld improve if sales and
prescribing information to ;%$52year2old asthmatics were incl"ded. However, the
8"ality of pharmace"tical based information wo"ld improve s"bstantially if New
Zealand developed a national dr"g register.
?1
#onclusions
The indices disc"ssed are indirect meas"res of 8"ality of care, and may in some
instances simply reflect "se of reso"rces. 0inear regressional analyses show no
strong relationship between indices of mortality, indices of morbidity and sales of
inhaled corticosteroids in New Zealand when analysed across districts. Not
s"rprisingly however, there is a good correlation between emergency department
"se, hospital admissions and intensive care "nit admissions. Therefore these 8"ality
care meas"rements sho"ld not be reviewed in isolation b"t rather regarded as a
Nwhole=. /or e<ample, a decision to red"ce admissions from the emergency
department s"bse8"ent to attendance by $& percent may contrib"te to an increase in
emergency department relapse rates if the decision was not "nderta3en as part of a
more comprehensive approach to emergency department management.
!nformation is available from the Health !nformation Service, from the Ainistry of
Health, from patient databases maintained at local instit"tions, and from
!ntercontinental Aedical Statistics +!AS,. Comparison with other regions in New
Zealand is valid and may reveal considerable variance from the national average.
This information may be "sef"l in planning interventions designed to improve care,
and in assessing their effectiveness.
T4$e )
7ort$!t" 4" Are 5e$th 'ord &Ne% Ze$nd(
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'ai3ato 1.;> 1.1; &.?5 1.1; 1.;?
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Aanawat":'angan"i 1.1# 1.;& 1.1$ 1.$$ &.&&
'ellington 1.1? 1.1; 1.>1 &.#5 1.>1
'est Coast 15.C$ 1.$& 5.5C &.&& &.&&
Nelson &.5$ &.C& &.&& 1.>& &.&&
Canterb"ry 1.&? 1.5& &.;$ 1.C5 1.;1
(tago 1.C& &.?1 &.?1 &.?1 &.?1
So"thland &.?$ 1.1? 1.1? 1.1? 1.1?
New Zealand +total, 1.5$ 1.#> 1.#1 1.#> 1.11
M"ality of care standards 1.5& 1.5& 1.5& 1.5&
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Are 5e$th 'ord Adu$t med!c$
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'est Coast 1CC.?$ 1&>.>1 &.11 1.1
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(tago 15;.1& 1#>.1$ &.$5 1.$
So"thland 1>&.?1 11>.&$ &.11 1.1
New Zealand +total, 11C.$$ 1>C.&& &.#; 1.1
M"ality of care standards 1$&.&& &.5& 1.1
F!3ure )
Ne% Ze$nd #thm mort$!t" nd dm!##!on rte#, )*+)<*; for ;<;1A"erAo$d#
?5
F!3ure /
F!r#t dm!##!on# nd redm!##!on# for #thm, )*+0<*/
?$
Append!D III8 Re#p!rtor" med!c!ne nt!on$ referr$ 3u!de$!ne#
B"idelines for specialist referrals6 diagnosis2based
http6::www.electiveservices.govt.n9:respiratoryWmedicineWreferral.html
B"idelines for specialist referrals6 symptom2based
http6::www.electiveservices.govt.n9:respiratoryWmedicineWreferral.html
National access criteria for first assessment +.C.,
http6::www.electiveservices.govt.n9:pdfs:respiratoryWmedicine.pdf
National clinical priority assessment criteria +C).C,
http6::www.electiveservices.govt.n9:pdfs:respiratoryWmedicineWC).C.pdf
?;
Append!D IV8 TSANZCRACP #tndrd# for tr!n!n3 !n re#p!rtor"
med!c!ne re9u!rement# for ph"#!c!n tr!n!n3, du$t med!c!ne, /00)
Thorc!c nd S$eep 7ed!c!ne Super-!#!n3 Comm!ttee
Specialist .dvisory Committee in Thoracic and Sleep Aedicine +S.C,
Introduct!on
Thoracic medicine and sleep medicine are intimately related areas of internal
medicine. C"rrently s"pervision of trainees wishing to gain e<perience in either
thoracic medicine or sleep medicine +or both, is by the specialist advisory committee
+S.C, in thoracic and sleep medicine.
Sleep medicine is considered an integral part of thoracic medicine and each trainee
m"st complete at least three months of core sleep medicine.
Thorc!c med!c!ne
,efinition of speciality
Thoracic medicine is a s"bspecialty of internal medicine encompassing diseases of
the respiratory system incl"ding the "pper airway, the l"ng, the chest wall and the
ventilatory control system. Thoracic medicine is a cohesive blend of6 clinical
3nowledge of respiratory diseasesE the respiratory sciences of normal and disordered
respiratory f"nctionE and e<perience with specialised diagnostic techni8"es, tests and
proced"res employed in clinical assessment.
$eneral principles of training
1. Training in thoracic respiratory medicine consists of a str"ct"red three2year
programme. .dvanced training commences with approval of a s"bmitted
programme. .t least two years= e<perience in clinical thoracic medicine is
necessary. The third year of training may be spent in research or in an
approved complementary year in a related discipline. Complementary training
will normally not be considered "ntil at least one year of core thoracic medicine
training has been completed.
1. Trainees are enco"raged to become conversant with all diagnostic proced"res
available, with the c"rrent literat"re, and with research activities in the
respiratory field, b"t are not e<pected to become e<pert in all branches of
thoracic medicine and in all techni8"es.
#. !t is desirable that training be "nderta3en at more than one instit"tion and it is
envisaged that this will be necessary for many trainees, to enable them to
ac8"ire a s"fficient breadth of e<perience.
?>
5. .dvanced trainees transferring to the specialist advisory committee in thoracic
and sleep medicine may be advised to "nderta3e some post /R.C) s"pervised
training in thoracic medicine to complete their three2year training programme.
$. Normally at least one year of advanced training sho"ld be "nderta3en in
."stralia or New Zealand.
#omponents of training
Core training
Clinical thoracic medicine
Training sho"ld incl"de a wide e<pos"re to all common respiratory disease incl"ding
l"ng cancer, t"berc"losis and e<perience in respiratory intensive care. !t is e<pected
that all advanced trainees in clinical thoracic medicine will also gain first2hand
e<perience in a respiratory f"nction laboratory and a sleep disorders clinic. This
e<perience will enable trainees to become familiar with the performance and
application of commonly "sed respiratory f"nction tests in the management of
patients with respiratory disease.
Clinical sleep medicine
.ll thoracic medicine trainees m"st "nderta3e the e8"ivalent of at least three months=
training in sleep medicine, as part of their core training in thoracic medicine. This
training sho"ld occ"r in an instit"tion with a sleep laboratory and its associated
clinic+s, where the trainee sho"ld receive6
3nowledge of basic sleep physiology
e<perience in the diagnosis and management of cardiorespiratory sleep disorders
3nowledge of the symptomatology and management of non2respiratory sleep
disorders, partic"larly those that enter into the differential diagnosis of sleep
apnoea +eg, disorders that ca"se e<cessive daytime sleepiness,.
Trainees sho"ld receive e<perience in the clinical application of polysomnography
and basic training in the polysomnographic techni8"es "sed to meas"re and score
sleep, and abnormal sleep2related respiratory events.
Desirable options
!t is recommended that some e<perience with s"bspecialty and related disciplines is
obtained and these incl"de6
thoracic s"rgery
infectio"s diseases incl"ding p"lmonary infection in the imm"no2compromised
ad"lt cystic fibrosis
l"ng transplantation
7NT s"rgery
clinical allergy and imm"nology and occ"pational l"ng disease.
??
Procedural skills
7ssential proced"ral s3ills
These incl"de fibreoptic bronchoscopy and transbronchial l"ng biopsy, ple"ral biopsy
and t"be thoracostomy. .s a g"ide to the n"mbers re8"ired to gain competence,
trainees sho"ld aim to complete appro<imately the following n"mbers of proced"res
d"ring their training period6
-ronchoscopies 1&&
Transbronchial l"ng biopsies $&
)le"ral biopsies 1&
T"be thoracostomies 1&
*esirable +optional, proced"ral s3ills
These incl"de rigid bronchoscopy, laser bronchoscopy, fine needle aspiration biopsy,
transbronchial needle biopsy and intensive care proced"res incl"ding int"bation,
central line placement and Swan Ban9 catheter insertion.
Complementary +elective, training
The specialist advisory committee in thoracic and sleep medicine may approve a
ma<im"m of one year of complementary +non2core, training which may be spent in
related clinical medicine, respiratory research or laboratory wor3.
Clinical complementary training will generally be restricted to related disciplines s"ch
as intensive care, infectio"s diseases, clinical allergy:imm"nology and cardiology.
.ny depart"re from this wo"ld re8"ire e<ceptional circ"mstances for consideration.
Complementary training m"st be approved by the specialist advisory committee
before training commences. The re8"irements for core training, as o"tlined "nder
core training in the g"idelines m"st be satisfied. Retrospective approval of the
complementary training will not normally be granted. Training in research will be
strongly enco"raged. *"ring the period of complementary training ongoing contact
with a respiratory s"pervisor is re8"ired.
Projects
Trainees are e<pected to6
present +or to be principal a"thor of, at least one paper to a meeting of a national
or international society +eg, Thoracic Society of ."stralia and New Zealand
+TS.NZ, or R.C),
prepare an article accepted for p"blication by a peer reviewed o"rnal. !n general,
single case reports will not satisfy this criterion.
Other specific requirements
.ttendance at meetings
Trainees are e<pected to attend and ta3e part in at least one ann"al scientific
meeting of the TS.NZ d"ring the three years of training.
?C
Sleep medicine
Trainees wishing to ma3e sleep medicine an important area of their practice +eg, to
manage comple< sleep breathing disorders and to report sleep st"dies, will be
e<pected to "nderta3e at least once year of training in clinical sleep medicine in an
approved centre +see Sleep Aedicine B"idelines, 0evels ! and !!,.
0ogboo3
.dvanced trainees are re8"ired to maintain a logboo3 which doc"ments clinical
proced"res incl"ding bronchoscopy, transbronchial l"ng biopsy, t"be thoracostomy
and ple"ral biopsy. The information re8"ired for each proced"re incl"des the
medical record n"mber, the proced"re performed and the o"tcome of the proced"re
incl"ding any complications or "n"s"al feat"res. The logboo3 sho"ld state whether
these proced"res were s"pervised or "ns"pervised. Competence will be assessed
by s"pervisors who will be as3ed to verify the details of the logboo3 and the trainee=s
e<perience and competence.
Clinical respiratory physiology
Those intending to ma3e clinical respiratory physiology an important area of their
practice +eg, to specialise in comple< respiratory f"nction testing, are e<pected to
spend at least one year of non2core training in a comprehensively e8"ipped and
staffed laboratory performing a wide range of respiratory f"nction tests "nder the
s"pervision of physicians in this area of medicine.
Those advanced trainees who wish to practise predominantly or solely in clinical
respiratory physiology will be e<pected to "nderta3e two years of core training in
thoracic medicine and two years in clinical respiratory physiology. (ne year of
respiratory physiology training may be devoted to f"ll2time research. Trainees who
wish to consider this option are enco"raged to disc"ss it with the Chair of the
specialist advisory committee in thoracic and sleep medicine in advance.
Research
!t is strongly recommended that trainees "nderta3e a significant research proect
d"ring their training in order to "nderstand and apply appropriately research
methodologies in laboratory and clinical settings. Trainees sho"ld become actively
involved in research activities incl"ding 8"ality ass"rance.
7<perience sho"ld be gained in6
st"dy design
literat"re research and review
writing s"bmissions for grants and 7thics Committee approval
data collection
storage and analysis
comp"ter programme eval"ation for res"lts analysis, statistics and graphics.
S"ccess in these activities sho"ld be demonstrated by p"blication or presentation of
a significant proect at a national or international meeting.
C&
Training posts
Centres at which programmes of advanced training in thoracic medicine are
"nderta3en ideally sho"ld have the following6
a f"ll2time staff thoracic physician or f"ll2time e8"ivalent by visiting thoracic
physicians
opport"nities for the trainee to ac8"ire broad clinical e<perience in respiratory
diseases as well as relevant aspects of imm"nology, epidemiology, pathology,
microbiology, and pharmacology
facilities for the performance of fibreoptic bronchoscopy, n"clear medicine st"dies,
thoracic s"rgery and ac"te respiratory intensive care, as well as relevant clinics in
thoracic oncology and imm"nology
a respiratory f"nction laboratory with facilities for spirometry and for
meas"rements of absol"te l"ng vol"mes, gas transfer, arterial blood gas tensions,
p"lmonary and respiratory m"scle mechanics, and the cardiop"lmonary response
to e<ercise
a facility for the investigation and management of respiratory sleep disorders
reg"lar clinical respiratory meetings designated for teaching and for cons"ltation
with related disciplines
library facilities with ready access to all maor respiratory o"rnals and te<ts, and to
literat"re search facilities s"ch as medicine.
S$eep med!c!ne
,efinition of speciality
Sleep medicine encompasses sleep breathing disorders, disorders of daytime
somnolence, insomnias, parasomnias, disorders of chronobiology, and the
ne"rological and psychiatric disorders affecting sleep. Sleep medicine is a cohesive
blend of6
clinical 3nowledge of sleep disorders
3nowledge of the basic sciences of normal and disordered sleep processes
e<perience with specialised diagnostic techni8"es, tests and proced"res employed
in clinical assessment
e<pertise in the management of all clinical sleep disorders.
2evels of training
!n addition to the comp"lsory three months of sleep medicine that m"st be
"nderta3en by all thoracic medicine trainees +detailed in the section on thoracic
medicine, there are a f"rther two levels of training in sleep medicine that lead to
8"alification to practise sleep medicine. These are6
0evel !6 11 months core training for thoracic medicine trainees, to enable them to
gain clinical practice in sleep medicine and to report sleep st"dies +this may
incl"de three months= training achieved d"ring the co"rse of a general thoracic
core year,
C1
0evel !!6 three years training +two core years pl"s an approved complementary
year, for advanced trainees to enable them to gain clinical practice mainly in sleep
medicine, and the opport"nity to direct a clinical sleep laboratory.
Advanced training programme in sleep medicine 2evel I
General principles
1. Completion of 0evel ! advanced training in sleep medicine 8"alifies thoracic
medicine trainees in sleep medicine +eg, manage sleep apnoea syndromes and
more comple< sleep2related breathing problems,, and for credentialing for
reporting sleep st"dies +as re8"ired by the Health !ns"rance Commission in
."stralia,. Twelve months of training in clinical sleep medicine is necessary.
1. This may be "nderta3en as an approved complementary year within the three
years of advanced training in thoracic medicine, altho"gh three months of the
11 months may be "nderta3en d"ring the two years of core training in clinical
thoracic medicine +as the mandatory three months of training in sleep
medicine,.
#. .lternatively the training may be "nderta3en as post2/R.C) s"pervised training
in sleep medicine.
5. !t may be "nderta3en in New Zealand, ."stralia or overseas.
$. .dvanced trainees from non2thoracic medical disciplines will generally not be
eligible to "nderta3e 0evel ! training.
;. S"ccessf"l completion of 0evel ! training will enable trainees to reach a
satisfactory of level of competence to report sleep st"dies.
#omponents of training
Core training
Clinical sleep medicine
M"ality training sho"ld incl"de a wide e<pos"re to all common sleep disorders
incl"ding sleep breathing disorders, disorders of daytime somnolence, and other non2
respiratory sleep disorders. Trainees will be e<pected to have a detailed practical
3nowledge of6
sleep physiology
the instr"mentation, recording, scoring techni8"es and interpretation of
polysomnographic st"dies.
They will need to obtain detailed e<perience and s3ill in the management of sleep
breathing disorders +incl"ding C).) and nasal ventilation,. They sho"ld also be
familiar with the diagnosis and management of non2respiratory sleep disorders. !t is
desirable that training sho"ld be "nderta3en in a m"ltidisciplinary sleep disorders
service.
C1
Procedural skills
7ssential proced"ral s3ills
/"ll polysomnography, AS0T, A'T, overnight o<imetry and transc"taneo"s C(
1

monitoring, C).) and nasal ventilation.
Other specific requirements
The trainee=s s"pervisor+s, will confirm in their written report+s, that a f"ll 11 months
of training has been spent in the clinical areas of sleep medicine o"tlined in the
programme of nine months, if three months are "nderta3en d"ring the two core years
of training in thoracic medicine.
. s"fficient n"mber of proced"res m"st be performed to allow the trainees to develop
competence in these proced"res. Competence will be assessed on the basis of the
written assessment by s"pervisors, and by interview to assess the trainee=s
e<perience and competence. . logboo3 of proced"res will be re8"ired to s"pport the
assessment of e<perience.
Training posts
See section "nder .dvanced Training )rogramme in Sleep Aedicine.
Advanced -raining Programme in "leep /edicine 2evel II
General principles
1. 0evel !! advanced training in sleep 8"alifies trainees to practise predominantly
or solely in sleep medicine.
1. Career training in sleep medicine consists of a str"ct"red three2year programme
with e<pectations from training different from those of trainees spending one
year in sleep medicine as part of their training in respiratory medicine +0evel !
training,. .dvanced training commences with the approval of a s"bmitted
programme. .t least two years= e<perience in clinical sleep medicine is
necessary. The third year of training may be spent in research or an approved
complementary year in a related discipline. .pproval of complementary training
will not be considered "ntil at least one year of core sleep training has been
completed.
#. /or thoracic medicine trainees who wish to gain d"al recognition +ie, 0evel !!
sleep pl"s thoracic medicine,, a minim"m of fo"r years of advanced training
wo"ld be re8"ired +two years of core training in each discipline,. !n this case,
the clinical sleep medicine component may precede of follow approved thoracic
advanced medical training.
5. .dvanced trainees from a non2thoracic bac3gro"nd +eg, ne"rology, who wish to
gain d"al recognition sho"ld prospectively see3 the advice of the specialist
advisory committee in thoracic and sleep medicine as to the s"itability of their
prior training as approved complementary training in sleep medicine.
Retrospective approval of non2relevant complementary training will not normally
be granted. /or non2thoracic sleep trainees "nderta3ing sleep medicine
advanced training, at least one year of their sleep training m"st involve
C#
s"bstantial e<perience in sleep breathing disorders and their commonly
associated respiratory diseases.
$. Trainees are enco"raged to become conversant with all diagnostic proced"res
available, with the c"rrent literat"re and with research activities in the sleep
field.
;. !t is desirable that training be "nderta3en at more than one instit"tion, and it is
envisaged hat this will be necessary for many trainees, to enable them to
ac8"ire a s"fficient breadth of e<pos"re and e<perience.
>. .dvanced trainees transferring to the specialist advisory committee in thoracic
and sleep medicine for sleep medicine training may be advised to "nderta3e
some post2/R.C) s"pervised training in sleep medicine to complete their
training programme.
?. Normally at least one year of advanced training sho"ld be "nderta3en in
."stralia and New Zealand.
C. S"ccessf"l completion of 0evel !! training will enable trainees to reach a
satisfactory level of e<perience and competence to report sleep st"dies and
direct a sleep laboratory.
#omponents of training
Core training
Clinical sleep medicine
M"ality training sho"ld incl"de a wide e<pos"re to all common sleep disorders
incl"ding sleep breathing disorders, disorders of daytime somnolence, insomnia,
parasomnias, disorders of chronobiology and psychiatric disorders affecting sleep.
Trainees will be e<pected to have a detailed practical 3nowledge of6
sleep physiology
the instr"mentation, recording, scoring techni8"es and interpretation for all
varieties of polysomnographic st"dies.
They will need to obtain detailed e<perience and s3ill in the management of sleep
breathing disorders +incl"ding C).) and nasal ventilation, and other non2respiratory
sleep disorders. They sho"ld also obtain e<perience in the diagnosis and
management of other respiratory, cardiovasc"lar and ne"rological disorders affecting
sleep.
'herever possible, training sho"ld be "nderta3en in a m"ltidisciplinary sleep
disorders service where interactions with other relevant disciplines are possible. .t
least one year m"st be spent in a service with a laboratory that has s"bstantial
e<pertise in sleep breathing disorders and their commonly associated respiratory
disorders.
/or non2thoracic trainees, there m"st be a core component of training in chronic
respiratory diseases +eg, chronic airflow limitation, respiratory fail"re,.
C5
*esirable options
!n addition to the core training in the fields of respiratory, cardiovasc"lar and
ne"rological disorders affecting sleep, it is recommended that some e<perience in
other s"bspecialty fields is obtained and these incl"de6 endocrinology, psychiatry,
7NT s"rgery and paediatrics.
Procedural skills
7ssential proced"ral s3ills
/"ll polysomnography +incl"ding a"diovis"al recordings,, AS0T, A'T, overnight
o<imetry and transc"taneo"s C(
1
monitoring, C).) and nasal ventilation.
*esirable +optional, proced"ral s3ills
!t is recommended that some e<perience be gained in one or more of the following
proced"res6
actigraphy
77B
respiratory f"nction testing
oesophageal pH monitoring
light therapy
penile t"mescence monitoring
endoscopic nasopharyngoscopy.
Complementary +elective, training
The specialist advisory committee in thoracic and sleep medicine may approve a
ma<im"m of one year of complementary +non2core, training which may be spent in
related clinical medicine, sleep research or in laboratory wor3. Clinical
complementary training will generally be restricted to related disciplines s"ch as
thoracic medicine, ne"rology, cardiology and endocrinology. .ny depart"re from this
wo"ld re8"ire e<ceptional circ"mstances for consideration.
.pproval for complementary training m"st normally be given by the specialist
advisory committee before commencement. The re8"irements for core training as
o"tlined "nder NCore Training= m"st be satisfied. Retrospective approval of
complementary training will not normally not be accepted, apart from trainees
see3ing d"al specialty recognition +see Beneral )rinciples,. Training in research will
be strongly enco"raged.
Projects or case reports
Trainees are e<pected to6
present +or to be principal a"thor of, at least one paper to a meeting of a national
or international society, for e<ample the Thoracic Society of ."stralia and New
Zealand +TS.NZ, or R.C)
prepare an article accepted for p"blication by a peer reviewed o"rnal. !n general,
single case reports will not satisfy this criterion.
C$
Other specific requirements
1. Trainees are e<pected to attend and ta3e part in at least one ann"al scientific
meeting of the ."stralasian Sleep .ssociation +or other relevant national or
international society, d"ring the three years of training.
1. . s"fficient n"mber of proced"res m"st be performed to allow the trainee to
develop competence in these proced"res. Competence will be assessed on the
basis of written assessment by s"pervisors, and by interview to assess the
trainee=s e<perience and competence. . logboo3 of proced"res will be re8"ired
to s"pport the assessment of e<perience.
Research
!t is strongly recommended that trainees "nderta3e a significant research proect
d"ring their training in order to "nderstand and apply appropriate research
methodologies in laboratory and clinical settings, and to be actively involved in
research activities incl"ding 8"ality ass"rance.
7<perience sho"ld be gained in6
st"dy design
literat"re research and review
writing s"bmissions for grants and ethics committee approval
data collection, storage and analysis
comp"ter program eval"ation for res"lts analysis, statistics and graphics.
The aim it to complete significant proect for presentation at a national meeting or for
p"blication.
Teaching
S"pervised e<perience in teaching for "ndergrad"ate, grad"ate, n"rsing and lay
a"dience gro"ps is desirable. Reg"lar presentation at hospital activities and
participation in peer gro"ps in e<pected.
Training posts
Centres at which programmes of advanced training in sleep medicine +0evel ! or !!,
are "nderta3en sho"ld have the following6
the e8"ivalent of a f"ll2time staff sleep physician of f"ll2time e8"ivalent by visiting
sleep physicians
opport"nity for the trainee to ac8"ire a broad clinical e<perience in sleep disorders
as well as relevant aspects of epidemiology, pathology and pharmacology
a sleep2disorders laboratory with facilities for f"ll polysomnography, AS0T, C).),
and nasal ventilation
reg"lar clinical sleep meetings designed for teaching and for cons"ltation with
related disciplines
library facilities with ready access to maor sleep o"rnals and te<ts, and to
literat"re search facilities s"ch as Aedline.
C;
!deally centres sho"ld have access to facilities for the performance of fibreoptic
endoscopy, ne"rophysiology st"dies, respiratory f"nction st"dies, 7NT s"rgery and
ac"te respiratory intensive care, as well as relevant clinics in psychiatry and
psychology. Training posts will generally be eval"ated at reg"lar intervals and may
be designated as s"itable for limited periods of training.
Recognition of adanced training programmes in thoracic and sleep medicine
There are a n"mber of pathways by which trainees may complete training in thoracic
medicine, sleep medicine or both. The confirmation of completion of training from the
R.C) will reflect the level of training achieved.
Combined thoracic and sleep medicine training
Two core years of thoracic medicine training and two core years of sleep training are
necessary to complete f"ll training in both disciplines. This wo"ld li3ely mean a year
of post2/R.C) training +after three years completed satisfactorily, eligible to be
recommended to fellowship,. The letter from the college at the end of the fo"r2year
training period will state that the fellow is a f"lly trained thoracic physician with
0evel !! training in sleep medicine.
Thoracic medicine training only
The letter from the college wo"ld reflect the fact that this trainee had completed
training as a thoracic physician, with or witho"t 0evel ! training in sleep medicine.
Sleep medicine training only
The fellow will be recommended to fellowship by the specialist advisory committee in
thoracic and sleep medicine, b"t not as a thoracic physician. The letter from the
college will ac3nowledge the training in 0evel !! sleep medicine.
Special societies
Thoracic Society of ."stralia and New Zealand +TS.NZ,
Trainees are enco"raged to oin the Society as associate members and to participate
in scientific meetings of the Society at both state and national levels.
/or f"rther information regarding the re8"irements for registration with the society,
please contact6
TS.NZ +New Zealand -ranch,
*r *enise .it3en
Honorary Secretary
TS.NZ +New Zealand -ranch,
C:2 Rotor"a Hospital
)rivate -ag
Rotor"a
72mail6 *enise..it3enXla3esdhb.govt.n9
C>
."stralasian Sleep .ssociation +.S.,
B)( -o< 1C$
Sydney NS' 1&5#
Tel6 &$&& $&& >&1
/a<6 &$&& $&& >&1
72mail6 mailto6sleepa"sXo9email.com.a"
Please note! .dvice relating to training re8"irements sho"ld be so"ght from the
specialist advisory committee thro"gh the college office.
