ICP West Respiratory Care

Transcription

1 ICP West Respiratory Care

2 Respiratory Group Established July 2013 Four meetings including Beacon site visit to the Integrated Respiratory Service Macclesfield District General Hospital, Cheshire

3 Terms of Reference Multi-disciplinary, multi-sectoral review of the respiratory service in the West. The purpose of the review was to look at the service in the context of TYC and to make it more community facing, streamlined and cost effective, maximising the involvement of the Community & Voluntary sector in education, reducing isolation & supporting people at home. There was a focus on reducing referrals through adherence to agreed protocols/pathways, reduction in admissions and shorter lengths of stay through enhanced community support for patients, pulmonary rehab and other appropriate measures.

4 Terms of Reference The group was asked to focus on producing four or five key recommendations which, based on their collective experience and knowledge, would make the most impact in terms of the TYC priorities. The Multi-disciplinary group is a clinical and service delivery focused group. It was agreed that following the production of the recommendations, the ICP Clinical and business support team would work with the local trust and other providers to refine the detail of the proposals. Their proposals were delivered on 17 October 2013.

5 Western Area Respiratory Multi-disciplinary group - membership Dr Rose Sharkey (Chair) Consultant Respiratory Medicine, Altnagelvin Area Hospital Dr Terry McManus Consultant Respiratory Medicine, South West Acute Hospital Mr Michael Curry Patient Representative Paula Devine Case Manager Western Trust Helena Phelan Respiratory Nurse Specialist Western Trust Pearl Donnelly Physiotherapist Western Trust Mary McMenamin Respiratory Coordinator Western Trust Dr Vincent Davidson GP, Lakeside Medical Practice, Enniskillen Dr Ciaran Mullan GP, Riverside Practice, Strabane Health Centre Norma Ferguson Northern Ireland Chest Heart and Stroke Fiona Greene Northern Ireland Chest Heart and Stroke Tom Mc Elhinney Northern Ireland Chest Heart and Stroke Mary Campbell Smoking Cessation Co-ordinator, Western Trust Carmel Darcy Consultant Pharmacist, Altnagelvin Area Hospital Brendan Moore Pharmacist, Altnagelvin Hospital Niall Corry Community Pharmacist Donna Keenan Western Trust Management

6 Respiratory Pathway

7 Proposed Western ICP Area Respiratory Pathway Model GP Assessment + / referral to single point of contact for Community Respiratory team Access to Respiratory Consultants for Advice Virtual Clinic Home +/ - other Specialists e.g. CVS, DM Stable Community Hub Admission to Ward or ICU if required Family Support Self Management Smoking Cessation Pulmonary Rehab Support Groups Dietician Palliative Care Service Psychology/Psychiatry Social Worker/ OT/Physio Community Respiratory Team Hospital and Community Pharmacy Reablement Team Maintenance of stability includes community/ voluntary and other statutory sector organisations

8 General Practice

9 Q & P Pathways GP Assessment Long term Oxygen Therapy Assessment Bronchiectasis management Chronic Cough Pathway-Adult Pulmonary Rehabilitation Sleep Apnoea QOF Asthma, COPD, Smoking ± Advice from Consultant

10 Long term Oxygen Therapy Assessment Diagnosis: -COPD -Interstitial lung disease -Neuromuscular disorders -Pulmonary hypertension -Palliation of dyspnoea due to terminal disease -Cardiac failure Essential Criteria; -On optimal inhaled treatment -SaO2<92% when breathing air in stable phase -non-smoker or willing to stop smoking -FEV1<1.5l/min Refer for consideration of LTOT therapy

11 Bronchiectasis Management Exacerbation definition Increased cough, sputum purulence and volume +/- Wheeze, breathlessness and systemic upset Indications for management of exacerbation of bronchiectasis in primary care Able to cope at home No new confusion or impaired level of consciousness No new cyanosis RR<25 / minute SaO2>90% on room air Syst BP >90 mmhgn and Diast >60 Temp <38 C Can take oral therapy if indicated If above indications are not present, consider hospital admission For intravenous therapy if; (a) Organism not sensitive to oral antibiotic (b) Patient cannot tolerate oral antibiotic e.g. vomiting (c) Clinical failure after antibiotics Antibiotic treatment If no previous sputum bacteriology Send sputum sample and give: Amoxicillin 500mg tds po OR Clarithromycin 500mg BD po if allergic to penicillin for 14 days and repeat sputum sample to confirm sputum clear If previous sputum bacteriology Send sputum sample and give sensitive antibiotic for 14 days and repeat sputum sample to confirm sputum clear Pseudomonas if sensitive to ciprofloxacin give ciprofloxacin 500mg bd po for 14 days and repeat sputum to confirm sputum clear. If pseudomonas NOT sensitive to ciprofloxacin for iv antibiotic Other factors in the management of bronchiectasis 1. Physiotherapist referral Airway clearance technique 2. Pulmonary rehabilitation patients with SOB associated with ADL 3. Offer influenza and pneumococcal immunization 4. Smokers smoking cessation advice/clinic

