Transcript Implementing the Respiratory Directive

Implementing the Respiratory
Directive
Claire Hurlin
Clinical and Service Lead CCM
Carmarthenshire Locality
Hywel Dda LHB
• Primary Care Pathway for COPD
• Better Breathing Project
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
• Reinforcement of accountabilities
• To facilitate communication & audit
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
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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
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Register of patients with a diagnosis of COPD
Confirmed by spirometry with reversibility
Smoking Status
Smoking Cessation advice
FEV1
Inhaler technique
Flu vaccination
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
• Yo-yo’d between home and 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
ICP TEMPLATE
• Colour coded sections
– Diagnosis
– Exception reporting
Unsuitable Dissent
– Significant History
HCA Plan
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Primary Language
Interpreter needed
Family History of Note
Home Situation
– Occupation
– Carer Details Housebound
O2
On Home
• 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
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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 dietitian 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
– SAO (swelling of ankles)
– Acute Cor Pulmonale
– Chronic
– O/E Heart
TEST RESULTS
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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
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
improvements include:
A reduction in GP appointments
Appropriate changes in management plan
A reduction in exacerbations
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.
Better Breathing Project
Home telemonitoring does not
affect quality of life in stable
COPD
K.E.Lewis, D.E.Warm, S.E.Rees, C.Hurlin, H.Blyth,
S.Yasir, L.Lewis, J. Annandale
Randomised control trial
Aim:
• To see if home telemonitors
reduce healthcare use in those
with optimized chronic obstructive
pulmonary disease (COPD).
Primary Outcome
• to test whether home monitoring is feasible
and safe for patients with moderate to
severe COPD.
Secondary outcome measures were also
examined:
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Does home telehealth reduce respiratory
hospital admissions?
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Does home telehealth reduce CDMT
visits?
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Does home telehealth improve quality of
life and mood?
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Is home telehealth cost effective?
Inclusion criteria
• Moderate/severe COPD 1
• 12/18 sessions OPD pulmonary
rehabilitation
• Known to Community COPD Team
• Telephone point
Procedure
randomised
n=20
Baseline QoL
n=20
Baseline QoL
Docobo 6 months
Standard care 6 months
QoL 4 & 25 wks
QoL 4 & 25 wks
Standard care 6 months
Standard care 6 months
QoL 30 & 52 weeks
QoL 30 & 52 weeks
Telemonitors
Freephone download at 2 am daily
Next day review by COPD Team
Docobo HUB (Bookham, UK)
Data collection
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From 0600 to 1200
Awake at night
Wheeze
Cough
Breathlessness
Daily activities
Temperature
Saturations & HR
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From 12.01 to 2300
Breathless
Wheeze
Sputum
Reliever use
• Saturations & HR
Data collection-contd.
• Better / same / worse / much worse
• Temp >38° C
• Pulse >120 bpm
If 2 or more alerts then automated e-mail
sent to respiratory nurses
Percentage of data capture points from Docobo
14
Number of patients
12
10
8
6
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2
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51-60%
61-70%
71-80%
81-90%
91-100%
Percentage of total available data capture
Median 96% (mean 98%) of total available data uploaded
Overall project:
To assess the safety and feasibility of
telehealth home care in COPD in a UK
healthcare system.
• Safe – YES
• Well used – YES well received by patients with
all reporting that it was easy to use and the
twice daily questions easy to answer.
• no reported adverse events and the 2 deaths
and 1 withdrawal were unrelated to telehealth
device use.
Results
Detailed analysis of the data showed
1. were fewer primary care contacts for
chest problems (p<0.03) in the TH group
2. No differences between the groups in
A&E visits, hospital admissions, days in
hospital or contacts to the specialist
COPD community nurse team, during the
monitoring period.
3.After the monitors were removed, there
were no differences between the groups
for any of the health care contacts.
4.The quality of life scores using the ED-5D
and SGRQ questionnaires were not
significantly different between the TH
and control groups at any of the
administrative intervals examined.
Discussion
• Patient selection
– Optimal treatment and support
– Few exacerbations and hospital admissions
• Size of study
– Small numbers, short time period
• Outcomes
– Quality of life scores appropriate
Next Steps
• Bigger Randomised Control Trialss
• Less stable group of patients
– Refused or cannot do PR
– Frequent exacerbations and admissions
– Severe dual pathology
• Alternative technology
• A follow-on research project is now
underway to provide better evidence of
cost-effectiveness and robust testing of
the delivery model so that
recommendations for a sustainable
telehealth and telecare model can be
implemented across health and social
services in Wales.
• Lewis K, Annandale J, Warm D, Hurlin C, Lewis M, and Lewis L
(2009) Does home telemonitoring further affect quality of life for
patients with COPD who have had pulmonary rehabilitation? A pilot
randomised trial. Journal of Telemedicine and Telecare (In Press).
• Lewis K, Annandale J, Warm D, Rees S, Blyth H, Hurlin C, Yasir S,
and Lewis L (2009) Does home telemonitoring after pulmonary
rehabilitation reduce healthcare use in COPD? A pilot randomized
trial. Journal of Chronic Obstructive Pulmonary Disease (In Press).
• Lewis K, Annandale J, Hurlin C, Warm D, and Lewis L (2009) Home
telemonitoring does not affect quality of life in stable COPD.
European Respiratory Journal 34: 237s.
http://www.ersnet.org/learning_resources_player/abstract_print_09/
main_frameset.htm