C?
Append!D V8 Re#p!rtor" #tndrd#Ctr!n!n3 !n other #pec!$t" re#
)> Crd!ore#p!rtor" ph"#!otherp"
,efinition of speciality
Cardiorespiratory physiotherapy is a s"b speciality in which a so"nd 3nowledge of
respiratory physiology and pathology is integrated with physiotherape"tic intervention
based on assessment of the cardiorespiratory system and analysis of the effect of
change on cardiorespiratory mechanics, gas e<change, peripheral m"scle f"nction
and e<ercise tolerance. !nterventions address ventilatory dysf"nction, impaired
airway clearance and limitations to e<ercise and f"nctional performance.
$eneral principles of training
1. The general 8"alification of -Sc +physiotherapy, or -HSc +physiotherapy, from
(tago Dniversity or ."c3land Dniversity of Technology which incl"des
competency in cardiorespiratory physiotherapy.
1. There is no defined pathway to specialisation and c"rrently no post grad"ate
training co"rses. Specialisation is by e<periential learning commencing two
years after obtaining initial 8"alifications.
#. !t is most li3ely that the e<perience will be gained in a tertiary hospital wor3ing
with senior physiotherapists and respiratory physicians.
5. Training sho"ld incl"de6
respiratory physiology with application to physiotherape"tic techni8"es
interpretation of l"ng f"nction tests, 7CBs, CFRs and HRCT scans
e<ercise testing and prescription of e<ercise for pop"lations with cardiac or
ventilatory impairment
"se and interpretation of findings from a"sc"ltation of the chest with
stethoscope
indications for and application of non2invasive positive press"re ventilation
appropriate prescription of airway clearance techni8"es incl"ding a"togenic
drainage, )7), fl"tter device, sp"t"m ind"ction
assessment of 8"ality of life , impairment and disability
principles and practice of p"lmonary rehabilitation
assessment and management of disordered breathing
management of l"ng transplant and:or l"ng vol"me red"ction s"rgery
man"al techni8"es for thoracic dysf"nction
involvement in research.
,esirable options
)rogression to ASc:AHSc. Aasters level cardiorespiratory practice papers will be
available in 1&&1 at ."c3land Dniversity of Technology and (tago Dniversity.
CC
Aembership of the College of )hysiotherapy.
.ffiliated membership of TS.NZ.
/> The nur#e prct!t!oner nd the preprt!on of the re#p!rtor" nur#e
);0,);)
The ed"cation pathway for respiratory n"rses in New Zealand is "ndergoing a
significant transition. N"rses have traditionally wor3ed in respiratory medicine with
little or no formal postgrad"ate ed"cation and have relied solely on developing their
s3ills from Nhands on= practical e<perience. Respiratory n"rses have wor3ed in a
variety of capacities in primary, secondary and tertiary settings with varying
responsibilities incl"ding6 patient ed"cation, cons"ltancy and case management of
gro"ps of patients.
C"rrently "ndergrad"ate and post2grad"ate n"rsing ed"cation is available thro"gh
"niversities and technical instit"tes. The "ndergrad"ate n"rse "ndergoes a three
year programme, which incl"des some respiratory competencies, and now grad"ates
with a baccala"reate degree.
The academic instit"tions providing n"rsing ed"cation have been challenged to
develop a clinical post2grad"ate level ed"cation pathway for n"rses. . driving force
for this has been the recent legislation of the n"rse practitioner role. The N"rsing
Co"ncil of New Zealand has driven a process whereby the n"rse practitioner title:role
has been b"ilt into n"rsing legislation. There is a clear process of credentialing of the
n"rses and it is e<pected that they will manage patient care within a defined scope of
practice. The n"rse practitioner role is e<pected to contrib"te significantly to the
management of respiratory patients across all settings.
-%e nurse practitioner
JN"rse practitioners are registered n"rses with Aasters degrees and at least fo"r to
five years e<perience wor3ing in their chosen clinical area. The n"rse practitioner
m"st meet n"rsing co"ncil assessment criteria and competencies before the Co"ncil
will recognise them as n"rse practitionersK +NZNC, 1&&1,.
)rescribing
N"rse practitioner
+advanced practitioner,
7<perienced
practitioner
-eginning
practitioner
+new grad"ate,
1&&
N"rse practitioners are e<pert clinicians who incorporate advanced 3nowledge and
s3ills into their practice.
N"rse practitioners, as interdisciplinary team members may wor3 collaboratively or in
independent practice. They are a reso"rce to the team, and can be "sed as
cons"ltants with others referring to them. Regardless of their area of practice they
are a reso"rce to clients, cons"mers, patients, and whana". .s highly s3illed and
e<perienced practitioners they 3now when to refer their clients and patients to other
healthcare professionals +NZNC, 1&&1,.
1ducation pat%ways for nurses
C"rrently there are many different respiratory foc"sed co"rses available ranging in
length and academic val"e. Some are accredited. (ne e<ample is the .sthma
/"ndamentals )rogramme, which is, aimed at novice respiratory n"rses. This is a
two2day programme which has limited academic val"e b"t serves a defined p"rpose
and pop"lation gro"p.
The Dniversity of ."c3land has a postgrad"ate pathway that enables a n"rse to
progress from a postgrad"ate certificate, postgrad"ate diploma to a Aasters degree
+Aaster of N"rsing, with an advanced n"rsing foc"s. These 8"alifications are
clinically based and allow the st"dent to p"rs"e their specialty clinical foc"s for
e<ample respiratory n"rsing. The New Zealand N"rsing Co"ncil has accredited
these programmes.
The )ostBrad"ate Certificate +)B Cert, and *iploma in Health Science +)B *ip,
+.dvanced N"rsing,, are designed to give n"rses the core generic 3nowledge, s3ills
and competencies for advanced n"rsing in a specialist area. Sho"ld n"rses wish to
progress to advanced practice roles or the n"rse practitioner role they can achieve
the Aaster of N"rsing. . two2point respiratory speciality co"rse is offered as part of
the )B Cert.
)B Cert.
? points
+5 papers,
)B *ip.
15 points
+incl"ding a
specialist
practic"m,
Clinical
Aasters of
N"rsing
1? points
The learning o"tcomes of the respiratory specialty paper have been defined.
Respiratory n"rses will6
artic"late an advanced role for n"rses in the respiratory practice setting
apply an "nderstanding of pathophysiological processes of specific respiratory
disease states and the care of clients with comple< health care needs
demonstrate the management of clients with comple< and specific healthcare
needs incl"ding client learning and the development of client health care plans
1&1
demonstrate competency in respiratory client assessment s3ills
demonstrate competency in respiratory s3ills or the "se and management of
specialty based technology
analyse the impact of illness and health care e<perience on the client:family
eval"ate the ethical and legal parameters of c"rrent n"rsing practice.
The respiratory section of the New Zealand N"rses (rganisation is in the process of
defining standardised criteria, which will f"rther g"ide respiratory ed"cation for
n"rses in New Zealand. !t will provide a g"ide, for n"rses see3ing f"rther
8"alifications, as to the level of ed"cation being offered, whether it has been
accredited and by whom, and how it fits into the overall ed"cation framewor3.
Recommendations for this doc"ment are6
that nationally recognised programmes be available for all n"rses see3ing f"rther
3nowledge and s3ills in respiratory medicine
the programmes be accredited and offered from ed"cation instit"tions in the North
and So"th !slands.
Respiratory n"rses are closely aligned with respiratory physicians and can become
affiliated members of the TS.NZ. They will be e<pected to f"lfil e<ec"tive f"nctions
on the New Zealand branch of the TS.NZ and also on regional and national
respiratory advisory boards.
?> Rd!o$o3" #upport for re#p!rtor" #er-!ce#
2ocal
"maging serices
CFR, CT, fl"oroscopy, "ltraso"nd
Radiologist staff
Radiologist on call 15 ho"rs
Radiologist to complete CA7 g"idelines recommended by Royal ."stralian and
New Zealand College of Radiologists +R.NZCR,
Non2vasc"lar intervention to incl"de some biopsy, aspiration or drainage "nder
CT, D:S or fl"oroscopic control to a level determined by the local radiology staff.
,istrict
"maging serices
CFR, CT, fl"oroscopy, "ltraso"nd
Non2vasc"lar intervention to incl"de biopsy, aspiration or drainage "nder CT, D:S
or fl"oroscopic control.
1&1
Radiologist staff
!n addition to g"idelines for local services, there sho"ld be at least one radiologist
who has s"pport for the clinical respiratory service as a 3ey performance indicator.
Regional
"maging serices
CFR, CT, fl"oroscopy, "ltraso"nd, angiography, n"clear medicine, AR!.
Non2vasc"lar intervention to incl"de biopsy, aspiration or drainage "nder CT, D:S
or fl"oroscopic control. The degree of technical diffic"lty of referred cases may be
greater than that of the district services.
Gasc"lar intervention to incl"de p"lmonary angiography, bronchial embolisation,
veno"s stenting and !GC filter placement. )"lmonary arterial embolisation may be
offered depending on e<pertise.
Radiologist staff
Radiologists s"pporting regional respiratory services sho"ld be trained at a fellowship
level in respiratory radiology. They sho"ld be enco"raged to be members of TS.NZ.
Their clinical practice sho"ld involve providing the imaging services listed above and
in addition, they sho"ld s"pport reg"lar regional clinical, pathological, radiological
meetings where respiratory and related imaging topics are disc"ssed. These
radiologists sho"ld be 3nown to district level clinicians and radiologists and they
sho"ld be available to give written or verbal opinions on cases referred.
1> Propo#$ on the def!n!t!on of the #tructure of 3ener$ thorc!c #ur3er" !n
Ne% Ze$nd
I3 ,efinition of general t%oracic surgery ($-"!
Beneral thoracic s"rgery encompasses the fact"al 3nowledge, technical s3ill and
"dgement re8"ired to diagnose acc"rately and to manage s"rgically diseases of the
thora< +chest,. The 3nowledge base incl"des, b"t is not limited to, diseases of the
chest wall, ple"ra, l"ngs, trachea and bronchi, mediastin"m, diaphragm and
oesophag"s. Beneral thoracic s"rgery re8"ires in2depth 3nowledge of physiology,
diagnostic imaging, organ f"nction testing, semi2invasive and invasive investigation,
pre2operative eval"ation, post operative care, critical care, tra"ma, oncology and
transplantation.
Clinical competence
Competency in general thoracic s"rgery entails the contin"ed appropriate and s3illed
management of general thoracic s"rgical problems. This re8"ires an active caseload
of diseases of the thora< as detailed above and contin"ed interest in the practice of
general thoracic s"rgery as evidenced by attendance and participation in appropriate
speciality meetings and symposia. !nvolvement in research and ed"cation is
necessary wherever possible.
1&#
Thoracic s"rgeons are specially 8"alified to manage s"rgical complications that
involve the organ systems detailed above. They are also 8"alified to assist in the
management of p"lmonary, ple"ral, oesophageal, mediastin"m and chest wall
problems as well as tracheal problems that arise in the co"rse of patient
management by allied specialists.
Core competencies
Beneral thoracic s"rgery incl"des all 3inds of open or video2assisted s"rgical
proced"res in both children and ad"lts. These s"rgical proced"res incl"de6
1. operations involving resection, reconstr"ction, repair and biopsy of the l"ng
1. operations involving the chest wall and ple"ra, incl"ding resection and
reconstr"ction of the chest wall for neoplasms, ple"rectomy, decortication,
drainage and resection of empyema, thoracoplasty and repair of pect"s
e<cavat"s and pect"s carinat"m and other chest wall deformities, as well as the
management of tra"matic chest wall instability
#. operations involving resection, reconstr"ction, and repair of the trachea and
bronchi for neoplasms, strict"res and tra"ma
5. operations involving resection, reconstr"ction, and repair of the oesophag"s,
incl"ding laparoscopic or thoracoscopic techni8"es and endol"minal
proced"res
$. operations involving resection, reconstr"ction, and repair of the diaphragm
;. operations involving the mediastin"m, incl"ding biopsy and resection of
neoplasms, drainage of infections, mediastinal lymphadenectomy,
mediastinotomy and mediastinoscopy
>. operations of the pericardi"m involving resection, reconstr"ction and drainage
?. endoscopic proced"res "sing both the fle<ible and rigid scopes and
instr"mentation of the tracheobronchial tree and oesophag"s
C. operations of biopsy of mediastinal and lymph nodes
1&. operations on the thoracic sympathetic nerves
11. operations to correct abnormalities of the thoracic o"tlet:chest wall
11. operations necessary for airway control incl"ding tracheostomy, tracheal
int"bation and endol"minal proced"res
1#. operations for management of ple"ral space problems, incl"ding thoracentesis,
t"be thoracostomy, and sh"nting for ple"ral eff"sion and management of
pne"mothora<
15. operations to provide e<pos"re for thoracic spine s"rgery
1$. all operations incidental to the performance of the above operative proced"res
1;. critical care management and proced"res incl"ding placement of central veno"s
lines, Swan2Ban9 catheters, arterial lines, ventilator management, and total
enteral and parenteral n"trition management
1&5
1>. operations for tra"matic in"ries to the chest or to organs within the chest and
their se8"elae
1?. operations on vasc"lar str"ct"res related to the management of any pathology
treated within the field of BTS.
!n maor tertiary centres6
1C. operations for f"nctional corrections of emphysema
1&. operations involving transplantation of one or two l"ngs or lobes, incl"ding all
diagnostic or therape"tic proced"res related to the field.
II3 "tructure of a general t%oracic surgical unit
To ens"re 8"ality patient care within the field of BTS and to promote contin"o"s
development of the speciality itself, BTS needs to be performed within the logistical
and economical framewor3 of specialised "nits. The str"ct"re of these "nits sho"ld
be designed to allow6
1. patient care at the level of accepted international standards
1. ed"cation and training of s"rgical trainees in the field of BTS according to
accepted standards
#. contin"o"s clinical and e<perimental research in the field of BTS.
To meet these demands and to become accepted as a "nit specialised in BTS a
certain organisational bac3gro"nd and a n"mber of minim"m re8"irements depending
on the individ"al level of standard or e<cellence are tho"ght to be necessary.
"nstitutional status
BTS "nits of standard can either be completely free2standing or within the
combination with cardiac, vasc"lar, general s"rgery. The "nit sho"ld be headed
preferentially by an ."stralasian recognised fellowship.
Recommended
1. Str"ct"ral reso"rces
. general thoracic s"rgery "nit sho"ld have access to !CD.
Beneral thoracic s"rgery patients sho"ld be on a general thoracic s"rgery
dedicated s"rgical ward or ward with general thoracic s"rgery e<perience. (ne
wo"nd treatment room sho"ld be available on every ward. There sho"ld be
facilities for o"tpatient visits at a rate of one room per >$& visits per year. Beneral
thoracic s"rgery "nits need own in2ho"se facilities for thoracic diagnosis. This
incl"des a laboratory for bronchoscopies and oesophagoscopies, a laboratory for
respiratory pathophysiology and in specialised centres one for oesophageal
pathophysiology. There m"st be access to <2ray, CT scan, laboratory medicine
and clinical pathology. )referably access to n"clear medicine and )7T scan
sho"ld be given.
Beneral thoracic s"rgery "nits need 8"alified physiotherapists.
Beneral thoracic s"rgery "nits sho"ld have affiliated endoscopy.
1&$
1. Staff reso"rces
Beneral thoracic s"rgery "nits sho"ld have a minim"m of two s"rgeons with
recognised ."stralasian /ellowship or e8"ivalent with a"dit and peer review per
$& maor thoracic proced"res per year. Cond"ct ongoing or a"dit consistent with
national standards.
#. )roced"ral g"idelines
1. The n"mber of maor thoracic proced"res per year sho"ld be more than $& in
standard centres and more than 1&& in centres of e<cellence.
1. (esophageal resections sho"ld be performed only in "nits with special interest.
#. 0"ng transplantation sho"ld be performed only at Breen 0ane Hospital.
5. 0GRS along with maor tracheal resection sho"ld only be "nderta3en at "nits
with training in the area and whereby post operative mortality rates can be
maintained at Q 1& percent.
#uality sureillance
M"ality s"rveillance has to be performed in every general thoracic s"rgery "nit.
There ideally sho"ld be doc"mentation of all proced"res performed together with a
doc"mentation of all maor adverse events. Res"lts sho"ld be analysed on a reg"lar
basis and recorded to all s"rgeons. There sho"ld be a recognised and generally
accepted system for ris3 stratification. Complications sho"ld be disc"ssed reg"larly
and a feedbac3 of ris3 stratified individ"al res"lts sho"ld be given to every s"rgeon.
)roced"re specific mortality standards % op mortality:morbidity for lobectomy:
pne"monectomy ple"rodesis, oesophageal resection, 0GRS, one year s"rvival for
l"ng transplantation sho"ld be in the official range given by the 7"ropean Registry
+please specify what the rates are when ! reviewed o"r res"lts for 1C?#%?C at B0H
post op mortality for lobectomy was 1.> percent and pne"monectomy # percent.
)resently +nSC, no post op deaths for 0GRS.
Beneral thoracic s"rgery "nits of e<cellence sho"ld provide the possibility for
advanced postgrad"ate ed"cation for general thoracic s"rgery s"rgeons.
Centres of e<cellence m"st have access to animal laboratories and to basic science
laboratories.
1&;
Append!D VI8 'roncho#cop" #er-!ce#
B"idelines for the6
training of bronchoscopists7rror6 Reference so"rce not fo"nd
,1$1
maintenance of competency of7rror6 Reference so"rce not fo"nd
bronchoscopists, and
bronchofibroscopy services,
have been prod"ced and recently "pdated by the Thoracic Society of ."stralia and
New Zealand +TS.NZ, +New Zealand branch,.7rror6 Reference so"rce not fo"nd
.dditional pertinent doc"ments incl"de6
TS.NZ position paper, Sedation for $ronchoscopy +1CC$,
1$#
TS.NZ position paper, %"DS and the Thoracic Physician +1CC$,7rror6 Reference
so"rce not fo"nd
TS.NZ position paper, %danced Training Programme in Respiratory &edicine
+1CC$,7rror6 Reference so"rce not fo"nd
bronchoscopy services +incl"ding transbronchial biopsy and -.0 techni8"es,
sho"ld be available at all s"bregional hospitals +serving a pop"lation of
O 1&&,&&&,. !mplicit in this is the availability of appropriately trained
bronchoscopist and provision of s"itable facilities +as o"tlined earlier,. There m"st
be appropriate diagnostic microbiology +as s"pport for -.0 in the imm"no2
compromised host +not "st .!*S,,.
Aore comple< techni8"es incl"ding removal of diffic"lt foreign bodies, transtracheal
+transbronchial, aspiration and rigid bronchoscopy wo"ld be available only at the five
regional centres.
There sho"ld be a single national centre for highly specialised techni8"es s"ch as
endobronchial laser, placement of stents, and brachytherapy +.ppendi< G!!!,.
Bu$!t" ##urnce
M"ality ass"rance sho"ld be an integral part of s"ch a service and relevant
meas"res wo"ld incl"de6
proced"ral morbidity:complications and mortality
diagnostic rate +"nder different b"t clearly designated circ"mstances,
obtaining ade8"ate tiss"e at transbronchial biopsy
tolerance and acceptability of the proced"re.
This sho"ld be "nderta3en in con"nction with 8"ality ass"rance meas"res of
s"pporting services, for e<ample6
radiology
histopathology
cytology
microbiology.
1&>
1&?
Append!D VII8 L#er, #tent!n3 nd 4rch"therp"
Num4er#
-ased on local and DI e<perience appro<imately #&%5& patients per ann"m are
s"itable for laser endobronchial s"rgery and $%1& for endobronchial stenting in New
Zealand.7rror6 Reference so"rce not fo"nd Breen 0ane Hospital has a Ng 4ag laser
and operators e<perienced with its "se, and e8"ipment for endobronchial stenting.
6u!de$!ne# for reAreferr$
43 2aser
)atients with intrinsic endobronchial t"mo"r +benign or malignant, or hemoptysis with
vis"alised bleeding site or benign tracheal webs.
3 "tenting
)atients with benign or malignant airway stenosis or torsion, or severe tracheo2
bronchomalacia.
Nt!on$ -# re3!on$
The small n"mbers "stify only one national centre in order to maintain e<pertise and
this has already been established at Breen 0ane Hospital. !deally laser and stenting
sho"ld be performed in a hospital with thoracic and (R0 s"rgical services. !n New
Zealand this hospital sho"ld also be the same as that performing l"ng
transplantation, so that anastomotic stenoses can be treated. . close association
with a radiotherapy department preferably with brachytherapy is also essential.
-rachytherapy has the potential to be administered in a single treatment and is as
effective as more e<pensive e<ternal beam irradiation in palliating an array of
respiratory symptoms ca"sed by bronchial carcinomas. This needs to be given a
high priority for development in ."c3land.
Bu$!t" ##urnce me#ure#
1. (perator training and contin"ing ed"cation is mandatory for all proced"res.
C"rrently this can only be performed in other co"ntries.
1. Aaintenance of e8"ipment sho"ld be reg"lar and the theatre sho"ld comply
with ."stralian National Standards for laser safety.
1$5
#. . hospital laser safety committee sho"ld e<ist. . complete record of all
proced"res be 3ept, recording all o"tcomes, incl"ding complications.
1&C
Append!D VIII8 Re#p!rtor" funct!on ##e##ment
(bective f"nctional assessment of the respiratory system is an essential component
of Respiratory medicine. Girt"ally all patients with respiratory symptoms which last
for more than a few wee3s or which rec"r sho"ld have at least r"dimentary
eval"ation of p"lmonary f"nction +this incl"des children and ad"lts,. The indications
for p"lmonary f"nction tests incl"de6
assistance in establishing a diagnosis
obective assessment of severity 6 baseline from which to meas"re change or
assessment of disability
fitness assessment6 for compensation, prior to s"rgery, flying or diving
determine treatment or treatment response, for e<ample need for p"lmonary
rehabilitation, o<ygen or response to steroids.
The need for p"lmonary f"nction assessments is growing and will contin"e to grow in
New ZealandE prevalence of most respiratory diseases are increasing and there is a
need for occ"pational and compensation related assessment. There is a strong
feeling that c"rrent facilities are not meeting the need and that even where service is
provided 8"ality may be s"boptimal. 'ith the emphasis on epidemiological and
biochemical aspects of respiratory medicine in the 1C>&s and 1C?&s many
respiratory services have allowed their physiological sections to decline. This trend
needs to be reversed.
Recommendt!on#
These are based on a position paper of the TS.NZ g"idelines for respiratory f"nction
laboratories.7rror6 Reference so"rce not fo"nd
Accreditation of respiratory function assessment services
1. /ive regional respiratory centres in New Zealand sho"ld have respiratory
laboratories capable of comprehensive p"lmonary f"nction testing s"ch as
TS.NZ. .t least category three standard assessment of respiratory f"nction
incl"ding meas"rement of static l"ng vol"mes +T0C, RG, /RC and GC,E
ma<im"m e<piratory flow rates before and after bronchodilator +ma<im"m
e<piratory flow vol"me c"rvesE carbon mono<ide gas transferE and ma<im"m
respiratory press"res meas"red at the mo"thE arterial blood gas analysis,
pharmacological and non2pharmalogical bronchial provocation tests and
cardiop"lmonary e<ercise tests,. 0aboratory staff sho"ld have special training
in p"lmonary f"nction testing in children. .ll five centres sho"ld see3 TS.NZ
accreditation. Senior staff sho"ld be certified with the CR/S credential.
1. .t Ndistrict= level category two testing sho"ld be available that is all of the above
e<cept bronchial provocation and e<ercise testing.
#. .t Nlocal= level spirometry, flow vol"me loop and p"lse o<imetry sho"ld be
available. B) practices sho"ld have ability to meas"re pea3 e<piratory flow
rate and spirometry, and have access to p"lse o<imetry.
11&
7ach regional centre sho"ld be responsible for standards of p"lmonary f"nction
testing and interpretation reporting in their region, that is arrange a"dit systems for
the district and local testing within their region.
1$$
These standards apply to both the
laboratory and its director and are defined within the TS.NZ g"idelines.7rror6
Reference so"rce not fo"nd
. system for ongoing monitoring of 8"ality of a national basis wo"ld be desirable.
The medical directors of the regional p"lmonary f"nction laboratories +and the senior
respiratory scientists, sho"ld meet ann"ally. They sho"ld establish themselves as a
gro"p to report on contentio"s tests for bodies s"ch as the .CC or for medicolegal
p"rposes.
111
Append!D II8 Lun3 trn#p$ntt!on
Single and bilateral se8"ential l"ng transplants are available in New Zealand at
Breen 0ane Hospital. The n"mber of transplants are limited by donor availability.
The availability of donor organs in New Zealand is 1& per million per year b"t as only
1$%1$ percent are s"itable for l"ng transplantation this translates into only 1&%11
transplants:year. .s s"ch there can be only one National Centre, to maintain
e<pertise. S"ccess rates sho"ld be e8"ivalent to top overseas centres. .ltho"gh
depending to an e<tent on patient selection, if one year s"rvival sho"ld fall to less
than >$ percent the programme sho"ld be reviewed.
To date $5 l"ng transplants have been performed and the one year s"rvival rate is
?$ percent and which is above the international average +>? percent,. Heart2l"ng
transplants are only re8"ired in patients with poor right ventric"lar f"nction or
irreparable congenital cardiac defects and sho"ld not e<ceed $ percent of all patients
considered for l"ng transplantation. S"ch patients sho"ld receive their s"rgery in
."stralia since the operation techni8"e is different to that of l"ng transplantation.
Cr!ter! for cceptnce for $un3 trn#p$ntt!on
!ndications for l"ng transplantation7rror6 Reference so"rce not fo"nd incl"de patients
with end stage l"ng disease with an anticipated poor prognosis and symptoms that
are severe and progressive despite optimal medical treatment.
