Neurophysiology Department Operational Policy

Clinical Operational Policy Register No: 090136

Status: Public

Developed in response to: National Performance Indicators

NHSLA Risk Management Standards
Contributes to HCC Core Standard number: C7a

Consulted With Individual/Body Date

John Tobin Divisional Manager November 2009
Philip Burns General Manager November 2009
Professionally Approved Dr K Nagendran October 2009
By

Version Number 1.0

Issuing Directorate Emergency Care & Medicine Division
Ratified by: Margaret Blackett, Chief Operating
Officer
Ratified on: 5th January 2010
Trust Executive Board Date n/a
Implementation Date 5th January 2010
Next Review Date January 2011
Author/Contact for Information Jill Nicol/Lyn Nield
Policy to be followed by (target staff) All Staff
Distribution Method Intranet & Website
Related Trust Policies (to be read in Infection Prevention, Mandatory Training,
conjunction with) Manual Handling, Fire Safety, IT, Patient
Safety, Record Keeping

Document Review History

Review No Reviewed by Review Date

It is the personal responsibility of the individual referred to this document to ensure that they
are viewing the latest version which will be the document on the intranet

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Index

1. Purpose of Document

2. Aims of the Service

3. Scope of the Service

4. Work Flows

5. Key Relationships

6. Staffing

7. Equipment Requirements

8. Infection Prevention

9. Equality and Diversity

10. Contingency

11. Auditing this Policy

12. Responsibilities

13. References

Appendix 1 Emergency and Elective Work Flows

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1. Purpose of Document

1.1 To outline the function and purpose of the Neurophysiology Department within Mid
Essex Hospital NHS Trust (MEHT).

2. Aims of the Service

2.1 To provide a high quality, evidenced based, patient centred service.

2.2 To provide Clinicians with Diagnostic Services to facilitate diagnosis and medical
management plans.

2.3 Ensure that all department resources are utilized efficiently and effectively.

2.4 To ensure access is available to all service users, E.g. Neonatal, paediatric, inpatient
and outpatient users.

2.5 This service is compliant with:

• Children’s National Service Framework
• ANS (Association Neurophysiological Scientists)

3. Scope of the Service

3.1 To provide the diagnostic service of routine, sleep deprived and portable
electroencephalographs (EEG’s), electromyography (EMG’s) and nerve conduction
studies.

3.2 National Performance Indicators e.g. all patients referred to this diagnostic facility will
receive their investigation in line with the diagnostic and 18 week performance target.

3.3 This service is largely outpatient based, however the department provide a portable
EEG service to the Intensive Care and Neonatal Units Clinics are cached daily and
statistics are broken down into referring speciality. This data is sent monthly to the
Divisional, General and Finance Managers.

3.4 The data is broken down into actual numbers and time units; this enables the
DM/GM to understand the time requirements for individual investigations.

3.5 EEG 1 unit = 60 minutes

Investigation Time Units Required.

EEG Routine 1
EEG Bed 2
EEG Sleep Deprived (adult) 1.5
EEG Sleep Deprived (child) 3
EEG Portable 3

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3.6 EMG 1 unit = 30-45 minutes dependent on complexity.

Investigation Time Units Required.

EMG Routine 1
EMG bed 2
EMG Portable 2

3.7 This service is provided by:

2 WTE Clinical Physiologists (Neurophysiology)
2 Consultant Clinical Neurophysiologists 2 sessions per week.
1 Consultant Neurologist 1 session per week.
1 Consultant Rheumatologist 1 session per week
0.8 WTE Secretary/receptionist

3.8 EEG activity for 2007 =1105 patients

EMG activity for 2007 = 1946 patients

EEG activity for 2008 =1131 patients.

EMG activity for 2008 = 2085 patients.

3.9 Hours of operation.

Monday to Friday 0.730 -17.30

There is no bank holiday or regular weekend service provision

Due to increased service demands, breech clinics are currently being undertaken on a
Saturday.

3.10 Inclusions;

This service is available to all adult and paediatric population of MEHT.

