Electrocardiograph (ECG) Policy · Medical Advisory Committee V1 2014 Medicines ... A4 ECG Easy Guide 15 A5 Training Needs Analysis ... Electrocardiograph (ECG) Policy

1 Electrocardiograph (ECG) Policy Version: 1 January 2017

SH CP 204

Electrocardiograph (ECG) Policy

Version: 1

Summary:

The aim of the ECG policy is to provide pragmatic advice as to what is best practice and inform clinicians of potential cardiac risks to patients treated in mental health services.

Keywords (minimum of 5): (To assist policy search engine)

Medication, Effects, Cardiovascular, Physical, Health, ECG, Electrocardiogram, HDAT

Target Audience:

All Clinical/Social Care Staff

Next Review Date: September 2018

Approved and Ratified by:

Medicines Management Committee

Date of meeting: 16 November 2016

Date issued:

January 2017

Author:

Juliet Wells, Principal Pharmacist

Sponsor:

Mayura Deshpande, Clinical Service Director, Adult MH


Version Control

Change Record

Date Author Version Page Reason for Change

2014 Juliet Wells 1 All Review and transferred to SHFT format

2014 Tim Coupland, Dr Raja Badrakalimuthu Dr Daniel Pearce Dr Amanda Taylor,

1 All “

2016 Steve Coopey 1 All Reviewed, TNA completed

2016 Ricky Somal 1 All Reviewed EqIA completed

2016 Juliet Wells 1 Medicines update

2016 Francis Johnson, Deputy Chief Pharmacist

1 Amendments following MMC

9/1/18 Review date extended from Jan to March 2018

23/3/18 Review date extended to July 2018

23/3/18 Review date extended to Sept 2018

Reviewers/contributors

Name Position Version Reviewed &

Date

Medical Advisory Committee V1 2014

Medicines Management Committee V1 2014

Medicines Committee Management V1 2016

Rebecca Henry V1 2016


CONTENTS

Page

1. Introduction 4 2. Background 4 3. Procedure 5 4. Training 8 5. Important Note 8 6. Monitoring 9 7. Associated documents 9 Appendices

A1 Psychotropic medication effects on QTc interval 10 A2 ECG Fax Back Service form 12 A3 ECG Fax Back Service 13 A4 ECG Easy Guide 15 A5 Training Needs Analysis (TNA) 16 A6 Equality Impact Assessment (EqIA) 17


ECG Policy 1. INTRODUCTION 1.1 The aim of the ECG policy is to provide pragmatic advice as to what is best

practice and inform clinicians of potential cardiac risks to patients treated in mental health services.

2. BACKGROUND 2.1 Increasingly there is recognition of the cardiotoxic effects of psychotropic

medication as well as the effect of physical intervention such as restraint. This is a summary of the information available and some of the factors that increase cardiac risks:

i) The drug factors ii) Patients factors that increase cardiac risk

2.2 Drug Factors: 2.2.1 QTc effects

Many psychotropic drugs are associated with ECG changes and it is possible that certain drugs are causally linked to serious ventricular arrhythmias and sudden cardiac death. Some antipsychotic drugs block cardiac potassium channels and are linked to prolongation of the QT interval which is a risk factor for ventricular arrhythmias which are occasionally fatal. Tricyclics antidepressants are sodium channel antagonists which prolong QRS and QT interval effects. These are usually evident only following overdose (see Appendix 1). Concurrent use of more than one QTc prolonging drug

2.2.2 Metabolic Inhibition

The effect of drugs on the QTc interval is usually plasma level dependent (i.e. dose) and drug interactions are therefore important, especially when metabolic inhibition results in increased plasma levels of the drug affecting QTc. Examples of metabolic inhibitors are : - Fluvoxamine, Fluoxetine, Paroxetine and Valproate.

2.2.3 Other Cardiac Effects Clozapine is associated with tachycardia, myocarditis, cardiomyopathy and atrial fibrillation (AF). Olanzapine, Paliperidone & Tricyclic antidepressants are associated with AF. Anticholinergics are associated with tachycardia. Acetylcholinesterase inhibitors used in management of dementia are associated with bradycardia and asystole. Also consider concurrent diuretic therapy and digoxin


2.3 Patient Factors: 2.3.1 Physiological risk factors for QTc prolongation and arrhythmia

These include pre-existing cardiac disease, long QT syndrome, bradycardia, ischemic heart disease, myocarditis, myocardial infarction, left ventricular hypertrophy, recent cardioversion with QT prolonging drug, metabolic causes, hypokalaemia, hypomagnesaemia, hypocalcaemia, extreme physical exertion, stress or shock, genetic predisposition, anorexia nervosa, malnourishment, extremes of age i.e. children or elderly and female gender, renal or hepatic impairment.