These patients sho"ld, e<cept for their l"ng disease, be healthy individ"als with
strong family s"pport. They sho"ld be able to comply with medical advice and be
3een to proceed with transplantation. )atients aged over $& years or "nder 1$ years
will be considered only in e<ceptional circ"mstances. (wing to "nsatisfactory
o"tcome worldwide, patients over ;& have not been considered for the programme.
The following factors are contra2indications to consideration of l"ng transplantation6
Systemic diseases +s"ch as l"p"s etc,6 )eripheral vasc"lar disease, chronic f"ngal
l"ng infections, ins"lin dependant diabetes are ischaemic heart disease are
relative contra2indications. Aoderately severe or severe coronary artery disease
not amenable to angioplasty or with left ventric"lar eection fractions below
5$ percent is an absol"te contraindication as is diabetes with end organ damage.
Dnresolved p"lmonary infection6 !nfections e<hibiting panresistance to antibiotics
are an absol"te contra2indication, those e<hibiting m"lti2dr"g resistance a relative
contra2indication.
Renal or hepatic fail"re6 Dnless mild and secondary to right heart fail"re.
(besity:severe maln"trition6 -A! 1&%1$ ideal.
History of severe or contin"ing mental illness and or alcohol or dr"g ab"se6
)atients sho"ld have stopped smo3ing for at least two years.
!mmobility6 )atients m"st be able to wal3 $& metres "nassisted, with o<ygen as
re8"ired.
111
Contin"o"s steroid therapy6 . relative contra2indication if prednisone therapy
Q >.$ mg average dose in previo"s yearE O >.$ mg partic"larly if associated with
side2effects of therapy is a definite contra2indication.
Aalignancy6 7vidence of complete remission for five years prior to referral is
essential, b"t remains a relative contra2indication depending on the type of
t"mo"r.
Cr!ter! for $un3 trn#p$ntt!on !n pt!ent# %!th c"#t!c f!4ro#!#
Inclusion criteria
/7G
1
Q #& percent predicted.
Respiratory disease maor determinant of c"rrent morbidity.
.bsence of absol"te e<cl"sion criteria.
Absolute e5clusion criteria
-iliary cirrhosis complicated by portal hypertension +as evidenced by *oppler
portal vein flow, oesophageal varices, massive splenomegaly, or previo"s episode
encephalopathy.
A"lti2dr"gL resistant bacterial infection +eg, -"r3holderia cepacia, gladioli or other
pse"domonas species resistant to fo"r or more !G antibiotics on two or more
occasions incl"ding ARS.,.
.spergilloma.
!ns"lin dependent diabetes mellit"s with evidence of Nend organ= damage +eg,
retinopathy, protein"ria,.
N-6 Beneral contraindications for l"ng transplantation apply.
Relative e5clusion criteria
Severe n"tritional impairment, for e<ample -A! less than 1>.
Dnstable ins"lin dependent diabetes mellit"s.
Reg"lar oral corticosteroid therapy greater than >.$ mg per day for O ; months in
last two years.
Coag"lopathy.
)revio"s ple"rodesis or thoracic or mediastinal s"rgery +"nless ple"rodesis is
limited and performed thro"gh thoracoscope,.
Severe malabsorption "nable to be corrected by pancreatic s"pplements +inability
to maintain cyclosporin levels,.
C"rrent .-). as evidenced by persisting f"ngal hyphae in sp"ta, typical CFR
infiltrates and positive serology.
Colonisation with .spergill"s species.
11#
Append!D I8 Lun3 -o$ume reduct!on #ur3er"
Introduct!on
.irflow limitation in C()* is d"e to varying combinations of airways disease and
emphysema. Aaor pathophysiological conse8"ences of emphysema can be
attrib"ted to a loss of elastic recoil, and consist of static and dynamic hyperinflation
as well as a preferential obstr"ction of e<piratory airflow d"e to a loss of traction on
the airways and increased wor3 of breathing.
The main symptom of patients with very advanced emphysema is dyspnoea which
may be contrib"ted to by impaired p"lmonary mechanics. The only treatment proven
to red"ce the rapid decline in /7G
1
is smo3ing cessation, and the sole treatment
proven to prolong life is long2term o<ygen therapy. !nhaled bronchodilators can
ameliorate symptoms and improve 8"ality of life b"t have little effect on l"ng f"nction
tests. )"lmonary rehabilitation does N(T improve l"ng f"nction, b"t can improve
e<ercise performance, 8"ality of life, and red"ce morbidity. 0"ng transplantation and
l"ng vol"me red"ction s"rgery +0GRS,
1$;
have gained acceptance as palliative
proced"res for a s"bgro"p of patients with advanced emphysema.
The criteria for selection of patients for 0GRS are c"rrently being investigated. The
goals of 0GRS are6
an improvement of the l"ng elastic recoil to enhance radial traction on the airways,
th"s lowering airway resistance and increasing driving force for ma<imal e<piratory
flow
a red"ction in p"lmonary hyperinflation, with a more physiological diaphragmatic
config"ration for generating inspiratory force and red"ced wor3 of breathing.
To date 1& patients have proceeded to 0GRS at Breen 0ane Hospital. There have
been no post operative deaths and mainly good o"tcomes in highly selected patients
aged less than >&. 'hilst overseas data s"ggest better res"lts are obtained in
centres also "nderta3ing transplantation, if centres o"tside ."c3land perform 0GRS it
sho"ld be mandatory that data be forwarded to the ."stralasian 0GRS
database.7rror6 Reference so"rce not fo"nd
Pt!ent e-$ut!on nd #e$ect!on &note recent$" mod!f!ed !n TSANZ po#!t!on
pper %h!ch ccompn!e# th!# 3u!de$!ne(
Inclusion criteria
.ge Q >& years +less than ?& years if health otherwise e<cellent,.
7mphysema confirmed on HRCT.
No evidence of ischaemic heart disease +angiogram needed prior to s"rgery,.
*yspnoea at rest, or with minimal activity res"lting in severe limitation of daily
activity with impaired 8"ality of life +si<2min"te wal3 test 1$&%#$& metres,.
Completed a rehabilitation programme and be shown to comply with programme.
115
Severe airflow obstr"ction +/7G
1
Q #$ percent predicted,.
No significant improvement with bronchodilators +Q 1$ percent improvement in
/7G1 with neb"lised bronchodilator,, 1& mg prednisone for three wee3s.
/"nctional aspects of emphysema +ie, RG O 1&& percent predicted, T0C
O 15& percent predicted, impaired *0C( +b"t O #& percent predicted,,
red"ced perf"sion to maor b"llae on 8"antitative G:M scan.
15clusion criteria
Smo3ing within two years of consideration of 0GRS.
NGanishing l"ng= on CT +namely independent of b"llae, little or no evidence of
normal f"nctioning l"ng,.
Coronary artery disease O $& percent diameter red"ction of more than one
coronary artery.
Neoplastic disease with life e<pectancy of Q 1 years.
(ther important medical problems +eg, renal fail"re, severe steroid2ind"ced
osteoporosisE )H CG.,
)rednisone O >.$ mg:day for O # months.
-ronchiectasis +cylindrical as opposed to traction,.
.spergillosis +aspergilloma,.
Colonisation of airways with m"lti2dr"g resistant organisms.
)rior ple"rodesis % "nless limited thoracoscopic +relative,.
Cor p"lmonale +right ventric"lar eection f"nction Q #& percent, determined by
gated n"clear scan, or good 8"ality 1* echo,.
Chronic prod"ctive co"gh of O 1 tablespoon per day.
d0C( Q #& percent predicted.
Hypercapnoea O >.# 3)a +$& mmHg,.
.ddiction to alcohol, dr"gs, psychiatric dist"rbance, non2compliance with dr"g
regimens +or rehabilitation,
-A! Q 1> +"nresponsive to )"lmocare:7ns"re )l"s,, or -A! O 1$.
A po#!t!on #ttement of the Thorc!c Soc!et" of Au#tr$! nd Ne% Ze$nd
B! Snell *epartment of Respiratory Aedicine, .lfred Hospital, Aelbo"rne,
Gictoria
A )eacoc3 *epartment of Thoracic S"rgery, M"een 7li9abeth Hospital,
.delaide, So"th ."stralia
H Barrett *epartment of Respiratory Aedicine, Breen 0ane Hospital, ."c3land,
New Zealand
)"blished in "nternal &edicine 'ournal 1&&1E #16111%11$. This doc"ment will be
reviewed in 1&&; or earlier if significant developments occ"r.
11$
http6::www.thoracic.org.a":lvrsposition1Cnov1&&&.pdf
Abstract
0"ng vol"me red"ction s"rgery involves the removal of emphysemato"s l"ng tiss"e
with the aim of palliating symptoms in selected patients with severe emphysema.
This form of s"rgery is being practised in ."stralia with favo"rable short2term
o"tcomes, similar to those reported in the literat"re. 0arge m"lticentre trials are
c"rrently "nderway in North .merica and the Dnited Iingdom to clarify iss"es of
safety and long2term efficacy. .s a res"lt, it is to early to apply an evidence2based
approach to this proced"re. !n the meantime, local a"dits of practice need to be
"nderta3en to define patient s"bgro"ps at higher ris3 of morbidity and mortality
+"ntern &ed ' 1&&1E #16 111%11$,.
Ieywords6 emphysema, l"ng red"ction s"rgery.
Correspondence to6
*r B ! Snell
*epartment of Respiratory Aedicine
.lfred Hospital
)rahran G!C #1?1
7mail6 g.snellXalfred.org.a"
Overview
0"ng vol"me red"ction s"rgery +0GRS, is a general term encompassing a variety of
s"rgical proced"res that involve resection of l"ng tiss"e with the aim of red"cing
symptoms in patients with severe emphysema.
The first series of patients treated with p"lmonary resection for emphysema was
reported by -rantigan et al in 1C$>.
1$>
He post"lated that removal of the most
diseased l"ng tiss"e wo"ld increase radial traction on small airways, reversing the
collapsibility that had ca"sed airflow obstr"ction and normalising diaphragm and
chest wall respiratory mechanics. The postoperative mortality rate was 1? percent
and the patient=s s"bective benefits were not confirmed obectively. Conse8"ently,
the proced"re was not widely accepted.
!n 1CC$, following observations made in l"ng transplant s"rgery and ta3ing
advantage of developments in anaesthesia and postoperative care, Cooper et al
revitalised the concept of s"rgical treatment of non2b"llo"s emphysema "tilising a
linear stapler reinforced with bovine pericardial strips to avoid e<cessive air lea3s.
1$?

Gigoro"s e<cl"sion criteria were applied and a peri2operative rehabilitation
programme was incl"ded to optimise fitness. His first 1& patients had a s"rprisingly
large improvement in forced e<piratory vol"me in +/7G
1
, of ?1 percent and no
mortality.
(ther centres have s"bse8"ently p"blished their res"lts "sing a variety of s"rgical
techni8"es.
1$C
These st"dies confirm the improvement in /7G
1
and patient 8"ality of
life +M(0, noted by Cooper et al.7rror6 Reference so"rce not fo"nd
11;
.ltho"gh Cooper advised ca"tion and s"ggested 0GRS be restricted to specialised
centres initially, early s"ccess led to a rapid rise in the n"mber of operations
performed at m"ltiple sites across the DS.. !t has since become clear that 0GRS
can be complicated by serio"s morbidity and mortality.7rror6 Reference so"rce not
fo"nd . review of Aedicare +DS., billing in 1CC$ noted a mortality rate of
1; percent.
1;&
.s a res"lt, Aedicare +DS., f"nding was withdrawn for 0GRS in 1CC;
and a large National Heart, 0"ng and -lood !nstit"te m"lticentre randomised trial was
proposed to compare 0GRS with best practice.7rror6 Reference so"rce not fo"nd
,1;1

This seven2year trial has now commenced
1;1
and other large national trials are
"nderway in Canada
1;#
and the Dnited Iingdom. Three st"dies, incl"ding two short2
term small randomised st"dies, have been recently reported comparing 0GRS and
medical therapy.
1;5,1;$,1;;
.ltho"gh not "niform in their analyses or res"lts, these
three st"dies tend to favo"r improvements in meas"res of p"lmonary f"nction and
M(0 in the 0GRS gro"p.
-y the end of 1&&&, 0GRS will have been performed on over 5&& patients in more
than 1$ ."stralian centres from all mainland states.
1;>,1;?,1;C
. National 0"ng Gol"me
Red"ction S"rgery *atabase has been established, in con"nction with the Royal
."stralasian College of S"rgeons= ."stralian Safety and 7fficacy Register of New
lnterventional )roced"res % S"rgical +.S7RN!)2S,, and analysis will help to define
selection criteria, o"tcomes and reso"rce allocation.7rror6 Reference so"rce not
fo"nd
,1>&
To avoid a repeat of the e<perience in the DS., the ."stralian medical profession
needs to review contin"ally local res"lts, follow closely the evolving literat"re and, if
necessary, set minimal ."stralian standards of medical care and technical
e<cellence. This position statement, and the recent .S7RN!)2S 0GRS Review,7rror6
Reference so"rce not fo"nd
,1>1
reflect a commitment to that process.
/ec%anisms of improvement in respiratory symptoms wit% 26R"
.n enhanced "nderstanding of the pathophysiological mechanisms altered thro"gh
0GRS has m"ch to tell "s abo"t l"ng diseases in general. Recent st"dies tend to
confirm -rantigan=s hypotheses.7rror6 Reference so"rce not fo"nd Sci"rba et al
have confirmed an improvement in elastic recoil following 0GRS
1>1
and others have
shown an improvement in respiratory m"scle performances.7rror6 Reference so"rce
not fo"nd
,7rror6 Reference so"rce not fo"nd
The proced"re may also act by improving
ventilation:perf"sion matching, decreasing the effects of dynamic hyperinflation on
the veno"s circ"lation or even by improving cardiac o"tp"t.7rror6 Reference so"rce
not fo"nd
,7rror6 Reference so"rce not fo"nd
6ariations in 26R" tec%ni.ue
Benerally, 0GRS programmes advocate a p"lmonary rehabilitation programme
preoperatively. )"rported benefits incl"de the optimisation of physical condition and
the opport"nity for patient ed"cation. .ltho"gh the limited evidence available
s"ggests that 0GRS is complementary to p"lmonary rehabilitation alone,7rror6
Reference so"rce not fo"nd
,1>#
patients may derive s"fficient benefit from the
p"lmonary rehabilitation to forgo or defer s"rgery.
11>
*ifferent s"rgical approaches to 0GRS have been "sed. There is general agreement
that ma<imal benefits obtained by operating on both l"ngs sim"ltaneo"sly "sing
some form of reinforced e<cision2stapling techni8"e.7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd
!nitial e<perience revealed that the "nilateral operation
afforded half the improvement, with the same ris3 of early mortality and an increased
ris3 of late mortality,7rror6 Reference so"rce not fo"nd b"t recent st"dies have fo"nd
no difference in s"rvival o"tcomes between the proced"res.
1>5
Reinforcement
material is e<pensive and its val"e in red"cing air lea3s has still to be determined.
There seems to be no significant difference in clinical o"tcomes "sing midline
sternotomy, bilateral thoracotomy or thoracoscopic techni8"es.7rror6 Reference
so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd
(perator e<perience with any given approach
appears to be the most important factor.
The limited ."stralian e<perience so far reveals that most "nits are performing
bilateral 0GRS "sing a stapling techni8"e.7rror6 Reference so"rce not fo"nd (pen
and thoracoscopic7rror6 Reference so"rce not fo"nd techni8"es are practised
e8"ally.7rror6 Reference so"rce not fo"nd
15pected outcomes of 26R"
-ased on res"lts reported in peer2reviewed o"rnals, abstracts and presentations at
international meetings, the proced"re appears efficacio"s for some, b"t not all,
patients with advanced chronic obstr"ctive p"lmonary disease d"e to
emphysema.7rror6 Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not
fo"nd
)erioperative mortality sho"ld vary between five and 1$ percent, depending on case
selection and centre e<pertise. Ca"ses of morbidity incl"de respiratory fail"re,
sepsis, persistent intercostal catheter drainage, late pne"mothora<, atrial
dysrhythmias and myocardial infarction.7rror6 Reference so"rce not fo"nd
%7rror6 Reference
so"rce not fo"nd
!n a recent large series, mortality approached #& percent at three years
post2proced"re.7rror6 Reference so"rce not fo"nd
Two to si< months following bilateral 0GRS, an improvement in /7G, and the si<2
min"te wal3 test of appro<imately $& percent can be shown.7rror6 Reference so"rce
not fo"nd )atient2reported dyspnoea, e<ercise tolerance and M(0 improve similarly.
The pea3 improvement in /7G1, is noted after si< months, with a variable decline
bac3 to baseline over the ne<t two to fo"r years.
1>$,1>;,1>>
. small proportion of
patients fail to improve l"ng f"nction significantly.7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd
"election and assessment of 26R" candidates
Candidate selection will determine clinical and f"nctional o"tcomes. .ltho"gh trials
have not been performed to compare different selection criteria, the literat"re allows
some broad generalisations +see Table 1,.7rror6 Reference so"rce not fo"nd
,7rror6
Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd
Certain preoperative variables, incl"ding a si<2
min"te wal3 of less than 1&& m, )C(
1
greater than $$ mmHg, gas transfer factor
+*0C(, less than #& percent predicted7rror6 Reference so"rce not fo"nd or
p"lmonary arterial hypertension, have been shown to portend a higher perioperative
ris3 of morbidity and mortality. .dvanced age +beyond >$ years,, left ventric"lar
11?
impairment or significant coronary artery disease are also li3ely to define patients at
higher ris3.7rror6 Reference so"rce not fo"nd
,1>?
Heterogeneo"s disease on n"clear ventilation perf"sion scanning and chest
comp"ted tomography +CT, with clear2c"t s"rgical Ntarget areas= at the apices or
bases of the l"ngs, in the presence of gross hyperinflation, is associated with the
greatest improvement in /7G, and symptom score.
1>C
!n other words, the best res"lts
are seen in hyper2inflated patients, with some well2preserved areas of l"ng and well
defined destroyed emphysemato"s target areas. The role of 0GRS in the treatment
of patients with alpha2l2 antitrypsin deficiency, "niformly diff"se emphysema or in
patients witho"t significant hyperinflation is controversial.7rror6 Reference so"rce not
fo"nd !t is not 3nown which factors best predict the d"ration of improvement.7rror6
Reference so"rce not fo"nd
.ssessment needs to incl"de caref"l medical review of a potential candidate.
C"rrently, the maority of patients referred do not meet selection criteria +see Table 1,
and are reected. The patient clearly needs to have a primary diagnosis of severe
airflow obstr"ction secondary to emphysema. The e<tent and nat"re of the disease
needs to be determined by detailed l"ng f"nction tests, CT scanning and n"clear
ventilation perf"sion scans. Significant comorbidities, incl"ding cardiac disease,
m"st be considered. Serio"s post2operative problems are not "ncommon and
caref"l e<planation of the proced"re and rehabilitation process is mandatory.7rror6
Reference so"rce not fo"nd
T4$e )8 Su33e#ted 3ener$ !nc$u#!on nd eDc$u#!on cr!ter!
for potent!$ LVRS rec!p!ent#
Inc$u#!on cr!ter! EDc$u#!on cr!ter!
7mphysema, on optimal management
/7G, 1$%5& percent predicted
RG O 1$& percent predicted
CT and G:M scans show macroscopic target 9ones of
partic"larly damaged l"ng s"itable for resection
.ble to comply with rehabilitation programme
Dnable:"nwilling to e<ercise perioperatively, that is
N4H. class !G, ventilator dependent, age O >& years
)revio"s thoracotomy:e<tensive ple"ral disease:
ple"rodesis
!ntrinsic airway disease re8"iring prednisolone
O 1$ mg per day
-ronchiectasis
)C(1 O $$ mmHg, )&1 Q 5$ mmHg on air
*istance Q 1$& m in si<2min"te wal3 test
)"lmonary artery press"re O $& mmHg +assessed on
echodoppler, *0C( Q #& percent predicted
Cigarette smo3ing in last three months
(ther maor organ dysf"nction, that is significant
coronary disease, CC/, cache<ia, obesity and so on
0GRS, l"ng vol"me red"ction s"rgeryE /7G, forced e<piratory vol"me in 1 sE RG,
resid"al vol"meE CT, comp"ted tomographyE G:M, n"clear isotopic ventilation:
perf"sion scanE N4H., New 4or3 Heart .ssociationE *0C(, gas transfer factorE CC/,
congestive cardiac fail"re.
11C
Re.uirements for a 26R" centre
Biven the earlier comments, 0GRS sho"ld only be practised in centres with access to
specialist thoracic medical, s"rgical, anaesthetic and intensive care facilities with
added e<pertise in p"lmonary rehabilitations.7rror6 Reference so"rce not fo"nd
,7rror6
Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd
#onclusion
0"ng vol"me red"ction s"rgery is still to establish its e<act role in the management of
severe emphysema and an evidence2based approach cannot be applied at this time.
The recent .S7RN!)2S review of 0GRS has concl"ded that 0GRS is an acceptable
short2term treatment in highly selected cases, b"t longer follow "p is needed to
assess long2term o"tcomes. . Cochrane review on the s"bect preferred to await the
res"lts of the large randomised controlled trials in the DS., Canada and 7ngland
before drawing any strong concl"sions.7rror6 Reference so"rce not fo"nd
,7rror6 Reference
so"rce not fo"nd,1?&
'hile there are still many 8"estions to be answered, the most important
will be to define the s"b2gro"p who gain the greatest physiological improvement for
the longest d"ration.7rror6 Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference
so"rce not fo"nd
."dits of practice need to be "nderta3en to define patient s"bgro"ps at higher ris3 of
morbidity and mortality. The National 0GRS *atabase provides a mechanism to help
answer some of these 8"estions and aids in dissemination of information on
."stralian and New Zealand clinical practice bac3 to the profession.7rror6 Reference
so"rce not fo"nd
%7rror6 Reference so"rce not fo"nd
(pen disc"ssion and the opport"nity to
meas"re the e<perience caref"lly are both critical to the development of this new
technology.
11&
Append!D II8 Ser-!ce #pec!f!ct!on < home oD"3en therp" #er-!ce#
http6::www1.moh.govt.n9:M"ic3)lace:nsfl:)age0ibraryCC1$;-5.&&>11&51.nsf:hW7$
;>5C171C-&55.*CC1$;-5.&&>11;5/:/;*.*-1;C#-&17//CC1$;7C#&&&7/?1>
:Y(pen*oc"ment
111
Append!D III8 S$eep re$ted 4reth!n3 d!#order#, po#!t!on pper of
the Ne% Ze$nd 4rnch of the Thorc!c Soc!et" of Au#tr$! nd
Ne% Ze$nd
)repared by a wor3ing party of the TS.NZ New Zealand branch6 *r .lister A Neill,
*r * Robin Taylor, *r I/ 'hyte.
O-er-!e%
Aims
To ens"re the ade8"ate provision of a 8"ality service for the diagnosis and
management of sleep related disorders in ad"lts to the pop"lation of New Zealand.
To ens"re e8"al access to these services.
To ens"re services reach a recognised professional standard.
Sleep related disorders in children differ in their presentation and management
from those in ad"lts, and paediatric sleep disorders are not part of the remit of this
doc"ment. . position paper on paediatric sleep disorders is in preparation by the
Respiratory Committee of the )aediatric Society of New Zealand.
Obstructive sleep apnoea
Prealence
Ainim"m estimates are 5 percent of ad"lt male pop"lation based on DS
pop"lation.
Ainim"m estimates are 1 percent of ad"lt female pop"lation.
7vidence that Aicronesian and )olynesian races at higher ris3 and present with
more severe disease and more associated comorbidity.
"mpact
)roven $%1& times increase in ris3 of road traffic accidents.
)roven independent ris3 factor for systemic hypertension.
High probability it is an independent ris3 factor for cardiovasc"lar and
cerebrovasc"lar disease.
)roven impact on 8"ality of life across many domains incl"ding employment and
increased divorce rates.
"nterention
7ffective treatment available for maority of s"fferers from moderate to severe
disease.
111
Ot%er causes of e5cessive daytime sleepiness (1,"!
Prealence
)eriodic leg movement disorder +)0A*,, prevalence "n3nown, probably &.$%1.&
percent of ad"lt pop"lations.
Narcolepsy, prevalence in non2New Zealand pop"lations &.&1$%&.1 percent of
ad"lts b"t diagnosis diffic"lt and prevalence is li3ely to be higher.
(ther rarer disorders incl"de6 post tra"matic head in"ry, post cerebrovasc"lar
events and idiopathic hyper2somnolence.
"mpact
7*S is associated with increased ris3 of accidents +wor3 and road traffic,.
7*S is associated with increased ris3 of "nemployment, failing to achieve
occ"pational s3ills in line with 1& and potential.
7*S is associated with increased incidence of divorce and mental illness.
"nterention
!n symptomatic )0A* effective pharmacological therapy is available.
!n narcolepsy a combination of patient ed"cation, lifestyle changes, nap strategies,
coping s3ills and "dicio"s "se of pharmacological agents can improve M(0, social
and economic performance.
&octurnal %ypo+ventilation and respiratory failure
Prealence
'ide range of ca"ses and prevalence widely variable, these conditions are all rare,
with the e<ception of chest disease s"ch as chronic bronchitis emphysema. (ther
conditions incl"de6
chest wall deformities +eg, 3yphoscoliosis,
ne"rom"sc"lar disease +wide range from ac"te degenerative diseases, eg, motor
ne"rone disease, thro"gh slowly progressive m"scle disease +eg, *"chenne
A"sc"lar *ystrophy,, to stable chronic conditions +eg, post2polio syndrome,,.
respiratory conditions which place a maor load on the respiratory +breathing,
m"scle p"mp incl"ding morbid obesity.