3.11 Exclusions;

There are no exclusions to this service provision

3.12 Work Flows

Patients access this service by both emergency and elective routes

See appendix 1

4. Key Relationships

• Portering
• Office Depot and Stores
• Hospital Transport and Ambulance Service
• Medical Records
• Infection Prevention
• Pharmacy
• Child Protection

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 • Facilities Management
• ICT
• All inpatient wards
• PCT Commissioners
• GP referrals
• Outpatients

5. Key Operational Requirements

5.1. The Neurophysiology Department has its own designated waiting area that is visible
to the reception staff; this reduces risks associated with patient safety for those
attending the department.

5.2 The EMG testing rooms are located behind the main reception. Due to the nature of
these investigations the testing rooms must not be located in close proximity to the
EEG testing rooms, as through noise disturbance EMG testing has the potential to
disrupt EEG testing. The EMG test rooms need to be a minimum of 8.5m2 to ensure
that the neurophysiologist is able to access the patient ‘top to toe’ with the relevant
equipment . The test rooms and waiting area has a warm ambient temperature as
limb temperature has a significant effect on test results.

5.3 The area assigned for EEG testing is self contained and there is no requirement for
through traffic during the hours of operation. This area is acoustically treated to
minimise the risk of noise disruption during testing, slow closers are fitted to the EEG
test room doors and also those in the immediate vicinity. Carpeting to the corridor
outside these rooms is in place to further reduce noise. This is a fundamental
requirement for this service as noise disruption must be kept to a minimum to ensure
the validity or the investigations undertaken.

5.4 Within the test rooms all flooring is resistant to biological fluids and is able to be
cleaned effectively with the Trusts preferred method.

5.5 Within the test rooms pedestal fans and natural light are accessible, this desirable for
the patient groups attending for this investigation.

5.6 All testing rooms have a phone that can be set to silent during investigations, but
enables emergency help to be summoned if required.

5.7 There is an alarm in each clinical area for medical emergencies

5.8 There is a sink available for general hand hygiene.

5.9 All clinical areas are accessible to patients in wheelchairs, trolleys or beds. There are
toilet facilities located near to the department.

5.10 This service is NSF compliant for all elective outpatients with the exception of medical
emergencies.

5. 11 As children also attend this department it is important that their needs are met,
therefore small chairs and a small selection of toys and books are available.
Wherever possible children are seen either at the beginning or the end of clinic to
reduce the exposure of sharing facilities with adult service users

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 Key Relationship with other Departments

5.12 The Neurophysiology Department provides a service to all wards and departments
within MEHT and Mid Essex PCT.This service also supports diagnostic investigations
for:
• Adult learning difficulties (Colchester PCT)
• Neurology & Rheumatology referrals from Colchester PCT
• Paediatrics via community health clinics
• Mental Health via Linden Centre and outreach clinics
• Referrals via St Andrews Centre from other Trusts

6 Key Requirements for Facilities Management (F.M.)

6.1 Maintenance for the department is provided via the Trusts Estate’s Department.

6.2 The equipment within the department is maintained by the Specialised Companies
Under service contract (companies will provide loan equipment if necessary or if
waiting for parts).

6.3 Hotel Services provide the department with domestic staff to ensure that the
department is clean. Service level agreement is 2 hours in the evenings, Monday to
Friday.

6.4 The department’s stores are provided via the internal stores department and are
requested on a fortnightly basis. Supplies required from external companies are
requested via the Trusts non-stock proforma.

7 Environmental Requirements

7.1 There is a requirement that the department is located in an area that supports a quiet
working environment.

7.2 The EMG and EEG rooms must not be clinically adjacent to ensure that there is no
noise disruption during the EEG testing.

7.3 The EEG rooms and the areas directly adjacent have undergone some soundproofing
to minimise the noise within the test rooms.

7.4 There is no requirement for through traffic during operational hours.

7.5 All flooring and surfaces within the clinical area should be resistant to biological
fluids and have the ability to be cleaned using the Trusts preferred method.

