Transcript 9yBusuSgk

COPD Pathway in Primary
Care
Claire Hurlin
Clinical and Service Lead CCM
Carmarthenshire Locality
Hywel Dda Health Board
INTEGRATED CARE
PATHWAYS
• An Integrated Care Pathway (ICP) is a
document that describes a process within
Health and Social Care
• ICP’s are both a tool and a concept
• They embed guidelines and protocols
• They are locally agreed, evidence-based,
patient-centred
• The aims of ICPs are that they have:– The right people
– In the right order
– In the right place
– Doing the right thing
– At the right time
– With the right outcomes
– All with attention to the patient experience
The aims of the pathway are:
•
•
•
•
•
Delivery of consistent high-quality care
Reduction in unnecessary variation in practice
Implementation of evidence-based care
Structured documentation
To facilitate communication & audit
DORIS
• In 1990, she died a premature death from
COPD aged 60 years, alone in a hospital
ward in the middle of the night, her family
were at home in bed thinking that she was
recovering from this recent exacerbation
• Years of untreated anxiety and depression COPD had sapped her ability to look
forward to anything
• Virtually housebound
• Had been a heavy smoker for many years, but
quit 8 years before she died
• BMI of 18
• No offer of any help from outside agencies until
after she died
• Revolving door patient in and out of hospital with
exacerbations for 4 years prior to death
• She saw her son married, but did not live long
enough to see her grandchildren born
The Initial Pilot in
Primary Care
• Local GP devised a computer (MSS InPS Vision clinical
system) based template for use in her practice
• Built on this work to develop pathway
• A Practice Nurse involved in care of patients with COPD
was needed to work with, and evaluate the use of, the
template during consultations, over a 3 month period
•
•
•
•
•
Practice Nurse since 1990
Tumble Surgery in the Amman Gwendraeth Valley
4 GPs, one with responsibility for Respiratory Disease
7,200 patients
188 patients on the COPD register – prevalence of 2.6%
Current management of
patients with COPD
QOF REQUIREMENTS
– Register of patients with a diagnosis of COPD
– Confirmed by spirometry with reversibility
– Smoking Status
– Smoking Cessation advice
– FEV1
– Inhaler technique
– Flu vaccination
– MRC Dyspnoea score
ICP TEMPLATE
• Colour coded sections
– Diagnosis
– Exception reporting
Unsuitable Dissent
– Significant History
HCA Plan
•
•
•
•
Primary Language
Interpreter needed
Family History of Note
Home Situation
– Occupation
– Carer Details
– Housebound
– On Home O2
• Smoking History
Record smoking status EVERY YEAR for non-smokers
until 26 years, and ex smokers annually until 3 years non
smoking
– Smoking History
• Passive Smoking Smoking Cessation Advice
PACK YEARS = number smoked x number of years
smoked, divided by 20
CIGARS –
1 HAVANA = 5 CIGS
1 HAMLET = 3 CIGS
1 SMALL CIGAR = 2 CIGS
TOBACCO FOR ROLL UPS 25gms = 50 cigs
•
•
•
•
•
•
•
•
•
Pack Years
Referred to Smoking Counsellor
OTC NRT
Refused smoking help
Smoking review not indicated
Weight
Height
Waist Circumference
BP
PRACTICE NURSE SECTION
• ADVICE RE EXERCISE – Encourage all COPD patients
to exercise within limits of disease. Consider referral to
exercise scheme for mild COPD patients. Consider referral
to Pulmonary Rehabilitation for moderate – severe COPD
• ADVICE RE DIET – Consider referral to dietician if BMI
<20
• REFER TO DIETITIAN
• EXACERBATIONS
– ACUTE EXACERBATION
• SYMPTOMS
– SPUTUM EXAMINATION
– List of symptoms in green
• INHALER TECHNIQUE
– Inhaler technique good
– Inhaler technique poor
• PULMONARY FUNCTION TESTS
– PEFR
• SPIROMETRY –
– NB: For QOF purposes, COPD diagnosed where
FEV1 <70% FEV1/FVC ratio <70%
• SPIROMETRY
Contra Indicated/Declined
Not Indicated
• REVERSIBILITY TEST RESULTS
– Reversible airway obstruction
– Irreversible airway obstruction
• STEROID TRIAL - protocol
• RESPIRATORY SYMPTOMS
– MRC Dyspnoea Scale
• PATIENT PROGRESS
– Excellent
– Fair
– Slight
• SELF MANAGEMENT PLAN GIVEN
• IMMUNISATIONS
• ANXIETY & DEPRESSION
– Same 2 questions asked in QOF
GP CONSULTATION
NEW DIAGNOSIS
–Mild = 50 – 80%
–Moderate = 30 – 49%
–Severe = <30%
–Asthma
–Emphysema
• EXAMINATION
– O/E Chest