"mpact
Sleep fragmentation with daytime sleepiness and red"ced f"nctioning and M(0
incl"des6
low o<ygen levels at night leading to right heart fail"re
polycythaemia +thic3ened blood, with increased ris3 of stro3es and heart attac3s
d"e to the low noct"rnal o<ygen levels
morning headaches from carbon dio<ide retention
increased n"mbers of chest infections d"e to shallow breathing and poor drainage
of l"ng secretions
11#
increased hospital admissions with chest infectionsE heart fail"reE cardiovasc"lar
problems
premat"re death.
"nterention
Nasal s"pport ventilation at night restores sleep 8"ality, improves o<ygenation,
red"ces carbon dio<ide levels and cardiac f"nction. !t red"ces hospital admissions,
incidence of respiratory infection and in some diseases it prolongs life e<pectancy by
averting death from respiratory fail"re. !t does not alter the nat"ral progression of the
"nderlying ne"rom"sc"lar disease.
The treatment is well tolerated by the vast maority b"t demands e<pertise in patient
assessment, initiating therapy and monitoring the ade8"acy of therapy.
Insomnia (disorders of t%e initiation and maintenance of sleep (,I/"!!
Prealence
.ffects C%1$ percent of the ad"lt pop"lation.
"mpact
.ssociation with maor impact on individ"als 8"ality of life +across most domains, and
with psychiatric illness.
"nterention
'ill remain principally a disorder dealt with by primary care providers, however there
is a clear need for provision of s"pport to primary care teams by sleep services in
terms of6
"ps3illing providers in non2pharmacological interventions
appropriate "se of psychological and sleep therapists
ongoing ed"cation and s"pport
specialist referral service for diagnostic problems and diffic"lt management
problems, for e<ample co2e<ists with other sleep disorders.
Ade.uate provision of service
Current deficiencies
0imited access to services thro"gho"t the co"ntry.
0imited and variable e<tents of f"nding for (S. in terms of provision of diagnostic
sleep st"dies +varies from 161&&& to 16$&&&,, f"nding of C).) machines and
organisation of services.
No provision for the on2going care of the increasing n"mber of patients on nasal
C).) therapy.
No f"nded service for the investigation and treatment of noct"rnal hypoventilation.
)atchy f"nding of e<cessive daytime somnolence.
No f"nded service for insomnia in New Zealand.
115
!n absence of dedicated f"nding and clearly defined contract"al criteria,
development of high 8"ality services capable of reaching a recognised
professional standard is impossible.
Proposed solutions
7stablishment of a national 8"ality service offering both comprehensive and
portable diagnostic sleep st"dies appropriate to each locality=s and the co"ntry=s
need.
National f"nding of sleep clinic slots at a rate of 16?$& of pop"lation and provision
of diagnostic sleep st"dies at a level of 161&&& of the pop"lation with f"nding of an
appropriate n"mber of C).) machines.
/"nding of the ongoing costs of treatment patients established on long2term C).)
therapy.
7d"cational and s"pport services for primary carers involved in the care of
patients with insomnia with a foc"s to limit the widespread inappropriate "se of
pharmacological agents +hypnotics,. This wo"ld incl"de some investment in a
networ3 of sleep therapists and psychologists with training in this area.
.dopt TS.NZ standards for the diagnosis and treatment of sleep breathing
disorders.
'c23round
Aims
To ens"re the ade8"ate provision of a 8"ality service for the diagnosis and
management o sleep2related disorders to the ad"lt pop"lation of New Zealand.
To ens"re e8"al access to these services.
To ens"re services reach a recognised professional standard.
7%at is sleep medicine8
The st"dy of sleep related disorders is less than 5& years old, and the recognition of
illness and morbidity of these disorders is m"ch more recent. The vast maority of
sleep disorders fall into two categories, altho"gh there is some overlap between them.
1. *isorders leading to e<cessive daytime sleepiness +7*S,6
(bstr"ctive sleep apnoea.
)eriodic leg movement disorder.
Narcolepsy.
Central sleep apnoea, often secondary to cardiac or cerebrovasc"lar
disease.
!diopathic hyper2somnolence.
Sleep hygiene problems.
*isr"ption of the sleep2wa3e rhythm and cycles.
11$
1. *isorders of initiation and maintenance of sleep incl"de6
primary insomnia
secondary insomnia.
7<cessive daytime sleepiness +7*S, is a maor clinical complaint. .part from its
s"bective impact, it leads to loss of prod"ctivity and increased accident rates. /or
some of the conditions listed above, as well as 7*S there are associated direct
effects on personal health, both physical and mental.
1?1,1?1
!nsomnia is a common problem for which there are no secondary or tertiary level
services provided. !n the maority of cases, insomnia can be managed in the primary
care setting. There is a need to ed"cate general practitioners regarding the different
forms of insomnia and non2pharmacological methods of management. These
strategies are partic"larly s"ccessf"l in short to medi"m d"ration insomnia.
The field of sleep medicine has developed in response to the recognition of the
importance of sleep disorders, s"ch as obstr"ctive sleep apnoea syndrome, and the
development of highly effective therapy. The recognition of the different ca"ses of
7*S re8"ires e<perienced practitioners who are able to appropriately assess and
determine the li3ely need of sophisticated techni8"e.
"leep and respiratory failure
.n ancillary area that involves sleep medicine is the treatment of respiratory fail"re.
*"ring sleep respiration is shallower, especially in dream sleep +R7A sleep,. !n
patients with limited respiratory reserve, beca"se of ne"rom"sc"lar diseases +eg,
m"sc"lar dystrophy, post2polio syndrome,E chest wall deformity +eg, 3yphoscoliosis,
or advanced l"ng disease, then their respiratory ins"fficiency manifests first in sleep
leading to sleep fragmentation, with the inevitable daytime sleepiness and other
effects of sleep deprivation, followed by carbondio<ide retention and hypo<ia, finally
c"lminating in cardiac and respiratory fail"re.
Sleep practitioners, many with a bac3gro"nd in respiratory medicine, are in a "ni8"e
sit"ation in having the s3ills to assess these individ"als and initiate non2invasive
noct"rnal ventilatory s"pport, if indicated, when their condition deteriorates
s"fficiently to "stify the introd"ction of s"ch therapy.
1?#
The res"lts of non2invasive
ventilation st"dies indicated impressive improvements in respiratory fail"re, red"ced
readmission rates and illness events combined with improved 8"ality of life.
1?5,1?$,1?;,1?>
!n addition in the ac"te setting nasal ventilation red"ces hospital stay, costs and
int"bation rates.
1??
15cessive daytime sleepiness9 a significant problem8
7<cessive daytime sleepiness +7*S, is now widely recognised as a maor clinical
problem in o"r comm"nity. . DS congress report has recently doc"mented its e<tent
and its cost to society.7rror6 Reference so"rce not fo"nd The report contained a
Nwa3e2"p call= to society. 7*S is often lin3ed to socioeconomic factors s"ch as shift
wor3, limited time in bed beca"se of wor3 patterns, or social press"res. Contin"o"s
process and transport ind"stries have increasingly identified 7*S as an important
problem, often driven by their ins"rers on safe practices to minimise accident
rates.7rror6 Reference so"rce not fo"nd
11;
!n many cases 7*S is d"e to a primary sleep disorder with associated sleep
disr"ption and poor 8"ality sleep. The fact that 7*S has only been recognised in the
last 1$ years and that only in this decade have reliable epidemiological data emerged
regarding prevalence and long term conse8"ences, has meant that this very diffic"lt
Nnettle= has not yet been ade8"ately grasped by health providers. *ata on
prevalence, conse8"ences and scope for s"ccessf"l treatment of 7*S will soon be
available within New Zealand. These will provide the imperative for providing a
nationwide sleep service that ens"res ade8"ate investigation for all New Zealanders.
C"rrent evidence s"ggests that fail"re to investigate and treat sleep disorders has
maor costs for one society as a whole ranging from direct costs of accidents to the
often hidden costs in terms of red"ced prod"ctivity of affected individ"als leaving
aside the socioeconomic costs to the affected individ"als and their families. The
costs to the health services of leaving these individ"als "ntreated is not well
doc"mented b"t it is 3nown that there are costs s"ch as the cost of treating
hypertension and other res"lting health problems.
1?C
Obstructive sleep apnoea9 :ust do;e v snores8
(bstr"ctive sleep apnoea +(S., is an important sleep related breathing disorder and
a maor ca"se of 7*S. !ts relatively high prevalence compared to other ca"ses
highlights the iss"e of sleep disorders for health providers. Rec"rrent obstr"ctive
apnoeas lead to both increased cardiac wor3, and physiological aro"sals d"ring
sleep with associated stim"lation of the sympathetic nervo"s system. Sleep
disr"ption also occ"rs, res"lting in 7*S. *epending on a n"mber of factors incl"ding
the fre8"ency and d"ration of apnoeas, and individ"al patient=s resistance to sleep
disr"ption, 7*S may be very significant, partic"larly when e<ternal stim"lation is not
intense, for e<ample when driving or contin"o"sly operating machinery.
There is now very convincing evidence that patients with (S. have a greatly
increased ris3 of road traffic accidents +odds ratios in most st"dies indicate a five to
1&2fold increase in ris3.
1C&,1C1,1C1
There is also evidence that when treated, at least
with contin"o"s positive airway press"re +C).),, the ris3 of road traffic accidents is
red"ced.
1C#
(ther effects on physical health are becoming increasingly apparent. Two large
prospective epidemiological st"dies +The 'isconsin Sleep Cohort St"dy and The
Sleep Heart Health St"dy, have provided evidence that (S. is an independent ris3
factor for systemic hypertension, similar in magnit"de to that of cigarette
smo3ing.
1C5,1C$
These data indicate that even mild (S. may lead to hypertension.
The role of (S. as a ris3 factor for cardiovasc"lar and cerebrovasc"lar disease is
both theoretical and based on obective evidence. /irstly, (S. res"lts in increased
left ventric"lar wor3 and stim"lation of the sympathetic nervo"s system d"ring
apnoeas.
1C;
Secondly (S. is an independent ris3 factor for hypertension, which in
t"rn is a 3nown ris3 factor for cardiovasc"lar and cerebrovasc"lar events. There is
also evidence that patients with pre2e<isting cardiac and respiratory disease are at
increased ris3 of morbidity if they have co2e<istent (S..
1C>
These observations have
prompted the National Heart 0"ng -lood !nstit"te to commence an epidemiological
11>
st"dy designed to provide even stronger evidence. This st"dy is 3nown as the Nsleep
heart health st"dy=.
1C?
Is O"A common8
The most rob"st epidemiological data from the 'isconsin Sleep Cohort St"dy
indicate that 5 percent of males and 1 percent of females have clinically significant
(S. +that is more than 1$ apnoeas per ho"r and 7*S,.
1CC
No comparable data are
yet available for New Zealand. However a st"dy in ."c3land revealed increased
incidence of sleep apnoea in Aaori and )acific !sland comm"nities.
1&&
. f"rther st"dy
from (tago has shown that the cranio2facial str"ct"re of )olynesian s3"lls p"ts these
races at increased ris3 of (S..
1&1
Now that definitions of obesity have been
standardised worldwide "sing 'H( obesity tas3force criteria, there is no evidence of
a significant difference in obesity rates between new Zealand and the DS..
1&1
Biven
that obesity is a mar3er for (S. ris3, it is li3ely that the 'isconsin data apply in New
Zealand. Th"s, "sing the widely accepted model that not everyone with a disease
will see3 investigation and treatment, then the need for treatment for (S. will be of
the order of &.$%1.$ percent of the middle aged male pop"lation and &.1$%&.>$
percent of the middle aged female pop"lation. C"rrent estimates from the DS.
s"ggest that at least ?1 percent of male s"fferers and C# percent of female s"fferers
remain "ndiagnosed.
1&#
Is effective t%erapy available8
/or many patients with (S. syndrome, conservative treatment which incl"des
sleeping in a lateral position,
1&5
alcohol red"ction, smo3ing cessation and weight
red"ction may be s"ccessf"l. The weight loss is rarely s"stained with evidence from
long2term st"dies indicating that only 1& percent of patient who lose weight will
maintain the lower weight in the long term. Nasal contin"o"s positive airway
press"re +C).), treatment is established as first line therapy for obstr"ctive sleep
apnoea syndrome. Nasal C).) consists of a nasal mas3 and machine that provides
position airway press"re to the "pper airway d"ring sleep and effectively Nsplints=
open the "pper airway.
The New Zealand and ."stralian Health Ainistries commissioned a report into the
efficacy and cost "tility of nasal C).) "nder the a"spices of the ."stralasian Health
Research and Technology .dvisory Committee +.HRT.C,. Their report concl"ded
that C).) was a proven and effective therapy in patients with moderate to severe
(S., and at reasonable cost.
1&$
This gro"nd2brea3ing report recommended
categories of patients who sho"ld be offered therapy. These were based on disease
severity and the li3elihood of clinical benefit, as well as benefit to society. The criteria
o"tlined in the .HRT.C report have been adopted by most sleep medicine
specialists in New Zealand as a g"ideline for management, whilst accepting that a
small percentage of patients with gross 7*S b"t apparently mild (S. will be offered
therapy based on clinical "dgement.
/or milder sleep apnoea, there is a place for both mandib"lar advancement splints
and other similar devices. Their s"ccess is based on repositioning the mandible and
the tong"e, th"s helping to maintain a patent airway.
1&;
Dpper airway s"rgery may be
s"ccessf"l in selected cases, and there is a rapidly increasing range of s"rgical
approaches. )revio"sly "sed "pper airway s"rgical techni8"es have been applied
with inconsistent res"lts, these incl"de "v"lopalatopharyngoplasty, laser
pharyngoplasty and palatal somnoplasty, and their role is "nproven and hence
11?
cannot be recommended in (S.. These techni8"es sho"ld generally be regarded
as treatment for snoring only as they have a very inconsistent effect in the
management of obstr"ctive sleep apnoea b"t do have a role in mild sleep apnoea
where alternative therapies are not tolerated or available.
1&>,1&?
Newer s"rgical
approaches involving the ma<illa and mandible show promise and are li3ely to be a
viable treatment option in selected yo"nger patients with obstr"ctive sleep apnoea
syndrome.
1&C
Other cu#e# of eDce##!-e d"t!me #$eep!ne## &EDS(
Periodic limb movement
7stimates of the prevalence of clinically significant periodic limb movement disorder
vary widely. /ig"res range from 1%1; percent of patients referred for investigation of
7*S. .ltho"gh periodic limb movements may be seen with no evidence of sleep
disr"ption and no daytime sleepiness, some patients may have severe daytime
sleepiness as a res"lt of gross sleep disr"ption, and will respond dramatically to
treatment, the therape"tic approaches incl"de ben9odia9epines, for e<ample
clona9epam and the anti2par3insonian dr"gs +carbidopa and bromocriptine,.
11&
&arcolepsy
Narcolepsy is an inherited sleep disorder characterised by e<cessive daytime
sleepinessE paro<ysmal episodes of daytime m"scle wea3ness +cataple<y, sleep
paralysis and vivid life2li3e dreams. The disease onset is often d"ring adolescence
or yo"ng ad"lt life.
111
The prevalence of this condition in New Zealand is "n3nown,
estimates in other pop"lations have varied between &.1%&.&1$ percent. *iagnosis
re8"ires caref"l clinical assessment, an overnight sleep st"dy and a m"ltiple sleep
latency test. *"ring m"ltiple sleep latency tests, patients "ndergo a series of daytime
naps at two ho"rly intervals. Sleep latency and the onset of rapid eye movement
sleep are recorded. Treatment incl"des nap strategies to red"ce daytime sleepiness,
tricyclic antidepressants to s"ppress associated cataple<y, and the "se of stim"lant
medications, for e<ample Aethylphenidate, de<amphetamine, to relieve daytime
sleepiness. !t is important that therapy is initiated and monitored thro"gh recognised
sleep clinics to ens"re correct diagnosis and management.
111
.ccess to a s3illed
clinician and appropriate sleep clinic based investigation will decrease the li3elihood
of dr"g ab"se.
-%e investigation of O"A and ot%er causes for %yper+somnolence9 w%y a
separate service8
The investigation of 7*S involves the appropriate "se of an investigative techni8"e
designed to e<amine sleep. 7ven in the most common disorder, obstr"ctive sleep
apnoea symptoms and e<amination feat"res alone are not s"fficiently reliable to
allow a clinical diagnosis.
11#
. sleep st"dy is essential in order that the correct
diagnosis is established, to allow an assessment of severity and to ens"re rational
treatment planning.
11C
. sleep st"dy involves the physiological eval"ation of patients d"ring sleep. . range
of technical sophistication is now available. /"lly polysomnography, in which
brainwave and breathing pattern variables are all sim"ltaneo"sly recorded is the only
investigation which has been convincingly shown to offer reliable res"lts. !t remains
the gold standard. The "se of partial sleep st"dy devices, which mostly record a
combination of respiratory signals, has increased b"t the reliability of many of these
devices has not been ade8"ately assessed to determine definitively their e<act role
in clinical diagnosis.
115
C"rrent devices have no role in identifying alternative ca"ses
of 7*S in patients who do not t"rn o"t to have significant obstr"ctive sleep apnoea
syndrome. (<imetry alone has been shown to completely miss appro<imately one
third of (S. cases and th"s even its role as a screening tool is controversial.
/"ll polysomnography remains an essential tool.
11$,11;
!t may be carried o"t in
dedicated sleep laboratories or in the home, as increasingly reliable portable systems
to allow ade8"ate data capt"re in the home are developed.
11>
. significant n"mber of
patients will not be able to be st"died at home for a variety of factors, ranging from
the presence of serio"s associated heart or l"ng disease to home circ"mstances
s"ch as overcrowding to geographical reasons. Therefore, dedicated sleep
laboratories will contin"e to be re8"ired in the foreseeable f"t"re and it is
recommended that these laboratories are in the best position to determine the
appropriate "se of home2based st"dies in any given individ"al patient. *epending on
the clinical circ"mstances and partic"lar e<pertise of the sleep laboratory staff, nasal
C).) can be initiated d"ring an attended single night polysomnography st"dy +a split
sleep st"dy,, or d"ring a f"rther overnight st"dy or "sing a C).) machine with a
micro2processor driven algorithm that ad"sts the press"re in response to each
apnoea, so called Nsmart= C).). These st"dies are essential for determining the
most appropriate press"re for long term therapy "sing a standard C).) machine.
!t is important to establish patients on C).) "sing a very caref"l and proactive
approach d"ring the first few nights and wee3s of treatment, and easy access to
s"pport in the first wee3s of therapy for tro"ble shooting problems enhances
compliance rates which have been reported to vary from 5$%C& percent depending
on the degree of s"pport offered.
11?
Gario"s strategies are available and can be
tailored to the individ"al patient=s clinical problem to achieve an appropriate clinical
o"tcome.
Insomnia and ot%er disorders of sleep initiation and maintenance
The disorders are common, and large proportions of patients with chronic insomnia
have psychological or psychiatric disease.
11C
/ormal sleep st"dy +polysomnography,
is rarely needed as the history is "s"ally highly s"ggestive and can be confirmed by
getting the patient to perform a simple sleep diary. Aany of the important initial
clinical steps in the diagnosis and management of insomnia sho"ld be "nderta3en by
general practice. The absence of a dedicated service for s"ch patients and a
therapist with sleep e<pertise ma3es this area diffic"lt for B)s who often resort to the
"se of hypnotics, which is often not appropriate or cost effective.
11&,111
There is a role
for sleep clinics to provide the B)s with f"rther ed"cation, advice and s"pport, b"t it
is neither cost effective nor practical for the sleep clinic to ta3e over the care of these
individ"als who wo"ld swamp the services. )atients with strong psychological or
psychiatric feat"res sho"ld be appropriately referred to those services. . gro"p of
1#&
patients who have sleep phase disorders may be identified and referred to sleep
clinics for f"rther advice and management in order to help shift the circadian rhythm.
&octurnal %ypoventilation leading to respiratory failure
*"ring normal sleep both ventilation and the bodies metabolic rate decrease. The
net effect is that the amo"nt of o<ygen carried in blood to the tiss"es contin"es to
meet the body=s re8"irement. However, in a range of disease states where there is
either intrinsic l"ng disease or limited respiratory m"scle f"nction, this fall in
ventilation in sleep leads to respiratory fail"re with res"ltant carbondio<ide and
hypo<ia +low blood levels,.
This can have the following effects on the patient6
sleep fragmentation and daytime sleepiness
morning headaches from C(
1
retention
right heart fail"re from rec"rrent and prolonged noct"rnal hypo<ia
polycythaemia from rec"rrent and prolonged noct"rnal hypo<ia
increased n"mbers of respiratory tract infections from inade8"ate depth of
breathing leading to stiffer l"ngs and increased ris3 of infection
mar3ed impaired 8"ality of life.
These patients are fre8"ently referred to sleep services for investigation of their
daytime sleepiness or beca"se it is recognised that they have noct"rnal
hypoventilation and re8"ire assessment for initiation of noct"rnal ventilatory s"pport
"sing nasal mas3 non2invasive ventilation.
There are a wide range of conditions that can lead to noct"rnal respiratory fail"re b"t
these can be gro"ped into the following categories6
,eformities of t%e c%est wall
.ny condition leading to maor deformity of the chest wall will inevitably lead to a loss
of respiratory reserve and the potential for noct"rnal hypoventilation. These
conditions range from congenital 3yphoscoliosis to iatrogenic chest wall deformities
from thoracoplasty proced"res "sed in the 1C$&s and 1C;&s to treat p"lmonary
t"berc"losis.
&euromuscular disease involving respiratory muscles
This encompasses a wide range of both primary m"scle disease and ne"rological
diseases that affect respiratory m"scles. These can broadly be divided into two
categories6
1. Rapidly progressive diseases s"ch as motor ne"rone disease where respiratory
m"scle involvement may be a relatively late development and leads to a
combination of problems of both hypo2ventilation and diffic"lty in maintaining
ade8"ate clearance of respiratory secretions d"e to inade8"ate co"gh and so
on. These patients may have maor problems in "sing nasal ventilation at night
d"e to wea3ness of arm m"scles and:or involvement of throat m"scles +b"lbar
1#1
palsy, b"t in a proportion of s"ch patients nasal noct"rnal ventilation may have
a role to play in alleviating distressing symptoms s"ch as dyspnoea in the latter
part of the co"rse of these diseases and sho"ld be seen as part of their
palliative care.
1. Slowly progressive ne"rom"sc"lar diseases for e<ample *"chenne=s A"sc"lar
*ystrophy or post2polio syndrome. !n these conditions there tends to be
relatively early involvement of respiratory m"scles in a patient who has
otherwise good health and 8"ality of life. (ften in the case of the hereditary
m"scle diseases when the individ"al is still attending ed"cational
establishments or wor3ing. The onset of symptoms from hypo2ventilation are
often insidio"s b"t progressive with increasing daytime sleepiness, repeated
chest infections and event"ally cardiac and respiratory fail"re. Noct"rnal nasal
ventilatory s"pport often leads to a significant improvement in 8"ality of life,
fewer hospital admissions and prolonged life e<pectancy.7rror6 Reference
so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd
Respiratory failure secondary to intrinsic lung disease
Chronic nasal s"pport ventilation in patient with l"ng disease has principally been
seen as having potential val"e in chronic obstr"ctive l"ng disease and airway
disease associated with s"pp"ration and l"ng destr"ction, bronchiectasis and cystic
fibrosis.
!n chronic obstr"ctive l"ng disease respiratory m"scle p"mp fail"re leading to C(
1

retention is a central part of the disease process in many patients, b"t there are also
other profo"nd dist"rbances of both respiratory mechanics, ventilation:perf"sion
matching and gas e<change in these patients to a variable e<tent. .s a r"le, their
hypo<ia and hypercapnia +C(
1
retention, are greater at night b"t the contrib"tion of the
noct"rnal deterioration in blood gases to o"tcomes is "nclear. )reliminary research
s"ggests that a proportion of these patients wo"ld benefit from chronic domiciliary
nasal s"pport ventilation at night b"t this awaits f"rther research st"dy.
111
Nonetheless
in the interim there will be occasional patients who following a period of ac"te nasal
ventilatory s"pport in hospital d"ring an ac"te e<acerbation of their obstr"ctive l"ng
disease will re8"ire ongoing s"pport to allow discharge from hospital.
!n bronchiectasis and cystic fibrosis, respiratory fail"re is inevitable in the later stages
of the disease and nasal s"pport ventilation can alleviate symptoms as part of the
palliative care of s"ch patients or as a bridge to p"lmonary transplantation. There is
no evidence of a significant effect on s"rvival, however this has not been
systematically eval"ated. .t this stage we recommend that this treatment be trialled
in selected patient on symptomatic gro"nds. Those patients with a large vol"me of
respiratory secretions or maor nasal and sin"s disease it may neither be appropriate
nor well tolerated.
Obesity+related %ypoventilation
Respiratory and cardiac fail"re in the morbidly obese is, "nfort"nately increasingly
common in New Zealand as we seen an e<plosion in obesity in o"r comm"nity.
There is a very high prevalence in Aaori and )acific !sland people.
11#
The ca"ses of
the respiratory and cardiac fail"re observed so fre8"ently in these patient is comple<
and often m"tifactorial.
1#1
.s the vast maority are snorers and in respiratory fail"re they are referred to sleep
clinics as cases of obstr"ctive sleep apnoea, in many cases there is indeed a degree
of obstr"ctive sleep apnoea ranging from mild to very severe (S., however in a
proportion +possibly a third, there is no evidence of significant "pper airway
obstr"ction. Aorbid obesity itself alters the mechanics of the l"ng and the efficiency
of the l"ng as a gas e<changer leading to a dramatically increased load on the
respiratory m"scles. Dpper airway obstr"ction, whether total as in obstr"ctive sleep
apnoea, or partial as in "pper airway resistance syndrome, will f"rther load the
respiratory m"scle p"mp. Th"s these patients are primed to develop noct"rnal
respiratory fail"re and event"ally, as chemoreceptors down reg"late, chronic
hypercapnic respiratory fail"re. Cardiac fail"re from a combination of hypo<ia,
obesity related cardiomyopathy and other factors that may be present s"ch as
diabetes or hypertension is common in these patients.