2.3.2 Patient cardio vascular risk factors:

With respect to cardio vascular disease, other risk factors are: smoking, elevated lipids, family history of heart disease/QTc prolongation, obesity and life style issues. Obesity and impaired glucose tolerance represent a much greater risk to patient morbidity and mortality than the uncertain outcome of QTc changes.

2.3.3 Behaviours responsible for increased risks:

Restraint and rapid tranquillisation of patients, and particularly the use of high dose antipsychotics, are associated with increased cardiac risk factors.

A history of illicit drug use, may compound the risks due to possible increased heart rate, exhaustion, hypotension and excitement. Patients on drugs such as methadone and cocaine which are associated with cardiogenic effects are recommended to have ECG at baseline.

3. PROCEDURES 3.1 Which patients require an ECG? 3.1.1 Before starting any psychotropic medications an electrocardiogram (ECG) should be offered if:

specified in the summary of product characteristics (SPC)

physical examination shows specific cardiovascular risk (such as diagnosis of high blood pressure)

there is personal history of cardiovascular disease, or

the service user is being admitted as an inpatient

or indicated in physical health monitoring guideline

3.1.2 For patients on high dose antipsychotics or antipsychotics such as Clozapine and Pimozide with high risk of cardiotoxicity regular ECG monitoring will be required. Regular monitoring may be required for patients on specific antidepressants such as Citalopram and high dose venlafaxine. Please refer to physical health monitoring guide for frequency of ECG monitoring.


Indications for ECG Monitoring

Psychotropic medication ECG Monitoring

Acetylcholinesterase inhibitors (APT,2007, 13, 178-184)

Baseline : If pulse > 60 bpm but with history of falls, syncopal attacks, on cardiovascular medications for rate/ rhythm control or with significant cardiovascular illness or if pulse <60 bpm 1

Citalopram & Escitalopram (Applies to patients with cardiac disease; MHRA, Dec 2011)

Baseline Citalopram: Every 6 months if dose greater than 40mg/day (or if dose greater than 20mg/day in patients 65 years of age or more) Escitalopram: Every 6 months if dose greater than 10mg/day in patients 65 years of age or more

Lithium (NPSA, 2009)

If there is a risk factor for, or existing, cardiovascular disease, an electrocardiogram is normally performed before treatment begins3.

Haloperidol Baseline is recommended prior to treatment in all patients, especially in the elderly and patients with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination

High dose antipsychotics (NICE) (HDAT)

Baseline, when steady state is reached, 6 monthly, after dose changes or change to other medications which can impact on QTc interval or if clinically indicated.

Clozapine (NICE) Baseline, if clinically indicated or change to other medications which can impact on QTc interval

Tricyclics Baseline If clinically indicated in patients with risk of cardiac arrhythmias.

Methadone All patients should be evaluated for the presence of risk factors for QT prolongation prior to initiating methadone treatment. If risk factors present, baseline ECG is required. ECG monitoring should be considered for methadone doses >150mg/day and in patients with risk factors for QT prolongation, or symptoms that may be attributable to arrhythmia

3.1.3 If an ECG cannot be carried out because of a patient’s mental state or behaviour

(e.g. on admission to an inpatient unit) then this fact and the reasons, must be recorded in the primary case record. An ECG should be done as soon as it is


practical. An ECG should be carried out once the medication dose has been stabilised.

3.1.4 All patients over 45 years old or all patients with a history of cardiac problems or

cardiac risk factors should have an ECG prior to ECT. Please refer to the ECT policy (CP69.1) on the Trust Website.

3.1.5 All patients prescribed two or more medications which impact on QTc interval or

associated with arrhythmias should have ECG as recommended by the Physical Health Monitoring Policy of Southern Health NHS Foundation Trust.

3.1.6 Routine baseline ECG may not be required when medications such as Citalopram

or Risperidone is used in small doses and for a short duration in managing behavioural and psychological symptoms of dementia.