12 Chronic Cough Pathway-Adult Box 1 Asthma aerosol Upper airway disorders nocturnal cough, wheezing, exercise, nasal discharge, previous sinusitis Cough >8/52 History and examination GORD stooping, dyspepsia, Environment Cough worse with or after meals, cough on phonation, dysphonia, abatement of cough during sleep cough associated with work/specific environmental irritant Chest X ray Spirometry + reversibility testing Recommendation: Trial of therapy directed at potential aggravants; aggravant avoidance Stop ACE-1 and consider alternative to ACE-1 Review in 3 months Yes Any obvious primary lung pathology? No Is the patient taking an ACE-1? No Yes Manage according to recommended treatment guidelines Trial of therapy Symptoms suggesting potential aggravants (see box 1) Cough still present Cough resolved No Cough resolved Cough still present Refer to respiratory clinic

13 Pulmonary Rehabilitation COPD, Chronic Asthma, Bronchiectasis, Pulmonary Fibrosis Any of the following criteria met; - Patient considers themselves functionally disabled with chronic lung disease - MRC dyspnoea scale grade 3 or above - Recent hospitalisation for an acute exacerbation Optimise medical therapy Assess patient for suitability for pulmonary rehabilitation using following referral criteria; - Confirmed diagnosis - Breathlessness assessed using MRC dyspnoea scale - Medical management optimised and patients using inhalers correctly -Medically stable -Drug history/allergies -Patient willing to attend and travel up to 8 weeks -Patient able to walk -Smoking history -Oxygen saturations >90% on room air or on appropriate oxygen therapy Contraindications; Do not refer patients who -Are unable to walk or have any medical problem which severely restricts exercise compliance - Have unstable angina - Have had a myocardial infarction within the last 6 weeks -Have aortic stenosis -Acute LVF -Uncontrolled cardiac arrhythmias Refer for pulmonary rehabilitation assessment (include spirometry and MRC score in referral) MRC Dyspnoea Scale Grade 1- Not troubled by breathlessness except on strenuous exercise Grade 2-Short of breath when hurrying on the level or walking up a slight hill Grade 3-Walks slower than most people on the level or stops for breath when walking at own pace due to breathlessness Grade 4-Stops for breath after walking about 100 yards on the level or a few minutes on level ground Grade 5-Too breathless to leave the house or breathless when dressing or undressing

14 Sleep apnoea pathway Signs and symptoms suspicious of obstructive sleep apnoea Height, weight, BMI, waist and neck size, occupation, medication, smoking status, alcohol intake. Risk assess/management regarding hypertension, coronary heart disease and cerebrovascular disease. Epworth sleepiness score >10 + two other symptoms of; Loud snorer Choking on waking Witnessed apnoea episodes Driving severely affected by sleepiness regularly waking unrefreshed in the morning collar size >17.5 inches Yes Refer to Respiratory department for sleep evaluation (with attached Epworth questionnaire result) No Lifestyle modification (including weight loss, smoking cessation, alcohol reduction, review of sedating medication) On going risk assessment ENT referral may be indicated for simple snoring only

15 QOF - Asthma (AST) Records AST001. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthmarelated drugs in the preceding 12 months Initial diagnosis AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or anytime after diagnosis Ongoing management AST003NI. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions NICE 2011 menu ID: NM23 AST004NI. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 15 months

16 QOF - Chronic obstructive pulmonary disease (COPD) Records COPD001. The contractor establishes and maintains a register of patients with COPD Initial diagnosis COPD002NI. The percentage of patients with COPD (diagnosed on or after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 15 months after entering on to the register Ongoing management COPD003NI. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 15 months COPD004NI. The percentage of patients with COPD with a record of FEV1 in the preceding 15 months COPD005NI. The percentage of patients with COPD and Medical Research Council dyspnoea grade 3 at any time in the preceding 12 months, with a record of oxygen saturation value within the preceding 15 months. NICE 2012 menu ID: NM63 COPD006NI. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March

17 Records QOF - Smoking (SMOK) SMOK001NI. The percentage of patients aged 15 or over whose notes record smoking status in the preceding 27 months SMOK002NI. The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 15 months. NICE 2011 menu ID: NM38 Ongoing management SMOK003. The contractor supports patients who smoke in stopping smoking by a strategy which includes providing literature and offering appropriate therapy SMOK004NI. The percentage of patients aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months. NICE 2011 menu ID: NM40 SMOK005NI. The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 15months. NICE 2011 menu ID: NM39