!n some of these patients C).) will treat any coe<istant sleep apnoea and, by
increasing l"ng vol"me, will alter l"ng mechanics s"fficient to improve the respiratory
fail"re. (thers will re8"ire noct"rnal ventilatory s"pport to improve the sit"ation.
("tcome st"dies are not available in this condition, b"t a n"mber of s"ch patients
have been treated in New Zealand with noct"rnal s"pport ventilation simply to
stabilise their condition and allow discharge from hospital with many ret"rning to
good levels of premorbid f"nction.
<ig% cervical spinal in:uries
Cervical spinal cord in"ries above C5:C$ level leads to loss of some respiratory
m"scle f"nction and very high in"ries leads to total ventilatory dependency. These
patients care involves a n"mber of specialist services incl"ding sleep services in
assessing the degree of respiratory ins"fficiency and the degree of respiratory
s"pport, if any, that is re8"ired.
7%at is an ade.uate provision of service8
'ith increasing recognition of sleep disorders and the availability of highly effective
therapy, sleep disorder clinics aro"nd New Zealand have received increasing
n"mbers of referrals and e<perienced diffic"lty in managing their waiting lists.
/"nders have responded by providing a relatively fi<ed level of service provision and
not ac3nowledged the important impact of sleep breathing disorders on health, the
new nat"re of the service and the e<pected increase in referrals that accompany any
recently identified disease and hence failed to provide an ade8"ate level of f"nding.
To identify important and treatable clinical pop"lations with sleep disorders, and
red"ce "nnecessary referrals, several strategies are re8"ired. /irstly, the ed"cation
of general practitioners abo"t the whole gam"t of sleep disorders and the treatments
available will allow them to ma3e informed decisions regarding which patients to
refer.
Secondly, increasing the level of f"nding and service provision for sleep disorders
foc"ssing partic"larly on the sleep related breathing disorders, for which there is
good evidence for treatment benefit. !t is clear that the c"rrent level of f"nding is
inade8"ate given the e<ponential growth in clinic waiting list times. . pragmatic
approach is to limit st"dies in patients with symptoms s"ggestive of sleep apnoea
1##
and to patients with significant daytime sleepiness. S"ch an approach is based on
the premise, only partially s"pported by the literat"re, that patients with (S. and
7*S form the overwhelming maority of patients who will benefit from and comply
with C).) therapy. .nother gro"p in whom a lower threshold for cond"cting sleep
st"dies is appropriate is patients with established cardiovasc"lar disease in whom
milder degrees of (S. associated with mild daytime sleepiness who may still
potentially benefit from therapy in terms of decreased cardiovasc"lar morbidity. .
degree of clinical freedom in determining the potential benefits of investigation is
re8"ired.
'ithin a sleep disorders service, it has to be recognised that waiting list management
in order to ma<imise effective "se of scarce reso"rce will be re8"ired. This is
recognised by all clinicians wor3ing in this field.
. reasonable level of service provision wo"ld be to f"lly f"nd the eval"ation of one
(S. patient per tho"sand of the pop"lation per year in the region stated. The sleep
disorders clinic wo"ld aim to see one patient per C&& pop"lation in order to provide
an ade8"ate thro"ghp"t to the diagnostic service. The ethnic ma3e"p and the
demographics of the pop"lation may re8"ire to be ta3en into acco"nt in different
regions. Specific data are not available regarding this aspect. /"nding wo"ld need
to cover the assessment, investigation, cost of C).) machine or alternative therapy,
follow2"p, ongoing costs of C).) maintenance and event"al replacement costs of
C).) machines +c"rrent life e<pectancy appro<imately eight years,.
#urrent ine.uity of access and funding
.t present there is a very limited and "ne8"al provision of sleep disorders services
within New Zealand and none can meet the above proposed provision of service. !n
addition, there are mar3ed variations in the f"nding of C).) machines and in the
contracts regarding the type of clinical problems that services are being as3ed to
investigate, ranging from Nsevere obstr"ctive sleep apnoea= thro"gh Ne<cessive
daytime sleepiness= to Nprovision of appropriate sleep services=. The present
approach is very m"ch Nad hoc=. There is no co"ntry wide approach to the f"nding of
sleep disorders cons"ltations, diagnostic sleep st"dies, the provision of C).)
machines or more sophisticated bi2level machines "sed to treat respiratory fail"re.
Similarly, there is variation in the type and 8"ality of sleep investigation services.
This is being addressed to some e<tent by the Thoracic Society of ."stralia and New
Zealand who are enco"raging sleep laboratories to achieve TS.NZ accreditation and
practising sleep physicians to attain TS.NZ sleep training credentialing.
The s"ccess of treatment depends on an active C).) monitoring programme with
ade8"ate patient access to maintenance and tro"ble2shooting services. The
provision of s"ch a service has to incl"de provision for the increasing wor3load
imposed on a service by the increasing n"mber of s"ch patients "nder the care of the
service year by year. S"ch provision has to incl"de systems for C).) machine
maintenance and the f"nding of a C).) machine replacement programme +machine
life span is si< to eight years,. C"rrently the need to f"nd replacement machines is
eroding into the b"dget providing machines to newly diagnosed patient and this will
become an escalating problem in f"t"re years.
1#5
7ould a boo*ing service allow control of demand8
-oo3ing systems are based on obective and validated instr"ments for assessing
severity of disease and th"s prioritising access to treatment. !n the investigation of
sleep disorders, partic"larly in the investigation of e<cessive daytime somnolence,
the rate limiting factor is access to clinical assessment and obective diagnostic
investigation by a sleep st"dy +li3ely cost @>$&%@?&&,. Thereafter treatment is
relatively cheap, ma<im"m average ann"al cost of @#&& +cost of C).) machine
+minim"m life e<pectancy si< years, @11&&:; S @1C& per year pl"s @$&%@>$ ann"al
maintenance cost pl"s the provision of a Ntro"ble shooting service= at @$& per year on
average leads to an ann"al treatment cost of @#&& ma<im"m,.
)atient self assessment of s"bective daytime sleepiness is poor compared to
obective meas"rement +m"ltiple sleep latency test,. )atients concerns abo"t driving
ris3s, employment ris3s and so on. often bias them to "nder report the e<tent of their
daytime sleepiness. Dse of 8"estionnaires for prioritising new referrals is not
convincingly validated,
115
nor is their "se in predicting final diagnosis.
11$
!n Breen
0ane Hospital in ."c3land a boo3ing system based on a 8"estionnaire was
attempted b"t the c"rrent evidence strongly s"ggests that a boo3ing system is not a
feasible or defensible option in this condition. This is beca"se the boo3ing system is
for a diagnostic test designed to identify one of a series of conditions that are
notorio"sly diffic"lt to disting"ish witho"t sleep st"dies.
-owards an acceptable sustainable level of service
There is overwhelming need to increase and rationalise service for sleep related
disorders within New Zealand. 78"itable access to diagnostic services as well as to
treatments re8"ires to be established. .chieving ade8"ate standards for both clinical
assessment and investigation is an essential part of providing an ade8"ate service.
'ith the recognition of the importance of these disorders, many hospitals have
developed a sleep investigation service that incl"des polysomnography. There
remains significant fragmentation and variation regarding f"nding. . planned service
is essential for the long term. Solving these problems clearly re8"ires decision
ma3ing at a national level.
'ithin this service strategy a cr"cial decision will be the mi<t"re of services available
in different regions b"t a provision for 3ey tertiary level sleep laboratories will be
re8"ired for the specific "se of polysomnography to allow the identification of
comple< sleep disorders, the provision of ventilatory s"pport services "sing bi2level
ventilation and the diagnosis and management of conditions s"ch as narcolepsy2
cataple<y syndrome.
1#$
Append!D IIII8 Chron!c d!#e#e mn3ement8 recommendt!on# on
#thm #er-!ce# for D!#tr!ct 5e$th 'ord#
This statement has been prepared by the .sthma 'or3ing Bro"p, a Ainistry of
Health .dvisory Bro"p. !t has been endorsed by the 7<ec"tive of the Thoracic
Society of ."stralia and New Zealand +New Zealand branch,.
Je" recommendt!on# for D5'# to !ncorporte !nto the!r #trte3!c p$n#
1. .ll patients sho"ld be enrolled with a )rimary Health (rganisation providing
contin"ity of care in an integrated framewor3 along with comm"nity and hospital
based services.
1. /inancial barriers to primary care and co2payments on asthma medications
sho"ld be eliminated or s"bstantially red"ced.
#. !wi and )acific people=s involvement sho"ld be so"ght to ens"re c"lt"rally
appropriate services incl"ding medical care, ed"cation and whana" s"pport are
provided.
5. .ccess to ed"cation in the comm"nity m"st be improved so that patients with
asthma have access to ed"cation from a s"itably trained provider.
$. 7d"cation needs to foc"s on self2management s3ills, the appropriate "se of
inhaled corticosteroids and long2acting beta agonists +0.-.s, and sho"ld be
based within the primary care setting.
;. High ris3 patients +eg, oral corticosteroid dependant, previo"s life threatening
attac3, two or more admissions in past year, sho"ld be followed2"p wherever
possible in a m"lti2disciplinary .sthma Clinic "ntil their control has stabilised.
>. .ll patients with persisting symptoms or severe episodic attac3s sho"ld be
offered a written self2management plan.
?. The New Zealand .sthma B"idelines for .d"lts sho"ld be promoted to primary
and secondary care organisations in each region. B"idelines for children
sho"ld also be developed.
C. )lanning for asthma services sho"ld be informed by analysis of health
o"tcomes and which sho"ld be collected and analysed ann"ally with
comparisons between regions, *H-s as well as nationally +and internationally,.
1&. . regional respiratory advisory gro"p with representation from all sta3eholders
sho"ld be established to provide ongoing advice to the *H-s concerning
asthma management.
'c23round
.sthma is the most common chronic condition affecting the health of yo"ng people in
New Zealand. *ata from recent research indicate that 1$ percent of ad"lts and "p to
1> percent of children have symptoms s"ggestive of asthma.
11;
.sthma is a very
high cost disease in terms of both direct and indirect health care costs. These costs
have been conservatively estimated at @#5C million per ann"m in New Zealand
11>

and asthma ran3s si<th in New Zealand -"rden of *isease estimates.
11?
/or Aaori
1#;
and )acific peoples the b"rden of asthma is higher with admission rates which are
two to three times higher than 7"ropeans. The ca"se appears to be mainly
socioeconomic altho"gh health care "tilisation practices and socio2c"lt"ral iss"es are
also "ndo"btedly important.
11C,1#&,1#1
!n 1CCC the then Health /"nding ."thority developed a chronic disease initiative and
set aside @1& million ann"ally for three years to provide for additional services in
diabetes, asthma and cardiovasc"lar disease. Some @1.# million was spent on new
asthma services in the 1&&&%&1 financial year, mainly on new primary care proects
for Aaori and )acific peoples.
'hile diabetes was s"bse8"ently identified as a health priority in the 1&&1 Health
Strategy, for "ne<plained reasons asthma was not. This was diffic"lt to "nderstand
given the b"rden of asthma in the comm"nity. *iabetes, respiratory disorders
incl"ding asthma and C()*, along with mental health have been listed by the 'H(
as global health iss"es re8"iring specific strategies in the 11st cent"ry.
The .sthma 'or3ing Bro"p, nested within the New Zealand B"idelines Bro"p
+NZBB, str"ct"re, has achieved a n"mber of important goals since it was
established. These incl"de6
1. a stoc3ta3e of asthma ed"cation reso"rces:providers +available from The
.sthma and Respiratory /o"ndation of New Zealand,
1. a disc"ssion paper on barriers to care in the primary sector +available on the
New Zealand B"idelines Bro"p website www.n9gg.org.n9,
#. a des3top comp"ter template for "se in primary care to improve the 8"ality and
content of asthma review visits +in final development available on re8"est,
5. a proect on clinical indicators which will define the asthma management
o"tcomes that sho"ld be prioritised for action:recording by the Ainistry of Health
+in final draft,
$. the development of a B"ideline for the management of ad"lt asthma in primary
care +http6::www.n9gg.org.n9:g"idelines:&&&#:/"llWte<tWB"ideline.pdf,. .
g"ideline for the management of childhood asthma is also in development.
Purpo#e of th!# document
The p"rpose of this doc"ment is to o"tline the nat"re of asthma services that are to
be e<pected in New Zealand in order to6
provide appropriate access to care in the correct c"lt"ral framewor3
ens"re that providers meet agreed standards and are wor3ing in an effective well2
organised service
promote integration of services
allow effective patient:health professional partnerships to evolve where the prime
goal is ac8"isition by patients +and their families, of appropriate self management
s3ills
provide cost2effective care.
1#>
)> Pr!mr" cre #er-!ce#
)rimary health organisations +)H(s, sho"ld provide a co2ordinated comm"nity
based service with ready access for people with asthma to medical, n"rsing and
ed"cational services. Beneral practitioners sho"ld establish and maintain a register
of asthma patients in the practice and ens"re that all patients with significant asthma
on inhaled corticosteroid treatment are seen at least once a year for review.
The ann"al review appointment sho"ld incl"de a review of the following6
acc"racy of the diagnosis
level of asthma control
short acting bronchodilator dose and "sage
inhaled corticosteroid dose
inhaler techni8"es
self2management 3nowledge.
N"rses and the "se of des3top comp"ter2based review pac3ages will s"pport this
process. The review sho"ld also incl"de a meas"re of airflow obstr"ction s"ch a
spirometry or pea3 e<piratory flow rate.
.ll )H(s sho"ld provide appropriate ed"cation for their patients and all patients
re8"iring inhaled corticosteroid therapy and or who have re8"ired after ho"rs
attendance at hospital or B) clinic sho"ld have a written self management plan.
Smo3ing stat"s sho"ld be doc"mented for all asthma patients and smo3ing cessation
advice offered for all smo3ers with specific targeted to those who are well motivated
to stop smo3ing.
1#1
*H-s sho"ld review the primary care based ed"cation proects f"nded in 1&&1 to
ens"re that the desired o"tcomes have been achieved before deciding on f"rther
f"nding. The maor changes in asthma management which re8"ire implementation
are listed below.
1. *evelopment and implementation of the ad"lt asthma management g"idelines.
1, !mplementation of asthma self2management pac3ages +to patients with
persistent symptomatic asthma or severe episodic asthma,.
#. *evelopment of an e<tended role for clinical n"rse specialists in asthma
management.
5. Collaboration and integration across the interface of primary and secondary
care.
'or3 cond"cted by the .'B has established that the maor barrier to good 8"ality
asthma care in New Zealand is financial and *H-s:Ainistry of Health sho"ld e<plore
methods of eliminating or red"cing co2payments on medication and on B) visits.
1#?
/> Secondr" cre #er-!ce#
'here respiratory physicians are employed they sho"ld provide oversight of the
asthma service and they and their team sho"ld provide timely s"pport of general
physicians in their hospital and in their region. 'here there is no respiratory
physician appointed, one of the general physicians sho"ld be nominated to oversee
the asthma programme and develop strategies in line with regional and national
developments with maintenance of reg"lar contact with the regional respiratory
physician.
1##
'ithin hospitals, professionals sho"ld ens"re that g"idelines on asthma
management are available in the emergency department
1#5
and all medical wards,
that self management plans are available where appropriate for patients on
discharge, and that high2ris3 patients are followed "p in an o"tpatient clinic
+preferably an asthma clinic,.
7ach *H- sho"ld record basic statistics for the Ainistry of Health. These sho"ld
incl"de6
hospital admission and readmission +# to 11 months, rates
ro"te of admission +B), 7*,
emergency department attendance and re2attendance
o"tpatient attendances and !CD admission rates bro3en down by age, se<, and
race
appropriate statistics from primary care "sing the clinical indicators developed by
the .'B.
The main regional p"blic hospitals +."c3land Healthcare, 'aitemata Health, So"th
."c3land Health, 'ai3ato, 'ellington, Christch"rch and *"nedin, sho"ld provide
specialist services that incl"de specialist medical staff, ed"cation programmes, and
m"ltidisciplinary teams with appropriate c"lt"ral representation as a regional
reso"rce for other providers with an appropriate f"nding provision.
)aediatric services sho"ld be provided in a paediatric facility where possible and be
led by a paediatrician and other appropriate sta3eholders. *H- clinical advisors
sho"ld refer to the )aediatric Tertiary Services Review doc"ment for detailed
recommendations.
?> Re3!on$ coAord!nt!on nd !nte3rt!on
.sthma services sho"ld be ade8"ately coordinated between primary and secondary
providers to avoid fragmentation of care. There sho"ld be ade8"ate comm"nication
between primary and secondary care providers "nderpinned by electronic
information systems, especially for those with more severe asthma. . regional
advisory committee for asthma +preferably in association with other respiratory
disorders, sho"ld be established by *H-s to ens"re that there is a for"m for
providers to comm"nicate abo"t the services they provide, and to avoid d"plication of
services.
1#C
Aembers of the liaison committee sho"ld incl"de6
respiratory physician
paediatrician
primary care physician
practice n"rse
pharmacist
.sthma Society representative
health planner +*H- representative,
Aaori health wor3er
respiratory n"rse specialist.
!n regions where there is a high density of Aaori and:or )acific peoples, *H-s
sho"ld be enco"raged to contract to iwi and:or )acific !sland services who can
provide c"lt"rally appropriate, effective, integrated services rather than relying solely
on mainstream services. S"ch providers sho"ld be "nder the same scr"tiny,
incl"ding reg"lar reporting of statistics, as e<ist for primary and secondary healthcare
services and sho"ld be capable of achieving the same health o"tcomes.
1> I%! nd Pc!f!c pro-!der#
.sthma services for Aaori and )acific peoples are s"b2optimal in many areas of New
Zealand. Aany of these patients s"ffer social and economic deprivation which is an
important ris3 factor for asthma morbidity and mortality. !ndependent of ethnicity,
asthmatics residing in poor compared with affl"ent socioeconomic areas +"sing the
New Zealand *eprivation !nde< Scale,, are 1.# times more li3ely to be admitted,
#.? times more li3ely to re8"ire an intensive care init admission and $.> times more
li3ely to die.7rror6 Reference so"rce not fo"nd
Reso"rces sho"ld be directed towards accredited iwi and )acific providers to ens"re
that c"lt"rally appropriate care is readily accessible if there is a deficiency of Aaori
and )acific health care wor3ers in mainstream m"ltidisciplinary clinics. 7d"cation for
comm"nity health wor3ers need to be developed within their own comm"nities with
s"pport from accredited training agencies or their local respiratory service.
!t is essential that close comm"nication be maintained between hospital asthma
management teams and iwi and )acific providers, thro"gh the regional advisory board.
;> Educt!on #er-!ce#
The .sthma 'or3ing Bro"p has identified in an a"dit of ed"cation services that there
is a very large gap in the services provided in many regions of New Zealand,
partic"larly in r"ral and remote areas. Training needs to be provided for comm"nity
based n"rses, pharmacists and health wor3ers to provide greater one to one
ed"cation for patients to improve "pon training in self management s3ills. This
training m"st be delivered in a c"lt"rally appropriate way to those wor3ing with !wi
and )acific providers or other ethnic minorities.
15&
.ccess to certified training programmes which f"lfil NZM. standards needs to be
s"stained tho"gh directed f"nding initiatives to accredited providers of ed"cation
programmes. S"ch programmes sho"ld be overseen by a national committee of
professionals e<pert in ed"cation and asthma management to ens"re they are of a
high standard. )rofessionals who attend s"ch co"rses sho"ld be re2certified
reg"larly to ens"re that their s3ills are maintained and that comm"nity sensitivities
are at an acceptable standard.
N"rse practitioners in primary and secondary role will have a central role in providing
ed"cation for patients with asthma. .sthma ed"cation has been shown to be of
greatest benefit when provided in association with an asthma clinic and with
"tilisation of self2management plans.
1#$,1#;
!t is li3ely only to be of "se if the strategies
are realistic, relevant to individ"al patients and reinforced over time and th"s
cond"cted as part of "s"al health care delivery, that is research s"pports greatest
benefit when provided in the conte<t of a team approach rather than by an ed"cator
wor3ing in isolation.
.> 6u!de$!ne de-e$opment nd d!##em!nt!on
The .sthma 'or3ing Bro"p is f"lly committed, in con"nction with the New Zealand
B"idelines Bro"p, to the development of g"idelines for the management of asthma in
both ad"lts and children in primary care. These evidence2based g"idelines which will
be la"nched in Aay 1&&1 sho"ld be adopted, disseminated, and implemented by
primary providers. )H(s sho"ld be re8"ired to report on dissemination and
implementation strategies.
@> Appropr!te u#e of phrmceut!c$#
The .'B will wor3 with )H.RA.C, the Thoracic Society of ."stralia and New
Zealand +TS.NZ, and the Royal New Zealand College of Beneral )ractitioners
+RNZCB), to promote effective best practice in asthma management. !nitiatives
already "nderway incl"de adoption of appropriate self2management plans, which
enco"rage bac3 titration of inhaled corticosteroid medications to the lowest effective
dose and the appropriate "se of inhaled long acting beta agonists. The .'B
strongly s"pports the need for a prescription dr"g plan along the lines established in
Sas3atchewan with the "se of "ni8"e NH! n"mber on prescriptions to allow
electronically lin3ed data collection.
1#>
+> Commun!t" or3n!#t!on#
There are a large n"mber of comm"nity organisations and gro"ps that contrib"te to
the care of people with asthma. 7<amples incl"de the .sthma and Respiratory
/o"ndation of New Zealand and their affiliated societies and .sthma New Zealand.
These gro"ps sho"ld be s"pported and enco"raged to form partnerships with
primary and secondary providers along with iwi and )acific providers. 7d"cation
services provide by s"ch gro"ps sho"ld be delivered by staff who have received
appropriate training and are recertified reg"larly.
151
*> Future !n!t!t!-e#
=34 &urse+run clinics
The .sthma 'or3ing Bro"p +.'B, enco"rages the role of practice n"rses and
specialist n"rses in the management of patients with asthma. N"rses can, with
appropriate training, contrib"te in a maor way to long2term asthma care incl"ding
ed"cation, training in self2management s3ills, review of medications and assessment
of ade8"acy of treatment. The .'B recommends that s"ch clinics sho"ld be
cond"cted as part of a larger primary or secondary care team with a doctor available
nearby, whilst the o"tcome of a f"ll scientific eval"ation of the place of n"rse r"n
clinics is "nderta3en.
=3 &urse prescribing
The .'B recommends that pilot programmes be f"nded to investigate the role of
N"rse )ractitioners prescribing for caref"lly selected patients with asthma. This
wo"ld incl"de provision of reliever medication and ad"stment of the dose of inhaled
corticosteroid medication, incl"ding device changes for patients already established
on these medications. (nly n"rse practitioners with appropriate training and ongoing
accreditation programmes sho"ld be allowed to prescribe within a collaborative team
model.
=3> Annual review visit
The .'B believes that primary care teams of doctors and n"rses sho"ld cond"ct an
ann"al review "sing recommended criteria developed as a des32top comp"ter
proforma. The clinician cond"cting these reviews wo"ld see3 inp"t from other team
members where necessary. !t is recommended that wherever possible s"ch reviews
be cond"cted in sit"ations where there is a doctor present.
)harmacists have an ac3nowledged place in the m"ltidisciplinary approach to
asthma management. They are 8"alified to review medication "se incl"ding device
techni8"e and self2management s3ills and provide basic ed"cation where needed.
Their inp"t m"st be comm"nicated to the primary health care team.
The .'B recommends that the Ainistry of Health and *H-s investigate the cost2
effectiveness of providing a s"bsidy for ann"al review visits to ens"re better
attendance and to enco"rage appropriate titration of medication, which co"ld accr"e
significant cost savings on pharmace"ticals.
)rofessor !an Town
Chairman
The .sthma 'or3ing Bro"p
/ebr"ary 1&&1
151
Append!D IIV8 Accred!tt!on of Spec!$!#t Ser-!ce#>
)> A mode$ of credent!$!n3 proce## %h!ch cou$d 4e pp$!ed to re#p!rtor"
#er-!ce# 4#ed on recommendt!on# of the 7!n!#tr" of 5e$th
/?+
Conf!dent!$ to the Un!t Credent!$!n3 nd Credent!$# Comm!ttee#
A7*!C.0 CR7*7NT!.0!NB
"ndiidual(s name
!ndivid"al self2assessment *7).RTA7NT (/ R7S)!R.T(R4 A7*!C!N7
)nit*serice name
See reerse of this sheet for e+planatory notes
1.& New Zealand Aedical Co"ncil Registration ACNZ Reg No...........................................................
1.1 "ndicate ,hether ocational -,hich speciality or
specialties./ general or other registration!
1.1 !f holding general registration/ ,ho ,ill proide
your oersight as required by the &edical
Practitioners %ct 01123
1.& Relevant 8"alifications and s"b2
specialty training
#.& Health .re yo" aware of any personal health iss"es that may impact on yo"r
clinical performanceY
4es
No
!ndicate on the scale +F, how yo" perceive yo"r s3ill:e<pertise in each of these areas of clinical practice.
5.& Core ct!-!t!e# Not competent Competent EDpert
.irways disease
0"ng cancer
!nterstitial l"ng disease
T"berc"losis
)le"ral disease
/iberoptic bronchoscopy
.ssisted ventilation
Thomboembolic disease
$.& Spec!$ ct!-!t!e# Not competent Competent EDpert
Sleep disordered breathing
Transplant
Cystic fibrosis
)rimary p"lmonary hypertension
)hysiology
-roncho2alveolar lavage and
transbronchial biopsy
Rigid bronchoscopy
Specialist rigid bronchoscopy %
laser, stenting
Thoracoscopy
Transbronchial needle aspiration
15#
.reas of practice re8"iring f"rther training6
.reas of practice yo" wo"ld li3e to relin8"ish6
Comments6
Signat"re6
A7*!C.0
CR7*7NT!.0!NB
*7).RTA7NT (/ R7S)!R.T(R4 A7*!C!N7
)nit*serice name
&)( De#cr!pt!on of un!tC#er-!ce *escribe the "nit:service in narrative form "sing the headings listed.
.spect *escription
1.1 Clinical role within *H- and within
the New Zealand health system.
0ist core and s"b2specialty
services.