– Peripheral Cyanosis
– Central Cyanosis
– SOA (swelling of ankles)
– Acute Cor Pulmonale
– Chronic
– O/E Heart
TEST RESULTS
– CXR CXR REQUESTED
– ECG
– ECHO – lots of info for clinicians to follow
– Pulse Oximetry O2 saturation
– Alpha 1 Anti-Trypsin Test – Think of doing this
test if patient has FH, early onset of
symptoms, or minimal smoking history
COPD REVIEW
–COPD self management plan given
–annual review done
–follow up review done
–frequency of exacerbations
–nutritional state
• depressed? -
REFERRALS
– Dietician
– CDM Team
– Expert Patient Programme
– Pulmonary Rehabilitation
– Chest Physician
– Occupational Therapy
– Oxygen assessment
• PULMONARY REHABILITATION
–Started Rehabilitation
–Finished Rehabilitation
• MEDICATION REVIEW
–Medication Review
–Medication Review with Patient
PALLIATIVE CARE PATHWAY
On Palliative Care Pathway
– Consider all patients with end-stage illness
including dementia, COPD, LVF etc. Include in
the register if any of the following apply:
• Death predicted in the next 12 months
• Clinical indicator of need for palliative care
• DS1500 issued
– DS1500 completed
– Medication Changed/Review/Review with
Patient
– Drug Dose altered Drug Stopped
• CARE PLAN
–Preferred Place of death
discussed with family
–Preferred Place of death
discussed with patient
• USEFUL CONTACT NUMBERS
–District Nurses
–Macmillan
–Cross Roads
–ART
–Canllaw
–CDM Team
DO WE NEED AN ICP?
BENEFITS TO PATIENTS
o It will avoid duplicating questions patients are
repeatedly asked at reviews
o It will avoid conflicting advice
o Patients will be offered all necessary services that
are available
o Offers them a better say in their management
o Allows the right steps to be taken at the right time
o Provides a robust method of capturing the patients
journey of care
o Clinical details are contained within one template
BENEFITS TO CLINICIANS
– Clinicians will know where the patient is on their
journey of care – includes prompts for guidance
– In Primary Care, all clinical details needed at a
consultation are on the one template
– Clinicians will all be “singing from the same hymn
sheet”
– Mini protocols/guidelines are included (the red text
added in), facilitating accuracy and consistency in
our care
– Efficient use of staffing resources
Benefits continued:
– Since the ICP captures patient information in a
consistent way, questions which were previously
repeated during reviews do not need to be
asked.
– Systematic provision of advice and information
– The BLF self management plan and ICP provide
robust, evidenced-based information that can be
repeated and reinforced as required.
– Referrals to other services are recorded and
monitored
DORIS
• In 2009, she died, aged 79, a peaceful
death having been implemented on to the
COPD ICP when first diagnosed allowing
her to self manage, have the support of
relevant services and when the time came
placed on the end of life pathway allowing
her to die in the place of here choice –
home with her family surrounding her.
Towards the last 5 years of her life it was
noted through the ICP that she was
depressed and commenced on the relevant
treatment.
Although she was virtually housebound a
team of relevant support staff had been
implemented allowing her to stay at home,
supported by an identified case manager
who linked all her care together
As well as seeing her son married she had
seen both the grandchildren born
Outcomes from Pilot
• Pilot showed 86% of patients had fewer
exacerbations after they had started on the
pathway
• There were 57% fewer exacerbations post
pathway
• 43% patients received a change in their
management plan as a direct result of
starting on the pathway
Next steps
1. A template which will enable the care pathway to be
used on other primary care clinical systems has
been developed.
2. Development of a report to include all of the clinical
information in the care pathway which can be printed
and sent with referral letters. This will avoid
duplication of tests and improve continuation of care
management between primary and secondary care.
3. Roll-out of the pilot to other practices within the
health community.
4. Improvements to the self management plan have
been identified and feedback given to BLF.