3.2 Equipment 3.2.1 Each inpatient unit should have an ECG machine which should be kept in good

working order

3.2.2 The preferred ECG machine for use within Southern Health NHS Foundation Trust is GE MAC 1200ST with interpretation module. When an ECG machine requires replacement this should be the preferred model of choice.

3.2.3 It is the responsibility of the Modern Matron in each in-patient unit to ensure the

functioning and maintenance of the ECG machine. 3.3 Inpatient Services 3.3.1 Each inpatient unit must have an understanding about who does the ECG, how it

is interpreted and when to refer to for specialist opinions. These arrangements will be agreed at a local level.

3.3.2 All inpatient services have to access a Fax Back service for cardiology opinions from Portsmouth Hospital Trust. The request sheet should be completed for all requests (appendix 2 & 3). However, some inpatient units may have arrangements with their local cardiology teams and with whom they can agree appropriate referral criteria.

3.3.3 Modern Matrons (or equivalent) are responsible for ensuring all clinical staff know

the local procedures for arranging ECGs. 3.4 Outpatient Requirements 3.4.1 In general the GP will be responsible for prescribing medication and therefore

also the appropriate monitoring. However, whenever a psychiatrist recommends any medication, they should inform the GP of the monitoring requirements.

3.4.2 If the psychiatrist retains responsibility for prescribing, they are also responsible

for ensuring that the drug monitoring requirements, including ECG, are met e.g. in the case of Clozapine, HDAT or depot medication.

3.4.3 Local arrangements will need to be made concerning how the ECG is obtained

i.e. through the GP or local general hospital. ECG results must be recorded in the appropriate place in the care record and the GP informed.


3.4.4 ECGs should be included as part of the Care Planning process with reference to the physical health shared care guidelines.

3.5 Practice 3.5.1 See Appendix 4 for flow chart. 3.5.2 Once the ECG has been carried out the following guidelines for referral should be

followed:

QTc <440 ms (men) or <470 ms (women) No action required unless abnormal T-wave morphology – consider referral to

cardiologist if in doubt.

QTc ≥440 ms (men) or ≥470 ms (women) but <500 ms Consider reducing dose or switching to drug of lower effect; repeat ECG and

consider referral to cardiologist.

QTc ≥500 ms Stop suspected causative drug(s) and switch to drug of lower effect; refer to

cardiologist immediately.

Abnormal T-wave morphology Review treatment. Consider reducing dose or switching to drug of lower

effect. Refer to cardiologist immediately.

3.5.3 For patients with dementia considered for Acetylcholinesterase inhibitors:

If HR more than 50 bpm but associated with syncope, falls or symptoms of bradycardia, then withhold/ stop drug and seek specialist/ GP advice for underlying cause; if cause is unrelated to drug or patient is fitted with pacemaker consider retrial of drug and check pulse after a week.

If HR less than 50 bpm then withhold/ stop drug and seek specialist/ GP advice for underlying cause; if cause is unrelated to drug or patient is fitted with pacemaker consider retrial of drug

4. TRAINING 4.1 Each Area/Service must organise training for staff to ensure that:

i) Adequate numbers of nurses (band 5 and above) and doctors in every team

are trained in use of ECG machine and in interpreting ECG. ii) Doctors should also familiarise themselves with the process involved seeking

physicians’ or cardiologists’ opinion. 4.2 Medical staff should receive a copy of this policy as part of their local induction. 5. IMPORTANT NOTE

At all times this policy should be used in conjunction with the latest SPC (manufacturer’s Summary of Product Characteristics or Datasheet), the latest Trust Guidelines, the latest NICE publications, the current Maudsley Guidelines, MHRA alerts, NPSA alerts, current BNF/eBNF and other relevant publications. If in doubt seek expert opinion.


6. MONITORING The implementation of this policy will be monitored as part of the annual physical

healthcare audits undertaken by service directorates. This will be the responsibility of the Clinical Governance leads of each directorate.