1.1 Role of clinical s"b2"nits +if any,.
1.# NCatchment= pop"lation and
bo"ndaries for 1
o
, 1
o
, #
o
and 5
o

services.
1.5 Contracted services and vol"mes +if
relevant, and relation of these to
clinical need.
1.$ Teaching, training and research
roles.
1.; Senior and "nior medical staff
establishments. +N"mber of
individ"als and total /T7 for Ho"se
(fficer +)B41T1,, SH(, Registrar,
A(SS and specialists.,
&/( 7tch of re#ource to %or2$od !dentify any significant discrepancies between available reso"rces
and role:wor3load. .ny deficiency m"st be s"bstantiated with data
and +if available, references to benchmar3s. Non2DS international
comparisons are preferred.
Reso"rce .ppropriate *etails of relevant wor3 and discrepancy
1.1 Aedical staff establishment.
1.1 Senior medical s3ill mi< +incl"de
"n"sed clinical s3ills,.
1.# N"rsing staff +ward, clinic, (R, etc,.
1.5 .llied Health s"pport.
1.$ Clerical, technical and other staff
s"pport.
1.; 78"ipment.
1.> .ccess to physical reso"rce +ward
beds, (R time, clinics, and so on,.
155
1.? 0in3ages with and s"pport from
other services.
1.C Reso"rces for teaching, training
and research.
&?( Bu$!t" ##urnce ct!-!t!e# !ndicate the level of achievementL of yo"r "nit:service in each area
of 8"ality ass"rance activity.
Standard Dnit:service
ratingL
*etails
#.1 (rientation programme+s, meet
the needs of senior and "nior
medical staff.
#.1 .ppropriate written clinical
g"idelines and protocols are
"sed.
#.1.1 )rocesses are established for the
development and reg"lar review
of policies, g"idelines and
protocols.
#.1.1 . policy for the introd"ction of
new or innovative proced"res is
"sed.
#.# Senior medical staff participate in
the m"ltidisciplinary 8"ality gro"p.
#.5 Reg"lar meetings occ"r with
relevant lin3ed services +eg,
radiology, pathology,.
#.$ *epartmental clinical case
reviews are "nderta3en.
#.; !ndivid"al senior medical staff
practice a"dits are operational.
#.> *epartmental clinical indicators
are "sed.
#.? *epartmental medical teaching
and learning for"ms are provided.
#.C )eer review occ"rs at least
ann"ally. +N#;& degree= model is
preferred.,
L S. % s"bstantial achievementE ). % partial achievementE A. % minimal achievement
&1( Core re#pon#!4!$!t!e# *escribe the responsibilities e<pected of all senior medical staff of
this "nit:service, with allowance for varying /T7 if appropriate. /or
core clinical responsibilities indicate minim"m 8"alifications and
incl"de o"tcome or fre8"ency standards only where they are
act"ally meas"rable. Core 8"ality ass"rance responsibilities
incl"de College CA7:A()S re8"irements and participation in the
c"rrent "nit:service 8"ality ass"rance activities +Section #,
5.& Ainim"m 8"alifications:
e<perience
5.1 Clinical activities Ainim"m re8"irements:standard
15$
5.1 M"ality ass"rance Ainim"m re8"irement
5.1.1 CA7:A()S
&;( Spec!$ re#pon#!4!$!t!e# !dentify the areas of "nit:service clinical practice where special
8"alifications, s3ills or e<perience are re8"ired. Specify the
minim"m re8"irements for granting privileges in each area,
incl"ding o"tcome or fre8"ency standards only where they are
act"ally meas"rable.
Clinical activity Ainim"m re8"irements:standards
/> Accred!tt!on of #$eep d!#order# #er-!ce#
http8CC%%%>#$eepu#>on>netCccred!tt!on#$eep>pdf
Introduction
04 Preamble
.ccreditation of sleep disorders services is, at present, vol"ntary. The Thoracic
Society of ."stralia and New Zealand +TS.NZ, and the ."stralasian Sleep
.ssociation +.S., have established an accreditation process to foster e<cellence in
the approach to management of sleep disorders. The process see3s to define
"niform minim"m standards for services in ."stralia and New Zealand. !t is intended
that, while rigoro"s, the process be N"ser friendly=. !t will be revised periodically and
constr"ctive s"ggestions for improvement are welcomed by the TS.NZ )rofessional
Standards S"bcommittee and the .S. Clinical Committee.
The process assesses the service=s organi9ation and administration, staffing and
direction, policies and proced"res, staff development and ed"cation, facilities and
e8"ipment, and 8"ality ass"rance programmes. !ts general approach is infl"enced
by programmes established by the ."stralian Co"ncil of Healthcare Standards
+.CHS, and the .merican Sleep *isorders .ssociation. !t is hoped that consistency
with .CHS g"idelines will decrease the amo"nt of wor3 necessary to prepare the
application for those laboratories that have already been involved in .CHS
accreditation proced"res +for e<ample, hospital accreditation, and help prepare the
way for .CHS accreditation where this is anticipated.
The first phase of the process involves answering a detailed 8"estionnaire that has
been designed to assess the laboratory=s readiness for accreditation. Self
.ssessment is a 3ey feat"re of this phase of the process. .bility to satisfactorily
respond to the 8"estionnaire, g"ided by the NStandards for .ccreditation= detailed
below, sho"ld indicate to the applicant service its li3ely ability to comply with the
re8"irements for accreditation. !f satisfied that its responses are ade8"ate the
service s"bmits a completed application. !f the TS.NZ*.S. .ssessment )anel is
15;
satisfied that the application meets the re8"ired standard a site visit follows. These
proced"res are detailed "nder N.dministration= below.
0aboratories that intend to st"dy children of 11 years of age or yo"nger m"st be
separately accredited for that p"rpose. Children over 11 years witho"t comple<
medical conditions or n"rsing re8"irements can be st"died in ad"lt accredited
laboratories provided ade8"ate res"scitation facilities incl"ding appropriately trained
staff are available.
54 Definition
.ccreditation is the process whereby the professional standards and competence of
a Sleep *isorders Service is formally recognised by the TS.NZ and the .S..
64 Purpose
a, To enco"rage appropriate standards of medical and technical practice, to
ens"re that a service is effective.
b, To grant recognition to services which achieve these standards.
c, To foster the standards of service by cons"ltation and advice rather than by
reg"lation, consistent with the vol"ntary nat"re of accreditation.
Administration
04 Coordinator
1.1 The process of .ccreditation will be administered on behalf of the TS.NZ and
.S. by an .ccreditation Coordinator.
1.1 The .ccreditation Coordinator will be a member of the )rofessional Standards
S"bcommittee +)SS. of the TS.NZ and a member of the Clinical Committee of
the .S.. He or she will have e<pertise in clinical respiratory physiology and
sleep disorders.
1.# The .ccreditation Coordinator will be elected yearly by the )SS at the time of
the TS.NZ .nn"al Scientific Aeeting.
1.5 The minim"m term of office of the .ccreditation Coordinator is one year, the
ma<im"m term is fo"r consec"tive years. .n individ"al is eligible for re2election
after a minim"m period of two years d"ring which he or she has not held the
office of .ccreditation Coordinator.
1.$ The .ccreditation Coordinator will be responsible for administering the process
of .ccreditation incl"ding receipt of applications, appointment of an assessment
panel, s"pervision of each accreditation process incl"ding prod"ction of a report
which is clear and reasonable in its comments and recommendations.
1.; The Chairperson of the )SS will act on behalf of the .ccreditation Coordinator
in his or her absence. The .ccreditation Coordinator will be the Gice2Chairman
of the )SS.
15>
54 Process
1.1 .pplications for accreditation will be received by the 7<ec"tive Secretary of the
TS.NZ.
1.1 The 7<ec"tive Secretary will respond to all applications by providing applicant
laboratories with .ccreditation g"idelines and the application forms which see3
information regarding the laboratory and investigations:meas"rements that it
performs +Nthe accreditation pac3age=,. These forms incl"de 8"estions
designed to indicate the laboratory=s readiness for accreditation. Self
assessment is a 3ey feat"re of this phase of the process. (nce satisfied it can
respond to the 8"estions ade8"ately the laboratory completes the forms and
ret"rns them to the 7<ec"tive Secretary, along with an Ninitial assessment= fee
which covers the cost of initial assessment of s"bmitted material. Copies of all
correspondence will be sent to the .ccreditation Coordinator. . f"rther fee +the
Nsite visit= fee, will be charged if the application is fo"nd to be acceptable and a
site visit is arranged +see below,. These fees, which are set to recover costs/
will be determined by the TS.NZ and revised from time to time. The c"rrent fee
sched"le is obtainable from the TS.NZ office.
1.# (n receipt of the Ninitial assessment= fee and application forms an .ssessment
)anel will be appointed. The assessors will be recognised e<perts in the
diagnosis and management of sleep disorders and:or the technical aspects of
their assessment. The assessment panel will have three members, at least one
of whom will be from a city other than the one in which the service "ndergoing
accreditation is located. The Chairperson will be a member of both the TS.NZ
and the .S. and will be appointed ointly by the .ccreditation Coordinator of
the TS.NZ and the Chairperson of the Clinical Committee of the .S.. The
other two members of the panel will be nominees of the .S. and TS.NZ
respectively, one of whom need not be a member of either society4 'here
practicable one member will be a sleep technologist.
The assessment panel for paediatric laboratories sho"ld incl"de a paediatrician
trained in respiratory2sleep medicine and a paediatric sleep technologist.
1.5 The Chairperson of the assessment panel will ca"se the doc"mentation
s"pplied by the applicant laboratory to be reviewed by the panel members and
see3 s"pplementary information where necessary. The res"lt of the initial
assessment will be given to the applicant within eight wee3s of receipt of the
application. !f the application is "nacceptable the reasons for the decision will
be provided. !f the application is acceptable a site visit will be arranged at a
m"t"ally convenient time +within two to three months of notice of approval,.
1.$ The site visit is a critical step in the accreditation process. .t the site visit the
veracity of answers provided in the application is e<amined. Specific 8"estions
raised by the application will be addressed and an inspection of the facilities will
be "nderta3en. The site visit will incl"de6
a, an inspection of patient set2"p proced"res and the cond"ct of a sleep
st"dy
b, an assessment of the interpretative and reporting s3ills of the medical
director and the reporting physicians
15?
c, an assessment of the practical and interpretive s3ills of the technicians in
attendance on the night of the site visit, and of the s3ills of the technical
staff responsible for analysis of records.
)olysomnographic records from the si< months prior to the site visit sho"ld be
available for inspection. The panel will randomly choose "p to 1& records for
inspection.
. re8"irement for ad"lt laboratories is that on the night of the site visit at least
two patients be st"died in the laboratory one of whom sho"ld be sched"led for a
C).) titration st"dy. -eca"se of the relatively small n"mber of patients treated
with C).) or non2invasive ventilation, a disc"ssion of the process of titration
pl"s a demonstration of familiarity with C).) e8"ipment by the staff can
s"bstit"te for observation of C).) titration in paediatric laboratories
The Chairperson of the assessment panel is responsible for the review process,
incl"ding prod"ction of a report and recommendations which will be forwarded
to the .ccreditation Coordinator.
1.; The assessment process has two p"rposes6
a, .dvisory % to advise on ways in which perceived deficiencies of a service
can be corrected.
b, 7val"ation % to establish whether a service is competent and effective.
64 Granting accreditation
#.1 To e<pedite the process an accreditation advisory panel is empowered to act on
behalf of the TS.NZ and the .S. and grant accreditation according to the
recommendations of the assessment panel. The advisory panel will comprise
the Chairman of the )SS of the TS.NZ, the Chairman of the Clinical Committee
of the .S./ the .ccreditation Coordinator and the assessment panel which
assessed the partic"lar laboratory.
#.1 The assessment panel may recommend that accreditation be awarded
"nreservedly or s"bse8"ent to rectification of identified deficiencies. !n the
latter case accreditation will be recommended on receipt of evidence that all
s"ggested changes have been implemented. The application will lapse after
11 months from the date of iss"e of the recommendations in the absence of
s"ch evidence. This provision will only apply where the panel considers that the
changes are relatively minor and can be implemented and verified witho"t need
for a f"rther site visit. The process see3s Ns"bstantial compliance= with the
standards. !t is recognised that local conditions may precl"de absol"te
compliance with every standard.
The service will be accredited to st"dy ad"lts, children or both ad"lts and
children, according to the type of application and compliance with the relevant
standards.
#.# 'here, in the opinion of a partic"lar accreditation advisory panel, a report is
potentially contentio"s or there is disagreement over its recommendations, the
report will be referred to a oint meeting of the )rofessional Standards
S"bcommittee of the TS.NZ and the Clinical Care Committee of the .S. for
consideration and decision.
15C
#.5 . recommendation against accreditation will normally be referred to the
)residents and 7<ec"tives of the TS.NZ and .S. for confirmation before the
report is iss"ed.
#.$ . Certificate of .ccreditation will be iss"ed on behalf of the TS.NZ and .S.
once the recommendation for accreditation has been made by the .ccreditation
.dvisory )anel. The certificate will be signed by the Chairs of the )rofessional
Standards S"bcommittee and the Clinical Committee of the TS.NZ and .S.
respectively, and by the )residents of the TS.NZ and .S.. .ccreditation is
granted for a period of five years.
#.; 0aboratories that fail accreditation will be advised of the reasons for the
decision. !f the laboratory wishes to challenge the decision it m"st do so in
writing to the .ccreditation Coordinator within 15 days of receiving the decision,
stating the reasons for appeal. The appeal will then be considered by a oint
meeting of the )rofessional Standards s"bcommittee of the TS.NZ and the
Clinical Care Committee of the .S. to be convened within si< wee3s of receipt
of the appeal. . recommendation against accreditation following appeal will be
referred to the )residents and 7<ec"tives of the TS.NZ and .S. for
confirmation before the report is iss"ed. The .ccreditation Coordinator will
advise the laboratory of the decision on the appeal and the reasons for the
decision. . laboratory that fails accreditation may reapply at any time that it
believes its standards have met those re8"ired for accreditation.
#.> 7ach accreditation report will be seen in f"ll by the )SS of the TS.NZ and the
Clinical Committee of the .S..
#.? The .ccreditation Coordinator will provide the 7<ec"tive of the TS.NZ with an
.nn"al Report, a copy of which will be sent to the 7<ec"tive of the .S.4
74 Re8accreditation of an accredited serice
5.1 No less than 11 months before the end of the five2year accreditation period the
7<ec"tive (fficer of the Society will provide to the Aedical *irector of the
Service6
a copy of the previo"s assessment panel report.
the c"rrent accreditation g"idelines and application for initial accreditation.
a re8"est for re2accreditation.
5.1 The re8"est for re2accreditation will elicit information regarding the laboratory
and the investigations or meas"rements it performs. .dditionally, the Aedical
*irector will be as3ed to detail changes to the service since the previo"s
accreditation. 7mphasis will be placed on the implementation of
recommendations s"ggested by the previo"s assessment panel report.
The service completes the re8"est for re2accreditation and ret"rns only these
forms to the 7<ec"tive (fficer, along with the site visit fee c"rrent at the time of
application. The service m"st also complete the application for initial
accreditation and "pdate laboratory man"als to reflect c"rrent practice. The
application for initial accreditation and laboratory man"als are to be retained by
the service for review at any s"bse8"ent site visit. Copies of all
correspondence will be sent to the .ccreditation Co2ordinator.
1$&
(n receipt of the re8"est for re2accreditation the .ccreditation Coordinator will
appoint an assessment panel and its Chairperson as described in
paragraph 1.#. 'here practicable at least one member of the assessment
panel will be from the previo"s assessment panel.
5.# The Chairperson of the assessment panel will arrange for the re8"est for
re2accreditation and the previo"s assessment panel report to be reviewed by
the panel members. The res"lt of this review will be provided to the service
within si< wee3s of receipt of the re8"est. !f the re8"est for re2accreditation is
"nacceptable then reasons for the decision will be provided and the site visit fee
ref"nded. !f the re8"est for re2accreditation demonstrates that the service has
ade8"ately addressed the recommendations contained in the previo"s
assessment panel report a site visit will be arranged.
5.5 Normally, the site visit will occ"r at least three months before the end of the
c"rrent five year accreditation period. .t the site visit attention will foc"s on
problems or deficiencies identified d"ring the previo"s accreditation.
Compliance with any new or revised standards introd"ced since the previo"s
accreditation will also be e<amined as may any aspect of the service=s
operations. The Chairperson of the assessment panel is responsible for the
review process incl"ding prod"cing a report and recommendations that will be
forwarded to the .ccreditation Coordinator.
5.$ The process of granting re2accreditation will be as described in Section #
+Branting .ccreditation,.
24 Confidentiality of assessment procedures
$.1 .ll information provided by a service in relation to preliminary en8"iries or to an
application for .ccreditation and all information obtained in the co"rse of, or in
connection with, an assessment of the service is considered by the TS.NZ and
the .S. to be completely confidential. S"ch information is received and st"died
only by members of the ..C, the ..C assessors and the TS.NZ and .S.
7<ec"tives, and these persons are all made aware of the confidential nat"re of
this information.
$.1 The TS.NZ and the .S. re8"ires that all doc"ments associated with
accreditation of a service be maintained in strict confidence. This re8"irement
imposes partic"lar obligations on assessors. .n assessor m"st not disclose
any information gained d"ring an assessment to any person other than a
member of the ..C. Dnder normal circ"mstances there is little need for an
assessor to retain a copy of the briefing notes provided for an assessment or a
copy of his or her report.
$.# !t may be pr"dent for an assessor to 3eep a copy of the report temporarily to
obviate loss in the mail, b"t this copy sho"ld be destroyed once
ac3nowledgement of receipt is received by the ..C. !f an assessor retains
copies of briefing notes or reports, they m"st be 3ept in a sec"re place. They
are not to be incorporated into the general records system of the assessors=
employer in a manner which wo"ld allow "na"thorised access by others.
1$1
"tandards for accreditation
This doc"ment o"tlines the minim"m standards re8"ired for accreditation of a sleep
disorders service. !t m"st be read in con"nction with the 8"estionnaire in the
application for accreditation. !t sho"ld be referred to when completing the application
to ens"re that the laboratory is li3ely to meet the re8"irements before s"bmission.
04 "dentifying information
That information identifying the applicant service be specified at the front of the
application +/orm .,.
54 9istorical oerie,
That a brief overview of the history of the development of the service be provided
with the application.
64 Organisation and administration
That the service is organised and administered to meet its obectives and the needs
of the pop"lation it serves.
#.1 6o$# nd o4Eect!-e#8 That the service=s goals and obectives are specified
and that they reflect its role and responsibilities.
#.1 Re$t!on#h!p to ho#t !n#t!tut!on, other $4ortor!e#8 That the relationship+s,
of the service to its host instit"tion and to related laboratories are appropriate to
the discharge of its responsibilities. These relationships m"st be specified and
clearly defined. There sho"ld be evidence of commitment by the host instit"tion
to its s"pport.
#.# Re$t!on#h!p# %!th other #pec!$!t!e#8 Services are enco"raged to develop a
broad range of s3ills in the management of sleep disorders. 'here this is
limited +eg, to sleep breathing disorders, the service sho"ld have established
appropriate relationships and comm"nication with other specialities with a
common interest in sleep disorders to ens"re that clinical problems are directed
to clinicians with relevant e<pertise and to facilitate advancement in clinical
standards. This applies, for e<ample, to the management of a patient referred
with e<cessive somnolence to a Nrespiratory= sleep disorders service in whom
sleep disordered breathing is s"bse8"ently e<cl"ded as a ca"se4
#.5 Referr$#8 That the so"rces and types of referrals to the service are relevant to
the services provided. 7ach patient sho"ld have had an appropriate clinical
eval"ation prior to a diagnostic st"dy. 'hile the service can perform tests
re8"ested by other clinicians witho"t direct cons"ltation with the patient, one of
the reporting cons"ltant medical staff of the service m"st obtain and review
s"fficient information prior to the test to ens"re that it is appropriate to the
patient=s condition. )olysomnography sho"ld only be performed for those
disorders of sleep for which it is of established diagnostic val"e. !n the case of
children, each patient sho"ld be eval"ated by a paediatrician with e<pertise in
sleep and or respiratory medicine prior to a diagnostic st"dy.
#.$ Wor2$od8 That the service=s reso"rces +staffing, e8"ipment, facilities and
finances, are s"fficient to meet its wor3load witho"t compromising the minim"m
standards set elsewhere in this doc"ment and in the TS.NZ g"idelines.
1#C
1$1
#.; Demnd8 That the service attempts to ade8"ately cope with the demand for its
services. 'here demand e<ceeds capacity, the service sho"ld have a system
for prioritising cases perceived to be "rgent. Drgent cases sho"ld be assessed
and st"died in less than two wee3s.
#.> 'ud3et8 That the service=s financial plan and b"dget covers it=s operational
costs or that there is a commitment by the host instit"tion or company to
"nderwrite b"dget deficits.
74 Staffing and direction
The service is directed and staffed to achieve its obectives.
5.1 Stff #tructure nd d!rect!on8
That the service has a medical director responsible for overall clinical
standards and development of policies governing the service. These sho"ld
be ratified by other committees in the host instit"tion as necessary.
That there are clear, doc"mented lines of acco"ntability:responsibility
between medical director and all staff members. These m"st represent the
act"al manner in which the service is organised, be reg"larly reviewed and
readily available to all staff.
That a single designated cons"ltant is responsible for each patient=s
investigation and advice regarding management.
5.1 Stff 9u$!f!ct!on# nd eDper!ence8
That staff members are appropriately 8"alified for their tas3s by ed"cation,
training, and or e<perience, and that their roles and responsibilities are
specified by ob description. The medical director sho"ld have specific,
detailed training in sleep disorders and meet the criteria set by TS.NZ
g"idelines.7rror6 Reference so"rce not fo"nd Consistent with the criterion
set by TS.NZ g"idelines for advanced trainees
15&
wishing to practice
predominantly in sleep disorders medicine, the medical director is e<pected
to have the e8"ivalent of two years= f"ll2time training in sleep disorders.
(ther reporting cons"ltant medical staff are e<pected to have completed the
e8"ivalent of at least one year f"ll2time training in sleep disorders medicine,
consistent with the g"idelines for trainees wishing to ma3e sleep disorders
medicine an important area of their practice.
There is c"rrently no recognised tertiary training programme in sleep
disorders eval"ation for scientific:technical staff, hence individ"als m"st
receive Non the ob= training in an established service. -asic 8"alifications will
depend on the local re8"irements for classification as either scientific or
technical staff +eg, a tertiary degree,. Scientific or technological staff are
responsible for acc"rate performance of sleep st"dies and other tests,
e8"ipment maintenance, eval"ation and development of new e8"ipment and
techni8"es, and patient safety d"ring performance of tests. . minim"m of
two years e<perience in a sleep disorders service and a tertiary degree in
biological or physical sciences, or e8"ivalent 8"alification, is desirable for a
scientist or technologist to be able to f"nction in a s"pervisory capacity "nder
medical direction.
1$#
)aediatric laboratories m"st have the facility to care for sic3 children or
children with comple< conditions. /or most laboratories this will re8"ire
n"rses with paediatric e<perience trained in polysomnography with additional
paediatric n"rsing s"pport as necessary. .ll staff m"st be certified as
competent in paediatric cardiop"lmonary res"scitation.
5.# Stff num4er#8
That s"fficient medical, technical and clerical staff are employed to
ade8"ately meet service needs. This will depend on the wor3load,
organisation, and type of e8"ipment and circ"mstances of the individ"al
hospital. . fo"r2bed sleep laboratory sho"ld employ appro<imately two f"ll2
time e8"ivalent medical staff. /or sleep st"dies rostering m"st allow for the
following conditions6
a technologist m"st be in attendance thro"gho"t the st"dy +see below for
f"rther e<planation or 8"alification,
the st"dy m"st be of at least eight ho"rs d"ration incl"ding at least one
ho"r for the preparation of each patient prior to st"dy and a f"rther ho"r for
completion of d"ties following termination of the st"dy
in general, a ratio of no less than one technologist to three patients sho"ld
be allowed for overnight
at least two ho"rs sho"ld be allowed for analysis of each st"dy.
. higher staff per patient ratio is re8"ired when st"dies of e<tra comple<ity
are "nderta3en, for e<ample non2invasive or invasive ventilation trials, or
titration of C).) in patients with respiratory fail"re. Rosters m"st also allow
for e8"ipment calibration and maintenance, preparation and processing of
reports, and in service ed"cation or professional development. Rosters m"st
meet relevant award re8"irements for meal brea3s, shift wor3, p"blic holidays
and leave.
!n the case of paediatric laboratories additional n"rsing re8"irements
necessitate a higher staff%patient ratio6 no less than one n"rse or
technologist to two patients. Rosters sho"ld be fle<ible to allow st"dy
commencement at or close to the child=s normal bedtime.
:+planatory notes!
J. technologist m"st be in attendance thro"gho"t the st"dy.K Short absences
from the facility +eg, toilet brea3s ta3en away from the laboratory, d"ring a
ro"tine diagnostic or C).) titration st"dy may be covered by staff who have
limited technical e<pertise in sleep st"dies b"t nevertheless are able to attend to
the needs of the patient and are trained in emergency proced"res. Aore
prolonged absences from the facility +eg, meal brea3s, in s"ch cases, or short
absences d"ring comple< st"dies +eg, nasal !))G trials,, sho"ld be covered by
another sleep technologist.
!n a free standing laboratory +that is a laboratory located away from a hospital
that has emergency bac3 "p, two staff trained in emergency proced"res sho"ld
be in attendance for the d"ration of the st"dy to ens"re safety and sec"rity of
patients and staff.
1$5
!n the case of paediatric laboratories a team trained in paediatric
cardiop"lmonary res"scitation m"st be available on site for the d"ration of the
st"dy.
5.5 Stff ppr!#$8 That a staff appraisal system is in operation, that a written
report is prod"ced, that the staff member involved is aware of the contents of
the report and that a plan to address deficiencies is defined.