7.6 Temperature plays an important role during the EMG testing therefore the department
should have a warm ambient temperature; fans are also available to maintain this
temperature during the summer months.

7.7 The lighting throughout the department should be tungsten to minimise the possibility
of interference when undertaking the EEG investigations.

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8 Way finding

8.1 The Neurophysiology Department is well signposted from all routes of entry to the
hospital. The department allows access for disabled patients. There is clear signage
at the department entrance and maps accompany all appointment letters.

9 Security Requirements

9.1 Data Security

• The service will be delivered in accordance with and compliance to the Trust’s IT
Policies.
• Data sharing agreements will be drawn up to cover all data sharing outside the Trust
in accordance with the Trust data sharing policy
• Hospital information/patient data will only be downloaded onto devices provided by
the Trust which are encrypted.
• Databases will be registered on the Trust database of databases.
• A data mapping form will be completed for all routine data flows leaving the Trust.
• Patient identifiable information will only be sent out of the Trust from an nhs.net
account or other secure route (never from an nhs.uk account)

9.2 Security for Patients

• The service will be delivered in accordance with and compliance to the Trust’s Patient
Safety Policies.

9.3 Security for Staff

• The service will be delivered in accordance with and compliance to the Trust’s
Lone Worker and Security/Risk Management Policies.

9.4 Manual Handling

• The service will be delivered in accordance with and compliance to the Trust’s Manual
Handling Policies.

9.5 Fire Safety

• The service will be compliant with the Trust’s Fire Safety Policy, Fire Evacuation
Policy and other local fire plans and procedures.

(The detail of these items will then be developed as part of the separate Fire Safety
Work Programme, as led by the Trust’s Fire Officer.)

9.6 ICT Requirements

• 2 Computers in EEG office area.

• 2 network points
• 1 Fax /PAS printer.
• 2 Telephone lines in office.
• 1 telephone line in each EEG room.
• 1 Computer point in EEG reader room.
• Computer support provided by ICT.
• Use of PAS

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10 Staffing

10.1 Staffing Chart

STAFF WTE

Clinical Physiologist 2.0

(Neurophysiology)

Medical Secretary/Receptionist 0.8

Consultant Neurophysiologist 0.4

Additional sessions;

1 session per week EMG Consultant Rheumatologist.

1 Session per week EEG consultant Neurologist.

10.2 Staffing Profile

10.2.1 Clinical Neurophysiologists time is divided between EEG/EMG investigations,

management of the department including triage of patients and clinical reporting.

10.2.3 The Consultant Neurophysiologist undertakes the complex EMG testing for one
session per week a further session is spent preparing the medical reports on EEG’s
and liaison with the Clinical Neurophysiologists.

10.2.4 The Consultant Neurologist undertakes the reporting of all EEG’s for his patients.

10.2.5 The Consultant Rheumatologist works for one EMG session per week, alongside
the Clinical Physiologist (Neurophysiology).

11 Training and Education

11.1 All staff within the Neurophysiology department attends the Trusts mandatory training
schedule and NHSLA requirements. In addition the Clinical Neurophysiologist are
required to attend a minimum of 2 local study days and 1 continuous professional
development conference per annum. The administrative support attend updates
relating to systems used with the Trusts as required

12 Facilities

12.1 The department is located in close proximity to both patient and staff toilet facilities,
there is also a disabled toilet facility. The department provides staff lockers to secure
personal items. There are canteen facilities located within the hospital that are
accessible to both patients and staff.

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13. Equipment Requirements

13.1 Test Rooms

• 2 EEG recording stations with time locked digital video and Photic stimulation.
• EEG reader stations
• Printer for EEG reader station
• Portable EEG machine with trolley.
• EMG machines with printers
• Adjustable operator chairs
• Televisions with video/DVD facilities on movable trolleys
• Free standing fans
• Phones with the facility to turn off the ringer
• Oxygen cylinder for the EEG room
• Hospital beds, fully adjustable
• Clinical trolleys
• Patient chairs, with arms.
• Standard chairs within test rooms for relatives or chaperons
• Clinical waste bins
• Household waste bin
• Alarms for medical emergencies
• Toy cupboards
• Wall mounted clocks
• Desk lamps
• Reporting tables
• Patient bedside table’s, adjustable.