7. ASSOCIATED DOCUMENTS

SH CP 134 - Guidelines for the use of High Dose Antipsychotics

SH CP 113 - Shared Care Guidelines for Prescribing Lithium

SH CP 46 - Electro Convulsive Therapy Policy

SH CP 17 - Zuclopenthixol Acetate Guidelines

SH CP 48 - Rapid Tranquillisation: Policy and Guidance for use in Mentally Ill Patients Displaying Acutely Disturbed or Violent Behaviour

SH CP 114 - Clozapine Guidelines

SH CP 44 - Physical Assessment and Monitoring Procedure for Integrated Community Services

SH CP 45 - Physical Assessment and Monitoring Procedure for Mental Health and Learning Disability Services

Current Summary of Product Characteristics (data sheet) www.emc.medicines.org.uk

SH CP 40 - Medical Devices Management Policy

Psychotropic Drug Directory 2009 by Stephen Bazirre. Published by HealthComm UK Ltd. Chapter 3.2 Cardiovascular disease p248 – 259.

British National Formulary no.71, March 2016

The Maudsley Prescribing Guidelines 12th edition by Taylor, Paton & Kapur.

HPFT Substance Misuse Services: ECG Assessment and Monitoring

SH CP149 - Physical health monitoring guideline for medicines commonly prescribed in mental health

QT interval and drug therapy. Drug and Therapeutics Bulletin. Vol 54 (3) p33-36. March 2016

http://www.emc.medicines.org.uk/

Appendix 1


Psychotropic medication effects on QTc interval (based on the Maudsley Guidelines 12th Edition)

1 No Effect 3 Moderate Effect

Aripiprazole Lurasidone

Reboxetine Mirtazapine MAOIs

Carbamazepine Gabapentin Lamotrigine Valproate

Benzodiazepines

Amisulpride** Chlorpromazine Haloperidol Iloperidone Levomepromazine Melperone Quetiapine Ziprasidone

Citalopram/ Escitalopram/ Fluoxetine Tricyclics antidepressants Lofepramine

4 High Effect

Any IntraVenous Antipsychotic Pimozide Sertindole Thioridazine

Any drug or combination of drugs used if exceeding recommended maximum. (see High Dose Antipsychotic Policy)

2 Low Effect

Asenapine Clozapine Flupentixol Fluphenazine Perphenazine Prochlorperazine Olanzapine* Paliperidone Risperidone Sulpiride

Bupropion Moclobemide Venlafaxine Trazodone

Lithium

Unknown Effects

Loxapine Pipothiazine Trifluoperazine Zuclopenthixol

Anticholinergic drugs (Procyclidine, Benzhexol etc.)

Zuclopenthixol Acetate (Acuphase®) – see Trust Policy

1. No effect drugs are those in which QTc prolongation has not been reported either at therapeutic doses or in

overdose. 2. Low effect drugs are those for which severe QTc prolongation has been reported only following overdose or

where small increases have been observed at clinical doses. 3. Moderate effect drugs are those that have been observed to prolong QTc by more than 10 milliseconds on

average when given a normal clinical dose or where ECG monitoring is officially recommended in some circumstances.

4. High effect drugs are those for which extensive average QTc prolongation is usually greater than 20 milliseconds at normal clinical doses has been noted and where ECG monitoring is mandated by the manufacturers data sheet (SPC). * isolated cases of QTc prolongation & has effects on cardiac ion channel,IKR, other data suggests no effect on QTc **Torsade de pointes common in overdose

However the effect on QTc may not necessarily equate directly to risk of torsades de pointes or sudden death

Appendix 1


Concurrent drug use: Non psychotropics associated with QT prolongation (see current BNF for complete list)

Antibiotics Antiarrhythmic

Erythromycin Clarithromycin Ampicillin Co-trimoxazole Pentamidine Some 4-Quinolones (see SPC)

Quinidine Disopyramide Dronedarone Flecainide Procainamide Sotalol Amiodarone Bretylium

Antimalarials Others

Chloroquine Mefloquine Quinine

Amantadine Antifungals (fluconazole, ketoconazole) Antiretrovirals eg foscarnit Ciclosporin Cisapride Antimotility & Antiemetic (domperidone, granisetron, ondansetron) Diphenhydramine Hydroxyzine Methadone** Protein kinase inhibitors e.g. Sorafenib, Sunitinib Nicardipine Tamoxifen

* not in 10th or 11th edition of Maudsley guidelines but added due to recent alerts ** was previously listed (in 10th ed) under psychotropic drugs, now listed under non-psychotropic drugs (11th ed Maudsley)