5.$ Tr!n!n3 of #tff !n crd!opu$monr" re#u#c!tt!on8 That all medical,
technological and n"rsing staff are trained in cardiop"lmonary res"scitation, and
that a basic level of competence is maintained and eval"ated reg"larly. !n the
case of paediatric laboratories, special training in paediatric cardiop"lmonary
res"scitation is re8"ired.
24 Policies and procedures
That the service has doc"mented policies and proced"res that reflect c"rrent
3nowledge and practice in the cond"ct of a sleep disorders service and, where
relevant, comply with stat"tory re8"irements.
$.1 Pt!ent referr$, hnd$!n3, documentt!on, fo$$o%Aup8
That proced"res e<ist for prompt, efficient handling of patient referrals, initial
cons"ltations and follow2"p, doc"mentation, comm"nication with the referring
doctor, and protection of patient confidentiality, and that these are consistent
with good professional practice. !t is e<pected that patients be clinically
eval"ated prior to sleep st"dy. . patient record sho"ld be maintained, which
is well ordered and contains all laboratory reports, records of cons"ltations
and proced"res, copies of correspondence, wor3ing and or final diagnoses
and, where appropriate, clearly defined treatment or follow2"p
recommendations.
Recommended treatments m"st be consistent with c"rrent 3nowledge and
practice. Correspondence sho"ld be completed promptly +within five wor3ing
days, following each patient contact. Special care sho"ld be ta3en with
transmission of information by facsimile. Dse of the fa< for this p"rpose
sho"ld be minimised and any information transmitted by these means sho"ld
be accompanied by a s"itably worded warning regarding the confidential
nat"re of the enclosed information. )atient records sho"ld be 3ept for a
period of time that complies with legislative re8"irements and is consistent
with good professional practice.
$.1 S$eep #tud!e#8 t"pe#, method# of me#urement8 That methods for the
cond"ct of sleep st"dies, are consistent with recognised standards, incl"ding
the relevant TS.NZ g"idelines7rror6 Reference so"rce not fo"nd and, where
applicable, paediatric g"idelines.
151
Types of sleep st"dies performed and the
parameters meas"red m"st be specified. Sleep st"dies m"st allow f"ll
disclos"re of the raw signals, which m"st be ade8"ately labelled and calibrated.
Standard physical calibrations sho"ld be "sed wherever possible. 'here
electrical calibration is "sed it m"st be chec3ed against physical calibration
reg"larly. Calibrations sho"ld be done prior to each st"dy and whenever
acc"racy is in do"bt. 7ach calibration proced"re sho"ld be repeated at least
twice to ens"re reprod"cibility. Calibration res"lts sho"ld be clearly labelled.
The e8"ipment m"st conform to specifications +linearity, sensitivity, fre8"ency
1$$
response, signal to noise ratio, stability, that ens"re collection of meaningf"l,
interpretable res"lts. (vernight vis"al monitoring of patients +by infra2red or low
light video, is a desirable feat"re.
$.# S$eep #tud!e#8 n$"#!# nd !nterprett!on8
That methods for the analysis of sleep st"dies are consistent with recognised
standards, incl"ding the relevant TS.NZ g"idelines.7rror6 Reference so"rce
not fo"nd Scoring and interpretation of the data sho"ld conform to .merican
Thoracic Society
151
and .merican Sleep *isorders .ssociation
15#,155

recommendations. !n the case of paediatric laboratories, scoring and
interpretation sho"ld conform with .TS and .S*. recommendations for the
analysis of polysomnographic st"dies in children and be age
appropriate.7rror6 Reference so"rce not fo"nd
,15$
'hile analysis of the sleep st"dy may be performed by a well2trained
technologist, interpretation is the responsibility of the patient=s clinician.
Comp"terised analysis systems are considered aids to the process6 final
analysis m"st be performed man"ally and involve reference to the raw data,
as m"st interpretation by the responsible clinician. The report m"st clearly
identify the Service, and the )atient and the date of the st"dy. !t sho"ld be
consistent with TS.NZ g"idelines,7rror6 Reference so"rce not fo"nd
containing the st"dy res"lts along with an interpretive s"mmary statement
signed by the interpreting clinician. The laboratory sho"ld have established
methods for assessing the 8"ality of meas"rements and analysis incl"ding
periodic assessment of inter2observer variability in analysis of sleep st"dies
+see also C, M"ality .ss"rance,.
$.5 Other procedure#8 That the methods for m"ltiple sleep latency testing +AS0T,
and related st"dies are consistent with established standards
15;
, incl"ding the
relevant TS.NZ g"idelines7rror6 Reference so"rce not fo"nd. !t is e<pected
that sleep services be able to perform AS0Ts, or have an affiliation with a
service with that capacity, to enable the f"rther investigation and diagnostic
refinement of the sleepy patient eg. to confirm or e<cl"de the presence of
pathological daytime sleepiness in diffic"lt cases, or to assist in the diagnosis of
narcolepsy.
$.$ N#$ cont!nuou# po#!t!-e !r%" pre##ure &nCPAP( nd other re#p!rtor"
pp$!nce#8 That proced"res for the prescription and s"pply of C).) therapy
and its follow2"p are consistent with good professional practice. This re8"ires a
diagnostic st"dy prior to prescription of C).) and a C).) titration st"dy. 7arly
follow2"p after prescription +within one month, is re8"ired to determine whether
problems affecting compliance e<ist.
$.; Sfet"8 That the laboratory meets standards of laboratory safety consistent with
State occ"pational health and safety reg"lations, incl"ding infection control,
handling of gas cylinders, fire and electrical safety and general safety
proced"res. 7lectrical s"pply to the monitoring room and the bedrooms of the
laboratory sho"ld be at minim"m body protected standard +class - Z.S
specification[,. Aonitoring e8"ipment sho"ld be s"pported by a certificate of
type testing to .S #1&&.1 +1CC&, or .S #1&& +1C?;, or e8"ivalent.
$.> L4ortor" mnu$8
1$;
That each type of test performed by the laboratory be described in detail in a
laboratory man"al. 7ach test sho"ld be separately described with the
following detail incl"ded or cross2referenced from other so"rces, preferably
"nder appropriate s"bheadings.
The p"rpose of the test.
a, . description of the e8"ipment "sed, with special reference to its
specifications and their applicability to the meas"rement.
b, The calibration proced"re.
c, The proced"re for performance of the test.
d, Tro"bleshooting. )roblems which may be enco"ntered in the
performance of each test and their appropriate remedies.
e, Specific 8"ality ass"rance. *etails of 8"ality control steps re8"ired for
the method.
f, Cleaning and maintenance.
g, !nfection control and other safety re8"irements.
h, Records and reports +with samples, incl"ding interpretation of the
res"lts,.
i, Normal val"es and prediction e8"ations "sed to interpret the res"lts.
, References. !f the test is based on "np"blished wor3, relevant details
of this wor3 sho"ld be incl"ded.
3, The date of iss"e of and alterations to the method.
l, The signat"re of the senior laboratory officer % this indicates that the
method.
.ppropriate cross2referencing +eg, to man"fact"rer=s man"al, "nder each
s"bheading co"ld minimise red"ndancy while ens"ring that all iss"es
relevant to each test have been addressed.
!deally this laboratory man"al sho"ld be part of a service policy and
proced"res man"al +see 11 below,.
;4 Staff deelopment/ teaching/ research
That staff have access to ed"cation programmes which maintain and develop their
3nowledge and s3ills.
;.1 Stff de-e$opment8
That programmes e<ist to orientate new staff, and for contin"ing ed"cation of
e<isting staff ta3ing into acco"nt res"lts of performance appraisal +see 5.5
above,, service obectives and 8"ality ass"rance activities +see C below,.
That opport"nities e<ist for senior staff to attend relevant professional
meetings +state, national, international,.
;.1 Tech!n38 That where the service operates in a teaching hospital environment
it offers ed"cation programmes for "ndergrad"ates and postgrad"ates.
;.# Re#erch8 That where the service operates in a teaching hospital environment
it has a commitment to research. This can be demonstrated by reference to
c"rrent proects, recent presentations +abstracts, and p"blications.
1$>
<4 =acilities and equipment
That ade8"ate facilities and e8"ipment e<ist for the service to meet its obectives and
comply with stat"tory re8"irements.
>.1 Con#u$t!n3 room#8 That the reception area, waiting room, offices and
cons"ltation rooms conform to generally accepted standards for medical s"ites
in si9e, appearance, privacy, lighting, f"rnit"re and provision of other
e8"ipment.
>.1 S$eep $4ortor"8
That the sleep laboratory has comfortably f"rnished bedrooms cond"cive to
sleep and of s"fficient si9e +minim"m appro<imately 1.$ < #.$ metres, to
allow access in an emergency, with ade8"ate lighting, so"nd2proofing,
e<cl"sion of light d"ring the st"dy, air conditioning, emergency o<ygen and
s"ction, res"scitation e8"ipment, and sec"rity.
That the rooms conform to local reg"lations with respect to entrances, e<its
and fire preca"tions.
That there is a separate bedroom for each patient with comfortable bedding,
wardrobe, chair and bedside lamp. !n the case of paediatric laboratories the
bedroom m"st be child2safe and age2appropriate, with age2appropriate
bedding for each patient. /acilities for a parent to sleep in the child=s
bedroom sho"ld be available.
That there are conveniently located and ade8"ate toilet and shower facilities.
That the monitoring room is located in close pro<imity to the bedrooms and
that a patient call system is available from bedrooms to monitoring room.
That office space e<ists with ade8"ate space, f"rnit"re, lighting and privacy
for analysis of sleep st"dies.
That the facilities are reg"larly cleaned.
>.# E9u!pment8 That the e8"ipment "sed for the cond"ct of respiratory sleep
st"dies and related tests is s"itable for the p"rpose +see $.1, $.#, $.5 above,
and is reg"larly maintained and safety chec3ed. !n paediatric laboratories the
sensors and other e8"ipment interfaced with the patient sho"ld be appropriately
si9ed and a range of si9es sho"ld be available for each st"dy.
>.5 Ident!f!ct!on8 That the service is identified by signage, telephone and
stationery so that it can be easily fo"nd and:or accessed.
1$?
>4 Proision for emergencies
?.1 7ed!c$ emer3enc!e#8
That ade8"ate provision is made for medical emergencies. These sho"ld
incl"de an on2call roster for medical staff, C)R training for all staff, availability
of res"scitation e8"ipment, o<ygen and s"ction, and easy access to the
laboratory and the patient.
!n the case of paediatric laboratories and a team trained in paediatric
cardiop"lmonary res"scitation m"st be available on2site for the d"ration of
the st"dy. .ll staff m"st be trained in paediatric cardiop"lmonary
res"scitation. . complete range of age2appropriate res"scitation e8"ipment
m"st be available in the laboratory for the d"ration of the st"dies and o<ygen
and s"ction m"st be available at the bedside.
?.1 NonAmed!c$ emer3enc!e#8 That provisions complying with relevant site and
stat"tory re8"irements are made for non2medical emergencies +fire and safety,.
14 #uality assurance programme
That proced"res e<ist to eval"ate the 8"ality of the service provided, correct
identified problems, and advance the service=s standards.
The process m"st incl"de the following elements6
Aonitoring. Reg"lar collection of data relevant to important aspects of service
delivery.
.ssessment. )eriodic assessment of the data to identify problems or
opport"nities to improve.
.ction. .ction to address s"ch problems or opport"nities.
7val"ation. 7val"ation of the effects of s"ch action.
/eedbac3. Reg"lar comm"nication to the staff of the res"lts of these activities.
The process m"st be doc"mented and patient confidentiality m"st be protected.
0?4 &eetings
That reg"lar sched"led meetings occ"r, at no greater than monthly intervals, for the
p"rposes of laboratory f"nction and planning, 8"ality ass"rance and clinical review,
in2service ed"cation, and, where applicable, research. There sho"ld be records of
these meetings. .ction statements are enco"raged where applicable.
004 Policies and procedures manual
That the department maintains a policies and proced"res man"al which specifies its
organisation and administration, staffing and direction, policies and proced"res +see
$.>, 0aboratory Aan"al,, staff development and ed"cation, facilities and e8"ipment,
and 8"ality ass"rance programme.
1$C
?> Accred!tt!on of re#p!rtor" funct!on ##e##ment #er-!ce#
Introduction
04 Preamble
.ccreditation of respiratory f"nction services is, at present, vol"ntary. The Thoracic
Society of ."stralia and New Zealand +TS.NZ, has established an accreditation
process to foster e<cellence in the approach to assessment of respiratory f"nction.
The process see3s to define "niform minim"m standards for services in ."stralia and
New Zealand. !t is intended that, while rigoro"s, the process be N"ser friendly=. !t will
be revised periodically and constr"ctive s"ggestions for improvement are welcomed
by the TS.NZ )rofessional Standards S"bcommittee.
The process assesses the service=s organisation and administration, staffing and
direction, policies and proced"res, staff development and ed"cation, facilities and
e8"ipment, and 8"ality ass"rance programmes. !ts general approach is infl"enced
by programmes established by the ."stralian Co"ncil of Healthcare Standards
+.CHS,. !t is hoped that consistency with .CHS g"idelines will decrease the amo"nt
of wor3 necessary to prepare the application for those laboratories that have already
been involved in .CHS accreditation proced"res +eg, hospital accreditation, and help
prepare the way for .CHS accreditation where this is anticipated.
The first phase of the process involves answering a detailed 8"estionnaire which has
been designed to assess the laboratory=s readiness for accreditation. Self
.ssessment is a 3ey feat"re of this phase of the process. .bility to satisfactorily
respond to the 8"estionnaire, g"ided by the NStandards for .ccreditation= detailed
below, sho"ld indicate to the applicant service its li3ely ability to comply with the
re8"irements for accreditation. !f satisfied that its responses are ade8"ate the
service s"bmits a completed application. !f the TS.NZ .ssessment )anel is
satisfied that the application meets the re8"ired standard a site visit follows. These
proced"res are detailed "nder N.dministration= below.
54 Definition
.ccreditation is the process whereby the professional standards and competence of
a respiratory f"nction assessment service, hereafter referred to as the service, is
formally recognised by the TS.NZ.
6/ Purpose
To enco"rage appropriate standards of medical and technical practice to ens"re
that a service is effective.
To grant recognition to services which achieve these standards.
To foster the standards of service by cons"ltation and advice rather than by
reg"lation, consistent with the vol"ntary nat"re of accreditation.
1;&
Administration
04 Coordinator
1.1 The process of .ccreditation will be administered on behalf of the )rofessional
Standards S"bcommittee +)SS, by an .ccreditation Coordinator.
1.1 The .ccreditation Coordinator will be a member of the )SS with e<pertise in
clinical respiratory physiology and sleep disorders.
1.# The .ccreditation Coordinator will be elected yearly by the )SS at the time of
the TS.NZ .nn"al Scientific Aeeting.
1.5 The minim"m term of office of the .ccreditation Coordinator is one year, the
ma<im"m term is fo"r consec"tive years. .n individ"al is eligible for re2election
after a minim"m period of two years d"ring which he or she has not held the
office of .ccreditation Coordinator.
1.$ The .ccreditation Coordinator will be responsible for administering the process
of accreditation incl"ding receipt of applications, appointment of an assessment
panel, s"pervision of each accreditation process incl"ding prod"ction of a report
which is clear and reasonable in its comments and recommendations.
1.; The Chairman of the )SS will act on behalf of the .ccreditation Coordinator in
his or her absence. The .ccreditation Coordinator will be the Gice2Chairman of
the )SS.
54 Categories of respiratory function assessment serices
1.1 Cte3or" )8 -asic assessment of respiratory f"nction incl"ding, as a minim"m,
meas"rement of static l"ng vol"mes +total l"ng capacity, resid"al vol"me,
f"nctional resid"al capacity and vital capacity,E ma<im"m e<piratory flow rates
before and after bronchodilator +ma<im"m e<piratory flow vol"me c"rves,E
carbon mono<ide gas transferE and ma<im"m respiratory press"res meas"red
at the mo"th.
1.1 Cte3or" /8 Aeas"rements as in Category 1 pl"s arterial blood gas analysis.
1.# Cte3or" ?8 Standard assessment of respiratory f"nction incl"ding
meas"rements as in Categories 1 or 1 pl"s pharmacologic and non2
pharmacologic bronchial provocation tests and e<ercise tests.
1.5 Cte3or" 18 Comprehensive assessment of respiratory f"nction incl"ding
meas"rements in Category # pl"s any of the following6
meas"rements of the control of breathing
of l"ng mechanics
of chest wall mechanics
of p"lmonary gas e<change
of nasal resistance
sim"lated altit"de meas"rements
any other comple< meas"rements of respiratory f"nction.
1;1
64 Process
#.1 .pplications for accreditation will be received by the 7<ec"tive Secretary of the
Society. The application sho"ld specify the category of respiratory f"nction
assessment for which accreditation is so"ght and a list of the individ"al tests for
which accreditation is so"ght. .ccreditation will be granted only in relation to
those categories or tests for which application is made.
The 7<ec"tive Secretary will respond to all applications by providing applicant
laboratories with accreditation g"idelines and the application forms which see3
information regarding the laboratory and investigations:meas"rements that it
performs +Nthe accreditation pac3age=,. These forms incl"de 8"estions
designed to indicate the laboratory=s readiness for accreditation. Self2
assessment is a 3ey feat"re of this phase of the process.
(nce satisfied it can respond to the 8"estions ade8"ately the laboratory
completes the forms and ret"rns them to the 7<ec"tive Secretary, along with an
Jinitial assessment feeK which covers the cost of the initial assessment of
s"bmitted material. Copies of all correspondence will be sent to the
.ccreditation Coordinator. . f"rther fee +the Nsite visit= fee, will be charged if the
application is fo"nd to be acceptable, and a site visit is arranged +see below,.
These fees, which are set to recover costs, will be determined by the Society
and revised from time to time. The c"rrent sched"le of fees is obtainable from
the Society office.
#.1 (n receipt of the accreditation fee and application forms the .ccreditation
Coordinator will appoint an assessment panel and its Chairperson. The
assessors will be recognised e<perts in the physiological and:or technical
aspects of respiratory f"nction assessment and its application to the diagnosis
and management of respiratory disease. The assessment panel will normally
have three members, at least one of whom will be from a city other than the one
in which the service "ndergoing accreditation is located. 'hile individ"al
assessors need not necessarily be members of the TS.NZ, at least two
members of the assessment panel will be. 'here practicable one member will
be a respiratory scientist:technologist.
The Chairperson of the assessment panel will ca"se the doc"mentation
s"pplied by the applicant laboratory to be reviewed by the panel members and
see3 s"pplementary information where necessary. The res"lt of the initial
assessment will be given to the applicant within eight wee3s of receipt of the
application. !f the application is "nacceptable the reasons for the decision will
be provided. !f the application is acceptable a site visit will be arranged at a
m"t"ally convenient time +within two to three months of notice of approval,.
The site visit is a critical step in the accreditation process. .t the site visit the
veracity of answers provided in the application is e<amined, and specific
8"estions raised by these responses and by inspection of the facilities
addressed. The Chairperson of the assessment panel is responsible for the
review process incl"ding prod"cing a report and recommendations which will be
forwarded to the .ccreditation Coordinator.
1;1
#.# The assessment process has two p"rposes6
.dvisory % to advise on ways in which perceived deficiencies of a service can
be corrected.
7val"ation % to establish whether a service is competent and effective.
74 Granting accreditation
5.1 To e<pedite the process an accreditation advisory panel is empowered to act on
behalf of the Society and grant accreditation according to the recommendations
of the assessment panel. The advisory panel will comprise the Chairman of the
)SS, the .ccreditation Coordinator and the assessment panel which assessed
the partic"lar laboratory.
5.1 The assessment panel may recommend that accreditation be awarded
"nreservedly or s"bse8"ent to rectification of identified deficiencies. !n the
latter case accreditation will be granted on receipt of evidence that all
s"ggested changes have been implemented. The application will lapse after
11 months from the date of iss"e of the recommendations in the absence of
s"ch evidence. This provision will only apply where the panel considers that the
changes are relatively minor and can be implemented and verified witho"t need
for a f"rther site visit. The process see3s Ns"bstantial compliance= with the
standards. !t is recognised that local conditions may precl"de absol"te
compliance with every standard.
5.# 'here, in the opinion of a partic"lar accreditation advisory panel, a report is
potentially contentio"s or there is disagreement over its recommendations, the
report will be referred to the )resident and the 7<ec"tive of the Society for
comment and decision.
5.5 . recommendation against accreditation will normally be referred to the
)resident and 7<ec"tive of the Society for confirmation before the report is
iss"ed.
5.$ . Certificate of .ccreditation will be iss"ed once the recommendation for
accreditation is ratified by the accreditation advisory panel or, where applicable,
the 7<ec"tive. The certificate will be signed by the Chairman of the )SS and
the )resident on behalf of the Society. .ccreditation is granted for a period of
five years.
5.; 0aboratories that fail accreditation will be advised of the reasons for the
decision. !f the laboratory wishes to challenge the decision it m"st do so in
writing to the .ccreditation Coordinator within 15 days of receiving the decision
stating the reasons for appeal. The appeal will then be considered by a
meeting of the )rofessional Standards S"bcommittee to be convened within si<
wee3s of receipt of the appeal. . recommendation against accreditation
following appeal will be referred to the )resident and 7<ec"tive of the Society
for confirmation before the report is iss"ed. The .ccreditation Coordinator will
advise the laboratory of the decision on the appeal and the reasons for the
decision. . laboratory that fails accreditation may reapply at any time that it
believes its standards have met those re8"ired for accreditation.
1;#
5.> 7ach accreditation report will be seen in f"ll by the )SS.
5.? The .ccreditation Coordinator will provide the 7<ec"tive of the Society with an
.nn"al Report.
24 Re8accreditation of an accredited serice
$.1 No less than 11 months before the end of the five year accreditation period the
7<ec"tive (fficer of the Society will provide to the Aedical *irector of the
service6
a copy of the previo"s assessment panel report
the c"rrent accreditation g"idelines and application for initial accreditation
a re8"est for re2accreditation +see /orms C, * and 7,.
$.1 The re8"est for re2accreditation will as3 for the category of respiratory f"nction
assessment for which accreditation is so"ght, a list of the individ"al tests for
which accreditation is so"ght and staffing information. .dditionally, the Aedical
*irector will be as3ed to detail changes to the service since the previo"s
accreditation. 7mphasis will be on the implementation of recommendations
s"ggested by the previo"s assessment panel report.
$.# The service completes the re8"est for re2accreditation and ret"rns Nonly these
forms= to the 7<ec"tive (fficer, along with the site visit fee c"rrent at the time of
application. The service m"st also complete the application for initial
accreditation and "pdate laboratory man"als to reflect c"rrent practice. The
application for initial accreditation and laboratory man"als are to be retained by
the service for review at any s"bse8"ent site visit. Copies of all
correspondence will be sent to the .ccreditation Co2ordinator.
$.5 (n receipt of a re8"est for re2accreditation the .ccreditation Coordinator will
appoint an assessment panel and its Chairperson as described in
paragraph #.#. 'here practicable at least one member of the assessment
panel will be from the previo"s assessment panel.
The Chairperson of the assessment panel will arrange for the re8"est for
re2accreditation and the previo"s assessment panel report to be reviewed by the
panel members. The res"lt of this review will be provided to the service within si<
wee3s of receipt of the re8"est. !f the re8"est for re2accreditation is
"nacceptable then reasons for the decision will be provided and the site visit fee
ref"nded. !f the re8"est for re2accreditation demonstrates that the service has
ade8"ately addressed the recommendations contained in the previo"s
assessment panel report a site visit will be arranged. Normally, the site visit will
occ"r at least three months before the end of the c"rrent five year accreditation
period. .t the site visit attention will foc"s on problems or deficiencies identified
d"ring the previo"s accreditation. Compliance with any new or revised standards
introd"ced since the previo"s accreditation will also be e<amined as may any
aspect of the service=s operations. The Chairperson of the assessment panel is
responsible for the review process incl"ding prod"cing a report and
recommendations that will be forwarded to the .ccreditation Coordinator.
$.; The process of granting re2accreditation will be as described in Section 5
+granting accreditation,.
1;5
;4 Confidentiality of assessment procedures
.ll information provided by a testing laboratory in relation to preliminary en8"iries or
to an application for accreditation and all information obtained in the co"rse of or in
connection with an assessment of the service is considered by the TS.NZ to be
completely confidential. S"ch information is received and st"died only by members
of the ..C, the ..C assessors and TS.NZ 7<ec"tive and these persons are all
made aware of the confidential nat"re of this information. The TS.NZ re8"ires that
all doc"ments associated with accreditation of a service be maintained in strict
confidence. This re8"irement imposes partic"lar obligations on assessors.
.n assessor m"st not disclose any information gained d"ring an assessment to any
person other than a member of the ..C. Dnder normal circ"mstances there is little
need for an assessor to retain a copy of the briefing notes provided for an
assessment or a copy of his or her report. !t may be pr"dent for an assessor to 3eep
a copy of the report temporarily to obviate loss in the mail, b"t this copy sho"ld be
destroyed once ac3nowledgement of receipt is received by the ..C. !f an assessor
retains copies of briefing notes or reports, they m"st be 3ept in a sec"re place. They
are not to be incorporated into the general records system of the assessor=s
employer in a manner which wo"ld allow "na"thorised access by others.
"tandards for accreditation
This doc"ment o"tlines the minim"m standards re8"ired for accreditation of a
respiratory f"nction assessment service. !t m"st be read in con"nction with the
8"estionnaire in the application for accreditation. !t sho"ld be referred to when
completing the application to ens"re that the laboratory is li3ely to meet the
re8"irements before s"bmission.
04 "dentifying information
That information identifying the applicant service be specified at the front of the
application +/orm .,.
54 9istorical oerie,
That a brief overview of the history of the development of the service be provided
with the application.
64 Organisation and administration
That the service is organised and administered to meet its obectives and the needs
of the pop"lation it serves.
#.1 6o$# nd o4Eect!-e#8 That the service=s goals and obectives are specified
and that they reflect its role and responsibilities.