13.2 Office

• Computers, networked to PAS

• Multifunction printer/fax/photocopier (Xerox machine)
• Office desks with draws
• Operator chairs
• Phones
• Fax line
• Household bins
• Recycle bin
• Filing cabinets
• Storage cabinets
• Staff lockers
• Chairs
• Wipe boards
• Notice boards
• Wall mounted clocks

13.3 Waiting Area

ƒ Chairs
ƒ Notice board
ƒ Toy box
ƒ Set children’s table and chairs
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 ƒ Household bin
ƒ Leaflet/information rack
ƒ Magazine rack/table

14. Infection Prevention

14.1 The service will be delivered in accordance with and compliance to the Trust’s
Infection Prevention Policies.

15. Equality and Diversity

15.1 The Trust is committed to commit to the provision of a service that is fair, accessible
and meets the needs of all individuals. The department supports access for disabled
users.

16. Contingency

16.1 EEG & EMG tests are performed on stand alone equipment and therefore failure
of PAS would not disrupt the service. Information would be kept in paper format and
uploaded to the PAS system when available.
If either EEG or EMG equipment fails the maintenance contract provider could provide
loan equipment.

16.2 The EMG service is unable to function without powe. If mains power failed within the
department, the service could continue to provide 3 urgent EEGs on a portable
system (battery). Any closure/movement of the department short term would cause
loss of output therefore we would not meet our diagnostic target in the 18 week
pathway. Extra clinical physiology breech clinics & extra Consultant sessions would
be essential to clear the backlog.

16.3 If a major incident should affect the hospital this would not immediately affect our
service as we are not ‘front line’, staff within the department would seek guidance
from the General Manger - Medicine relating to their roles during the incident.

17 Auditing this Policy

17.1 This policy will be audited annually by the General Manger for the Neurophysiology
Service. Updating of the policy will be undertaken by the Clinical Neurophysiologists
following audit feedback from the General Manager. The information will be shared
within the team and more formally at the bilateral. The revised policy will be submitted
to the Document Ratification Accreditation Group and then submitted to the Trust
Board.

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18. Responsibilities

18.1
Chief Executive Officer

Director of Delivery

Divisional Manger

General Manager

Department Manager

Consultants Clinical Neurophysiologist

Medical support staff

18.2 The General Manager - Medicine is operationally and financially accountable for
service delivery. The Clinical Neurophysiology Team will remain professionally
accountable for their actions. They will work in conjunction with the General Manager
to ensure that the service is delivered within the confines of the agreed budget and
operational requirements.

19. References

19.1 Setting Up & Running a Department of Clinical Neurophysiology.

Raymond Cooper, Colin Binnie & Richard Billings.

Clinical Neurophysiology at the Whittington Hospital 2008 & beyond : issues for the
future.

Children’s National Service Framework

http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111

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Appendix 1
Emergency Flows/Elective Patient Flows

Patient Pathways

Elective Pathway Emergency Pathway

Referrals received via outpatient

setting, e.g. MEHT OPD, GP,
North East Essex Mental Health, Referrals received from wards
Colchester P.C.T’s or community either by post, fax or hand
paediatric clinics. delivered

Date stamped and logged Date stamped and logged

electronically by administrative electronically by administrative
support. support

Triaged by Clinical Physiologist

Triaged by Clinical Physiologist
(Neurophysiology), appointment
booked based on clinical
presentation, appointment within
4 – 6 weeks
(Neurophysiology) appointment
booked based on clinical urgency.
Patients requiring EEG are usually
seen within 24 – 48 hours.
Patients requiring EMG usually
seen within 1 week.

Appointment and information sent Ward area contacted and advised

to patient referral received and planned
appointment time.

Diagnostics undertaken in the

Neurophysiology Department,
results of investigations forwarded
to relevant Medical Personal

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