Appendix 2


CONFIDENTIAL

Cardiology Department, Queen Alexandra Hospital, Portsmouth, PO6 3LY ECG FAX BACK SERVICE

Instructions to referring Doctor: 1. Please identify each faxed page with the patient’s name. 2. Fax the fully completed form and recent 12 Lead ECG to 02392 286092 3. Note that this is NOT a referral and the Cardiologists will merely fax back a report Date: ________________________ Patient Details: Name: ___________________ D.O.B _____________________ NHS Number ___________________ Gender: ___________________ Ethnicity: _____________________ Reason for ECG, Relevant Medication & Known Cardiac History (Brief Summary) To Whom should the Fax Report be sent: Drs Name: _______________________ Fax No:_________________ Drs Tel No:_______________________ Consultant Report: Recommendations: Name: ____________________________ Date: ___________________

Appendix 3


ECG Fax Back Service

Parties to the Agreement: Supplier: Portsmouth Hospitals NHS Trust Customer: Southern Health NHS Foundation Trust Purpose: This agreement represents a contract between Portsmouth Hospitals

NHS Trust and Southern Health NHS Foundation Trust for the provision of an ECG Fax Back service for routine ECG reports faxed in by Adult, Old Age, Specialised Services and Learning Disabilities Psychiatrists employed by Southern Health NHS Foundation Trust.

The Service: Service Principles: The service principle is to provide timely and accurate specialist cardiological interpretation and advice in relation to 12 lead ECG reports. Service Aims and Objectives: The service aims to provide timely interpretation of ECG reports, to include identification of any noteworthy anomalies and recommended resulting actions where appropriate. Service Specification: HPFT will ensure that:

Staff use the agreed ECG fax back service form, ensuring that each faxed page includes the patient name and that all details are completed as outlined on the form, including details of referrer, secure fax number and telephone number for a response.

PHT will undertake to:

Ensure a cardiological opinion (i.e. consultant cardiologist or cardiology registrar) is obtained for all ECG reports faxed to the service and that a response is faxed back to the requesting Doctor within 2 working days of receipt. The Faxback will include interpretation and recommended actions where appropriate. The timeframe for response is conditional on the appropriate form being fully completed.

Locations Served: All Southern Health NHS Foundation Trust services

Appendix 3


Normal Working Hours: The Department is open Monday – Friday 9.00am – 4.30pm. ECG reports can be faxed outside these times and will be dealt with within 2 working days (excludes Saturday and Sunday). Activity Levels: Activity levels have been estimated at roughly 300 fax back requests per year. Service Charges: Cost per ECG faxback is £10.00 Invoice details will need to include details of referrer, team/unit base and relevant Directorate Monitoring Arrangements: Initial review meeting at six months to review the following:

Activity to include referrer and team/unit base as per those on invoice details

Fax-back return times

Common anomalies identified on ECG reports, including frequency of poor quality ECG reports being received

Following this initial meeting, review meetings to occur on an annual basis.

Appendix 4

15 Electocardiograph (ECG) Policy Version: 2 August 2016

ECG EASY GUIDE

Patient admitted to ward

Normal ECG

(QTc <440ms men <470ms women)

No acute action needed

Repeat prior to discharge, then

follow guidelines for outpatient

management If on clozapine will need ECG after 3 and 6 months then

annually If on high-dose

antipsychotics refer to policy

Perform ECG

Where possible prior to starting psychotropics In conjunction with physical examination and blood tests

Abnormal

QTc

Abnormal T-wave

morphology

Other abnormality

on ECG

QTc > 440ms men

or > 470ms women

but <500ms

Consider reducing dose or switching to drug

of lower effect Repeat ECG and consider referral to cardiologist

QTc >500ms

Stop causative drug(s) and

switch to drug of lower effect,

refer to cardiologist immediately

Review treatment.

Consider

reducing dose or switching to drug of lower

effect. Refer to cardiologist immediately

Treat any urgent abnormality.

Seek specialist advice.

Patient is unable to have an ECG, attempt physical

monitoring (HR, BP, T, RR) & retry ECG as soon

as possible. Record.


Appendix 5 Training Needs Analysis

If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy approval process.