#.1 Re$t!on#h!p to ho#t !n#t!tut!on, other $4ortor!e#8 That the relationship+s,
of service to its host instit"tion and to related laboratories are appropriate to the
discharge of its responsibilities. These relationships m"st be specified and
clearly defined. There sho"ld be evidence of commitment by the host instit"tion
to its s"pport.
1;$
#.# Re$t!on#h!p# %!th other #pec!$!t!e#8 That the service has established
appropriate relationships and comm"nication with other specialities with a
common interest in respiratory disease to ens"re that clinical problems are
directed to clinicians with relevant e<pertise and to facilitate advancement in
clinical standards.
#.5 Referr$#8 That the so"rces and types of referrals to the service are relevant to
the services provided. Referrals to the service sho"ld be related to respiratory
f"nction assessment or other matters for which there is local e<pertise.
#.$ Wor2$od8 That the service=s reso"rces +staffing, e8"ipment, facilities finances,
are s"fficient to meet its wor3load witho"t compromising the minim"m
standards set elsewhere in this doc"ment. . reg"lar "pdated a"dit of the
laboratory=s wor3load in terms of n"mbers of tests of each partic"lar type sho"ld
be 3ept and these records sho"ld be available on a 8"arterly or yearly basis.
#.; Demnd8 That the service attempts to ade8"ately cope with the demand for its
services. 'here demand e<ceeds capacity, the service sho"ld have a system
for prioritising cases perceived to be "rgent. The service sho"ld be able to
assess new patients within two wee3s of referral. Drgent cases sho"ld be
assessed within two days.
#.> 'ud3et8 That the service=s b"dget covers its operational costs or that there is a
firm commitment by the host instit"tion or company to "nderwrite b"dget
deficits.
74 Staffing and direction
The service is directed and staffed to achieve its obectives.
5.1 Stff #tructure nd d!rect!on8
That the service has a medical director responsible for overall standards and
development of policies governing the service. These sho"ld be ratified by
other committees in the host instit"tion as necessary.
That there are clear, doc"mented lines of acco"ntability and responsibility
between medical director and all staff members. These m"st represent the
act"al manner in which the service is organised, be reg"larly reviewed and
readily available to all staff.
5.1 Stff 9u$!f!ct!on# nd eDper!ence
15>,7rror6 Reference so"rce not fo"nd,15?
That staff members are appropriately 8"alified for their tas3s by ed"cation,
training, and:or e<perience, and that their roles and responsibilities are
specified by ob description. The medical director sho"ld have specific,
detailed training in clinical respiratory physiology and meet the criteria set by
the relevant TS.NZ position paper.7rror6 Reference so"rce not fo"nd (ther
cons"ltant medical staff are e<pected to have completed the e8"ivalent of
one years f"ll time training in respiratory physiology, consistent with the
TS.NZ g"idelines for advanced trainees7rror6 Reference so"rce not fo"nd
wishing to ma3e respiratory physiology an important area of their practice.
1;;
Scientific or technological staff are responsible for acc"rate performance of
tests, e8"ipment maintenance, contin"ing 8"ality ass"rance of both
e8"ipment and techni8"es and patient safety d"ring performance of tests.
The basic 8"alification for classification as either scientific or technical staff
depends on local re8"irements +eg, two years tertiary training in biological or
physical science for technologists, -achelor of Science or e8"ivalent for
scientists,.
Dntil 1CC$ there was no recognised tertiary training programme in respiratory
physiology or f"nction assessment for scientific or technological staff in
."stralia. Hence most staff received their professional or vocational training
thro"gh e<perience in an established service. However formal training in
respiratory science is now offered by several co"rses. These are strongly
endorsed, partic"larly for new staff and those witho"t s"bstantial e<perience
in respiratory f"nction assessment. !t is recommended that scientific or
technical staff ac8"ire the Certified Respiratory /"nction Scientist +CR/S,
credential based on e<amination by the ."stralian and New Zealand Society
of Respiratory Science +.NZRS,.
To f"nction in a s"pervisory capacity "nder medical direction a scientist:
technologist sho"ld have a -achelor of Science in biological or physical
sciences, and between three and five years e<perience, depending on the
nat"re of that e<perience and the range of tests performed by the laboratory.
!n addition ac8"isition of the CR/S credential is strongly recommended.
5.# Stff num4er#8 That s"fficient medical, technical and clerical staff are
employed to ade8"ately meet service needs. This will depend on the wor3load,
organisation, type of e8"ipment and circ"mstances of the individ"al hospital.
'here three or more scientific or technological staff are employed it is advisable
that there be a designated chief scientist or technologist to assist the Aedical
*irector to administer the service.
5.5 Stff ppr!#$8 That a staff appraisal system is in operation, that a written
report is prod"ced, that the staff member involved is aware of the contents of
the report and that a plan to address deficiencies is defined.
5.$ Tr!n!n3 of #tff !n crd!opu$monr" re#u#c!tt!on8 That all medical,
technological and n"rsing staff are trained in cardiop"lmonary res"scitation, and
that a basic level of competence is maintained.
24 Policies and procedures
That the service has doc"mented policies and proced"res that reflect c"rrent
3nowledge and practice in the cond"ct of a respiratory f"nction assessment service
and, where relevant, comply with stat"tory re8"irements.
$.1 Pt!ent referr$, hnd$!n3, documentt!on, fo$$o%Aup8 That proced"res e<ist
for prompt, efficient handling of patient referrals, doc"mentation, comm"nication
with the referring doctor, and that these are consistent with good professional
practice. . patient record sho"ld be maintained which is well ordered and
contains all laboratory test res"lts and reports +see $.$ and $.;,, records of
cons"ltations and copies of correspondence. Reports and correspondence
sho"ld be completed promptly +within five wor3ing days, following each patient
1;>
contact. Records sho"ld be 3ept for a period of time that complies with
legislative re8"irements and is consistent with good professional practice.
$.1 Re#p!rtor" funct!on te#t#8 e9u!pment nd method# +see also $.# M"ality
Control, below,6 That the methods for cond"cting respiratory f"nction tests are
consistent with recognised standards, incl"ding relevant TS.NZ g"idelines.
$.1.11.uipment
That the e8"ipment "sed for the cond"ct of respiratory f"nction and
related tests is s"itable for the p"rpose +see also $.#, and is reg"larly
maintained and safety chec3ed.
The choice of e8"ipment will depend on the re8"ired acc"racy of
partic"lar meas"rements, the wor3load, ease of "se, servicing and
economic considerations as well as biochemical and electrical safety
standards.
.rterial blood gas analysis . Aost e8"ipment "sed for this proced"re
is now self2calibrating. . 8"ality control proced"re m"st be "sed
reg"larly to ens"re the validity of the res"lts.
Spirometry and gas transfer . 78"ipment "sed for spirometry and gas
transfer and the "se of comp"ters for data collection and analysis
sho"ld meet p"blished standards of the .merican Thoracic
Society.
15C,1$&,1$1
78"ipment and systems "sed for other meas"rements sho"ld have
linearity, sensitivity, signal to noise and fre8"ency response
characteristics which are appropriate to the partic"lar meas"rement and
sho"ld meet c"rrently accepted, p"blished criteria which help to ens"re
acc"rate meas"rement.
7ach service m"st p"rchase and maintain the e8"ipment necessary to
perform ro"tine calibration of all e8"ipment "sed in the performance of
the above tests.
$.1.1/et%ods
!n the field of respiratory f"nction testing, rigid insistence on the "se of
partic"lar p"blished methods is inappropriate and wo"ld detract from
versatility and originality of e<pertise which reflects the competence of
the service. However, test proced"res sho"ld be validated. The
TS.NZ does not specify which methods a service may or sho"ld "se
for any partic"lar test.
.ccreditation will involve e<amination of the doc"mentation of
laboratory methods and their availability to staff wor3ing within the
service. To this end each service sho"ld have a proced"res man"al
which contains not only the essential proced"ral elements of the
method b"t also information on problems that may be enco"ntered and
details of any e8"ipment chec3s and calibrations or other aspects of
8"ality control which may be necessary for that method +see $.#,
below,. )ersonnel performing tests sho"ld have ready access to the
methods man"al and sho"ld be enco"raged to refer to it fre8"ently.
1;?
/or a general description of commonly employed methodology for most
respiratory f"nction tests, reference to standard te<ts may be
"sef"l.
1$1,1$#,1$5,1$$,1$;
Specific information s"mmarising c"rrent or
standard practices for performing the commonly employed respiratory
f"nction tests and investigations is available from the c"rrent
literat"re.7rror6 Reference so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6
Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd,1$>,1$?,1$C
.
$.1.##omputer+aided respiratory function tests
The basic principles of assessment of comp"terised testing systems are
the same as for any other 3ind of testing e8"ipment. -y their very
nat"re however, comp"ter or microprocessor2aided e8"ipment often
re8"ires additional proced"res for testing and 8"ality control. *etails of
any s"ch additional proced"res sho"ld be doc"mented in the laboratory
man"al +see $.1.5 below,. Aicroprocess or controlled systems are by
nat"re prone to s"btle errors not normally enco"ntered in p"rely man"al
systems.
0aboratories "sing s"ch systems sho"ld demonstrate that the methods
"sed and res"lts obtained are valid. . general approach to the "se of
comp"ters in respiratory laboratories is given by Cla"sen H07rror6
Reference so"rce not fo"nd +Chapter 1>,. Specific g"idelines for the
general "se of comp"ters are also given in6 B"ide to .ssessment of
0aboratories, National .ssociation of Testing ."thorities, ."stralia,
/ebr"ary 1C?5.
1;&
These principles will be followed in the assessment
of services in so far as they relate to respiratory f"nction testing.
$.1.52aboratory procedures manual (2P/!
0aboratory proced"res sho"ld be described in detail in a laboratory
man"al. 7ach test sho"ld be separately described with the following
detail incl"ded or cross referenced from other so"rces, preferably "nder
appropriate s"bheadings6
@P& ????????0. The p"rpose of the test.
@P& 5. . description of the e8"ipment "sed, with special reference
to its specifications and their applicability to the
meas"rement.
@P& 6. The calibration proced"re.
@P& 7. The proced"re for performance of the test.
@P& 2, Tro"bleshooting. )roblems which may be enco"ntered in
the performance of each test and their appropriate remedies.
@P& ;. Specific 8"ality ass"rance. *etails of 8"ality control steps
re8"ired for the method.
@P& <. Cleaning and maintenance
@P& >. !nfection control and other safety re8"irements.
@P& 1. Records and reports +with samples, incl"ding interpretation
of the res"lts,.
@P& 0?. Normal val"es and prediction e8"ations "sed to interpret the
res"lts.
@P& 00. References. !f the test is based on "np"blished wor3,
relevant details of this wor3 sho"ld be incl"ded.
1;C
@P& 05. The date of iss"e of and alterations to the method.
@P& 06. The signat"re of the senior laboratory officer. This indicates
that the method section has been chec3ed by a senior staff
member for proced"ral and typographical errors before being
incl"ded in the man"al.
.ppropriate cross2referencing +eg, to man"fact"rer=s man"al, "nder
each s"bheading co"ld minimise red"ndancy while ens"ring that all
iss"es relevant to each test have been addressed.
Special re8"irements for comp"ter2aided respiratory f"nction tests 6
'hether written in the laboratory or p"rchased Noff the shelf=, comp"ter
programmes sho"ld also be ade8"ately doc"mented in the laboratory
man"al. Ainim"m re8"irements for this doc"mentation incl"de6
details of programme flow and logic chec3s performed when
implementing the system
for programmes written in the laboratory incl"ding6
+i, an o"tline of the basic str"ct"re and logic of the programme
+ii, an "p2to2date listing of the programme
details of comparisons between comp"ter derived res"lts and
man"ally derived res"lts
operating instr"ctions for r"nning the programme, incl"ding details
on restoration of the comp"ter to r"nning condition in the event of
comp"ter fail"re.
*oc"mentation of proced"res sho"ld be reviewed reg"larly so that any
alterations to methods can be dealt with before the acc"m"lation of
s"ch alterations re8"ires the entire man"al to be revised. These
reviews sho"ld be carried o"t at least ann"ally.
)ersonnel performing tests sho"ld have ready access to the methods
man"al and sho"ld be enco"raged to refer to it fre8"ently.
!deally this laboratory man"al sho"ld be part of a service policy and
proced"res man"al +see 11 below,.
$.# Bu$!t" contro$ of me#urement#Error8 Reference #ource not found +see
also C, 8"ality ass"rance, below,6
That reg"lar monitoring of the acc"racy of meas"rement is "nderta3en, "sing
appropriate calibrations, internal 8"ality control proced"res and, where
possible, participation in appropriate inter2laboratory test programmes.
.ppropriate 8"ality control proced"res and e8"ipment for performing them
are an essential component of any respiratory f"nction laboratory.
+a, #alibration9
Services sho"ld p"rchase and maintain the e8"ipment necessary to
perform ro"tine calibration chec3s of all testing e8"ipment and set
aside non2patient time for e8"ipment calibration. Standard physical
calibration sho"ld be "sed ro"tinely. 'here electrical calibration is
"tilised, it m"st be chec3ed against physical calibration reg"larly.
Calibration res"lts sho"ld be labelled, dated and filed for at least the
last two years of "se of the instr"ment. 7ach calibration proced"re
sho"ld be repeated at least twice to ens"re reprod"cibility.
1>&
Calibration proced"res sho"ld be done on a reg"lar basis, or
whenever acc"racy is in do"bt.
/ollowing the calibration of e8"ipment, normal individ"als may be
"tilised to verify the overall performance of the e8"ipment, 3eeping in
mind the reprod"cibility of the test within a given individ"al. 'ith
more comple< tests involving m"lti2component systems, normal
s"bects sho"ld be employed more fre8"ently.
B"idelines for the calibration and 8"ality control of all individ"al l"ng
f"nction tests are available from the literat"re.7rror6 Reference
so"rce not fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd
/"rther
specific information regarding 8"ality control and calibration
g"idelines for spirometry, l"ng vol"me and diff"sing capacity
meas"rements is also available.7rror6 Reference so"rce not
fo"nd
,7rror6 Reference so"rce not fo"nd,7rror6 Reference so"rce not fo"nd
+b, Internal .uality control9
!nternal 8"ality control proced"res are the responsibility of the senior
laboratory personnel and sho"ld be practised in association with
each test method at appropriate levels. *etails of s"ch proced"res
m"st be recorded as part of each test method in the laboratory
man"al. 'hen ro"tine 8"ality ass"rance testing indicates that the
method is moving o"t of control, written protocols are helpf"l in
specifying the co"rses of action to be followed for diagnosis and
correction. Braphic records assist the monitoring of internal 8"ality
control proced"res.
Ro"tine preventive maintenance of e8"ipment "sed sho"ld be
doc"mented in the laboratory man"al.
+c, 15ternal .uality control9
7<ternal 8"ality control, that is participation in inter2hospital
proficiency testing programmes, assists in monitoring the
effectiveness of internal 8"ality control proced"res.
$.5 Pred!cted -$ue#8
That the laboratory "tilises appropriate predicted val"es for comparison with
the res"lts of each respiratory f"nction test it performs.
The p"rpose of s"ch a comparison is to help determine whether respiratory
f"nction is normal or abnormal. There are a great n"mber of p"blished
Npredicted= val"es for many respiratory f"nction tests. Dnfort"nately, the
variability among them is often large, ma3ing the choice of predicted val"es
diffic"lt. /re8"ently there is no obective means of singling o"t one set of
data as being s"perior to others partic"larly when different e8"ipment and
methodologies have been "sed.
'hen a laboratory chooses a set of predicted val"es, the following
recommendations sho"ld be ta3en into acco"nt6
predictions of e<pected normal val"es sho"ld be based on st"dies with
large n"mbers of s"bects of both se<es and covering a wide range of
ages, heights and weights
the e8"ipment and techni8"es "sed by a service and those "sed to obtain
predicted val"es sho"ld, to the e<tent possible, be similar
1>1
the pop"lation samples sho"ld be heterogeneo"s, going across
socioeconomic gro"ps. S"rveys sho"ld be of comm"nities or towns, not
of professional gro"ps. Homogeno"s gro"ps % religio"s gro"ps, miners,
s"bects in sanatoria, and so on, sho"ld be avoided "nless a special
p"rpose pop"lation is so"ght
ethnic factors, smo3ing habits and respiratory symptoms sho"ld be
acco"nted for if possible
the e8"ipment and methods "sed to obtain and analyse the data sho"ld be
described.
!t is highly recommended that the appropriateness of any chosen predicted
val"es sho"ld be chec3ed by comparing predicted data with data obtained
from a representative sample of JnormalK people.
/or general information regarding normal reference val"es is refer to
Cla"sen H0 +Chapter ;,,7rror6 Reference so"rce not fo"nd Cotes7rror6
Reference so"rce not fo"nd and the relevant .TS statement.
1;1
$.$ L4ortor" te#t record#8
That the laboratory maintains a record of all respiratory f"nction
meas"rements performed.
The TS.NZ=s basic re8"irement is that the res"lts are recorded in a clear and
"nambig"o"s way, are complete in respect to the performance of the test and
can be chec3ed against the original data obtained at the time of meas"rement.
The application of these concepts will vary from one laboratory to another and
will depend "pon the e<tent to which the records system is comp"terised, b"t
the following g"idelines will generally be applicable.
!f a man"al recording system is "sed, all test data sho"ld be recorded clearly
and permanently on pro2forma sheets, on test cards or in wor3 boo3s.
Sheets of plain paper sho"ld not be "sed beca"se they are easily lost and
beca"se they engender a less disciplined approach to recording the
information re8"ired. Test records sho"ld contain all information needed to
show "nambig"o"sly what has been done, by whom and when. This will
"s"ally mean the following details6
@P& 07. *ate and time of test.
@P& 02. !dentity of the testing officer.
@P& 0;. !dentity of the test method.
@P& 0<. .ny variations from the standard method.
@P& 0>. !dentification of the s"bect.
@P& 01. Reference standard employed +where different from "s"al,.
@P& 5?. .ll test data +incl"ding "nits,.
@P& 50. .ny necessary calc"lations.
@P& 55. The final res"lts.
@P& 56. The ro"nded test res"lt.
@P& 57. .ny other information re8"ired by test method.
@P& 52. .ny pertinent observations of the testing officer.
@P& 5;. Signat"re or initials of the testing officer.
@P& 5<. Signat"re or initials of the chec3ing officer.
1>1
Corrections to the recorded data sho"ld be made witho"t obliterating the
original data, the reasons for the corrections recorded, and the corrections
initialled by the person ma3ing them.
The whole records system sho"ld be organised in an orderly manner so that
any element +sample records, test data, copies of test reports, and so on,
may be readily retrieved.
!n the case of traditional processes of recording, calc"lation and typing,
printed pro2forma test doc"ments are "sef"l for ro"tine tests. !t is the
responsibility of the signatory to ens"re that all calc"lations and data
transfers have been chec3ed before he or she signs the report.
!f test reports are prod"ced by electronic data processing, in some cases
remotely from the site of the test, s"ch systems sho"ld have b"ilt in
safeg"ards as described "nder comp"ter2aided respiratory f"nction tests
+see section $.$,.
. copy of all test res"lts and reports sho"ld be maintained in a readily
accessible state in the records system of the service. .part from spirometry,
hard copies of original tracings and wor3ing sheets sho"ld ideally be 3ept for
at least seven years.
$.; L4ortor" te#t report# nd !nterprett!on of re#u$t#8
That the test reports provide a clear "nambig"o"s statement of test res"lts.
7ach report sho"ld contain6
@P& 5>. Name of service.
@P& 51. Dni8"e identification of report for reference.
@P& 6?. Dni8"e identification of patient.
@P& 60. Test res"lts accompanied by interpretive s"mmary statement+s,
relating to clinical significance of test data and addressing any
specific 8"estions raised in the re8"est for the test.
@P& 65. Signat"re, identification and position of the approved signatory.
@P& 66. *ate of report separately from date of test.
@P& 67. The reasons for test re8"est sho"ld be on, or attached to, the
report.
!n e<amining reporting practice the assessment team will ta3e acco"nt of the
n"mber of test reports being iss"ed in relation to the n"mber and availability
of people a"thorised to sign them. The n"mber of test reports e<pected to
be signed by any one officer of the laboratory sho"ld not e<ceed that
person=s capacity to review and chec3 them ade8"ately before iss"e.
$.> Conf!dent!$!t" of record# nd report#8
That the service protects confidentiality of the patient records and reports.
The service sho"ld maintain circ"mspection regarding the availability of test
reports. Benerally this sho"ld be restricted to the medical and paramedical
staff directly involved in re8"esting the test and in the assessment and
management of the partic"lar patient. !nformation re8"ested by the patient
himself or herself sho"ld normally be dealt with by the medical officer
responsible for the service or by the medical officer:s responsible for the
patient=s management.
1>#
!n teaching instit"tions, access to individ"al patients= res"lts sho"ld be made
available to individ"al st"dents involved in that partic"lar patient=s
management "nder the s"pervision of the medical laboratory staff and the
individ"al patient=s attending medical staff. Test reports "sed for teaching
p"rposes of a general nat"re +eg, lect"res, sho"ld have specific patient
identifying information removed before "se.
Special care sho"ld be ta3en with regard to transmission via facsimile of
information which identifiably pertains to individ"al patient+s,. Dse of the fa<
for this p"rpose sho"ld be minimised and any information transmitted by this
means sho"ld be accompanied by a s"itably worded warning regarding the
confidential nat"re of the enclosed information.
$.? Sfet"8
That the laboratory meets standards of laboratory safety
5
consistent with
State occ"pational health and safety reg"lations.
The areas to be covered by doc"mented safety proced"res sho"ld incl"de
infection control, sterilisation, performance of arterial blood gas sampling and
handling of samples, handling of ha9ardo"s material, handling of gas
cylinders, electrical safety and general safety proced"res. 7lectrical s"pply
to the electric monitoring e8"ipment attached directly to patients sho"ld be at
minim"m body protected standard +class - Z.S specification[,. 0aboratory
e8"ipment sho"ld be s"pported by a certificate of type testing to .S #1&&.1
+1CC&, or .S #1&& +1C?;, or e8"ivalent +where available,.
;4 Staff deelopment/ teaching/ research
That staff have access to ed"cation programmes which maintain and develop their
3nowledge and s3ills.
;.1 Stff de-e$opment8
That programmes e<ist to orientate new staff, and for contin"ing ed"cation of
e<isting staff ta3ing into acco"nt res"lts of performance appraisal +see 5.5
above,, service obectives and 8"ality ass"rance activities +see C below,.
That opport"nities e<ist for senior staff to attend relevant professional
meetings +state, national, international,.
;.1 Tech!n38 That where the service operates in a teaching hospital environment
it offers ed"cation programmes for "ndergrad"ates and postgrad"ates.
;.# Re#erch8 That where the service operates in a teaching hospital environment
it has a commitment to research. This can be demonstrated by reference to
c"rrent proects, recent presentations +abstracts, and p"blications.
1>5
<4 =acilities
That ade8"ate space and facilities e<ist for the service to meet its obectives and
comply with stat"tory re8"irements.
>.1 Spce $$oct!on8 That ade8"ate space e<ists for the service to f"nction
efficiently and effectively. The re8"irements of a respiratory f"nction service for
space will depend on the type of service provided and in general will consist of6
Primary service areas9 These will incl"de the areas set aside for test
systems, scientific:technologist staff, and wor3 space for the performance of
specific tests or proced"res.
"upport areas9 'ill incl"de waiting room for patients, patient toilet facilities
and ade8"ate storage areas for e8"ipment, cons"mable stores, gas
cylinders and records of investigations.
Administrative space9 These facilities will depend "pon the relationship of
the "nit to other "nits, its overall si9e, and the n"mber of personnel employed
in it, as well as occ"pational health and safety reg"lations applicable to the
location of the "nit. This space may incl"de a Aedical *irector=s office,
service s"pervisor=s office +if applicable,, clerical space, record storage
facilities, conference room and staff loc3ers and facilities.
>.1 Fc!$!t!e#8 That the facilities sho"ld conform to generally accepted standards for
medical s"ites in si9e, appearance, privacy, lighting, f"rnit"re and provision of
other e8"ipment, incl"ding office e8"ipment, telephone and other e8"ipment for
internal:e<ternal comm"nications. Some modern e8"ipment is highly sensitive
to ambient temperat"re ma3ing air2conditioning of primary service areas
essential.
>.# Ident!f!ct!on8 That the service is identified by signage, telephone and
stationery so that it can be easily fo"nd and:or accessed.
>4 Proision for emergencies
?.1 7ed!c$ emer3enc!e#8 That ade8"ate provision is made for medical
emergencies. These sho"ld incl"de an on2call roster for medical staff, C)R
training for all staff, availability of res"scitation e8"ipment, o<ygen and s"ction,
and easy access to the laboratory and the patient.
?.1 NonAmed!c$ emer3enc!e#8 That provisions complying with relevant site and
stat"tory re8"irements are made for non2medical emergencies +fire and safety,.
14 #uality assurance programme
That proced"res e<ist to eval"ate the 8"ality of the service provided, correct
identified problems, and advance the service=s standards.
The process m"st incl"de the following elements6
Aonitoring. Reg"lar collection of data relevant to important aspects of service
delivery.
.ssessment. )eriodic assessment of the data to identify problems or
opport"nities to improve.
.ction. .ction to address s"ch problems or opport"nities.
1>$
7val"ation. 7val"ation of the effects of s"ch action.
/eedbac3. Reg"lar comm"nication to the staff of the res"lts of these activities.
The process m"st be doc"mented and patient confidentiality m"st be protected.
0?4 &eetings
That reg"lar sched"led meetings occ"r, at no greater than monthly intervals, for the
p"rposes of laboratory f"nction and planning, 8"ality ass"rance and clinical review,
in2service ed"cation, and, where applicable, research. There sho"ld be records of
these meetings. .ction statements are enco"raged where applicable.
004 Policies and procedures manual
That the department maintains a policies and proced"res man"al which specifies its
organisation and administration, staffing and direction, policies and proced"res +see
$.>, 0aboratory Aan"al,, staff development and ed"cation, facilities and e8"ipment,
and 8"ality ass"rance programme.
1>;
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