Training Programme

Frequency Course Length Delivery Method Facilitators Recording Attendance Strategic & Operational

Responsibility

E- learning

Once

30- 45 minutes E- Learning online Via MLE

Operational responsibility Dr Mary Kloer, Consultant Psychiatrist Strategic Responsibility Julie Dawes Director of nursing

Directorate Service Target Audience

MH/LD/TQ21

Adult Mental Health

All staff required to perform an ECG as part of their role

Specialised Services


Learning Disabilities


TQtwentyone

Not applicable

ISD’s

Older Persons Mental Health


ISD’s

Adults


ISD’s

Childrens Services

Not applicable

Corporate

All

Not applicable


Appendix 6 Equality Analysis Form

The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act 2010. Stage 1: Screening

Name of policy/procedure Electrocardiograph (ECG) Policy

Name and job title of person

completing the assessment:

Ricky Somal: Equality and Diversity Lead

Date of assessment: April 2016

Responsible department:

Intended equality outcomes: The aim of the ECG policy is to provide pragmatic advice as to what is best practice and inform clinicians of potential cardiac risks to patients treated in mental health services. The Trust is implementing the EDS2 which allows a robust examination of Trust performance on Equality, Diversity and Human Rights. This is based on equality key objectives that include:

1. Better health outcomes for all

2. Improved patient access and experience

3. Empowered, engaged and included staff

4. Inclusive leadership

JSNA 2015

Good life expectancy for both men and women that compares well to

our CIPFA neighbours. Life expectancy has increased by 3.2 years

for men (to 81.1 years) and 2.3 years for women (to 84.2 years) from

2000/02 to 2011/13

Fewer people dying from conditions that could be avoided comparing

very well to our CIPFA neighbours

Fewer children living in poverty and less infant mortality comparing

well to our CIPFA neighbours

Good overall educational attainment particularly in the early years

Less long-term unemployment compared to national and regional

rates

Who was involved in the

consultation of this

document?

Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: www.legislation.gov.uk/ukpga/2010/15/contents

http://www.legislation.gov.uk/ukpga/2010/15/contents


Protected

Characteristic

Positive Impact Negative Impact

Age The population of Hampshire is changing; our population is getting older and we are becoming more diverse:

The population of Hampshire is estimated

to be 1.34 million people, making it the

third most populous county in England

after Kent and Essex.

Young people (aged 0-19) make up 23%

of the population compared to 24%

nationally.

Hampshire has fewer young working aged

people (aged 20-39) compared to England

as a whole; 23% in Hampshire compared

to 27% in England.

Older people (over the age of 75) make up

10% of the population compared to 8%

nationally.

No adverse impacts identified at this

stage of screening

Disability For people with mental health problems

and learning difficulties, additional time is

given to communicate effectively with the

patients to create better understanding of

what the tests involve.

Southern Health aims to ensure service

are designed to meet the health needs of

the local community and offers

interpreting and translation services.


stage of screening

Gender

reassignment

Individual patients’ health needs are

assessed, and resulting services

provided, in appropriate and effective

ways


stage of screening

Marriage & civil

partnership




ways


stage of screening

Pregnancy &

maternity




ways


stage of screening

Race Southern Health aims to ensure service

are designed to meet the health needs of

the local community and offers interpreting

and translation services.

The ethnic diversity in Hampshire is much

lower than England as a whole (8.2%

compared to 20.2% respectively) but it is


stage of screening


gradually increasing across the county.

While the population remains

predominantly white British, the proportion

of the population that is of ethnic origin

has increased from 4.6% in 2001 to 8.2%

in 2011

Asian ethnic groups make up the largest

non-white categories in Hampshire.

Rushmoor has the largest non-white

population at 15.3% (up from 4.4% in

2001); mostly due to a growing Nepalese

population.

Religion/Belief Individual patients’ health needs are



ways


stage of screening

Sex Life expectancy for men in Hampshire has

risen from 77.9 years in 2000-02 to 81.1

years in 2011-13 and is significantly

better than the male life expectancy for

England.

Life expectancy for women in Hampshire

has increased from 81.9 years in 2000-02

to 84.2 years in 2011-13 and is

significantly better than female life

expectancy for England


stage of screening

Sexual

orientation




ways


stage of screening

Stage 2: Full impact assessment

What is the impact? Mitigating actions Monitoring of actions

Electrocardiograph (ECG) Policy · Medical Advisory Committee V1 2014 Medicines ... A4 ECG Easy Guide 15 A5 Training Needs Analysis ... Electrocardiograph (ECG) Policy

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