18 Maintenance of stability at home

19 Self Management Stanford CHS expansion model to be developed, engagement with other statutory agencies and community voluntary sector

20 Smoking cessation Strong existing team in WHSCT working with PHA QOF - Smoking (SMOK)

21 Support Groups CHS BLF Sarcoidosis in Enniskillen & Derry, being formed on Omagh Sleep aponea difficult group to get established expansion model to be developed, engagement with other statutory agencies and community voluntary sector

22 Delivered by Trust staff Pulmonary Rehabilitation Delivered through by community organisations through engagement with Councils Current Capacity - 10 patients per programme Estimated number of patients requiring PR in WHSCT Experience of current practice suggests that the benchmark population rate for uptake of pulmonary rehabilitation in COPD patients would be 0.23%, or 230 per 100,000, per year. For a standard primary care trust population of 250,000, the average number of COPD patients expected to receive pulmonary rehabilitation annually is likely to be 575. There is no estimation of the numbers of non-copd patients eg. pulmonary fibrosis and bronchiectasis requiring PR on a yearly basis. However, based on the current % of non-copd referrals for PR across the Trust (30%), this number would be estimated at 190 per year making a total of approx. 750 PR referrals / year.

23 Palliative Care /Reablement/ Physio/OT/SW/ Dietetics Delivered by core trust teams to Respiratory patients

24 Psychology/Psychiatry Psycho-educational groups for individuals with co-existing respiratory conditions, and mild-moderate mental health difficulties 8-week psycho-educational programme for individuals with a respiratory condition. This group will be aimed at those with mild-moderate mental health difficulties, most specifically in terms of anxiety and depression as screened using the Hospital and Anxiety and Depression Scale. A cognitivebehavioural approach will be used to challenge negative/unhelpful thoughts and behaviours, which can impact on mood and ability to self-manage physical symptomatology.

25 Community Respiratory Team

26 Community Hub A key theme emerging from the review of the evidence is that all people with chronic Respiratory disease should have access to a Community Specialist Respiratory Team that is operating at the interfaces between the acute hospitals and the community service and the primary care teams. Preferred model: A designated community specialist Respiratory team is located within a community setting and reaches into both the primary and the acute hospitals settings. Team to cover COPD, Asthma, Bronchiectasis and Pulmonary fibrosis comprised of; Composition TBC likely to include; Respiratory Consultant or GPwSI Respiratory nurses Respiratory case managers Physiotherapists ESD team Oxygen Nurses Service co-ordinator Administration support

27 Community Hub Community Respiratory Team would have close links to and may be co-located with Rapid Response and Reablement teams Response times: Rapid Clinical Assessment- 3hours Rapid access to Diagnostics - 1hour Community Respiratory Team response Urgent within two hours, nonurgent within 24 hours Access to Community Respiratory Team would be by GP contact with the service coordinator - single point of contact

28 Community Hub - Long Term Conditions Team Trust Proposal- PCOP 8 Greater integration of proactive and rapidly reactive long term conditions scheme across primary, community and secondary care. development of 3 locality Long Term Condition/Respiratory Teams within the Trust geography. seven day ESD service Trustwide including direct access to physiotherapy and incorporating the new development of the role of a HealthCare Assistant band 4. Change in care practice from current self care model to acute complex care at home in the Case Management service. Review the future role of health care assistants in this service also. Upskill current staff to deliver acute care at home including arterial blood gasses, spirometry testing, flight assessments, long term oxygen therapy, non-invasive ventilation assessments. Enhance working relationships with GPs to access long term conditions risk registers for their practices. In reach to acute wards to promote early supported discharge service. Develop service to include patients with intestational lung disease

29 Acute Interface

30 Advice from Consultant Trust TYC proposal ref A7 Virtual Clinic Change to respiratory pathway. This pathway will facilitate shift left and provide telephone advice to GPs including a Respiratory Virtual Clinic, Sleep Apnoea Service, Pulmonary fibrosis clinic. The establishment of a virtual Respiratory Clinic will triage referrals of respiratory patients and initiate one of the following to avoid an OP attendance if possible: 1. Initiate patient investigation without OP attendance 2. Contact GP and provide advice 3. Refer to Respiratory Nurse Specialist or 4. Initiate New OP attendance for the referral

31 Hospital and Community Pharmacy Specialist Chronic Conditions Pharmacist Case Management of Respiratory Patients The specialist chronic conditions pharmacist (SCCP) case management of respiratory patients is a new vertical model of integrated working which aims to deliver pharmaceutical care across the primary secondary care interface. The specialist chronic conditions pharmacist will assume pharmaceutical responsibility for the patient at the point of referral/pick up or admission to the hub and for 30 days post-discharge from the hub or on returning home. The SCCP would also be linked to a number of community pharmacies (determined by geography) who currently provide Medicine Use Reviews (MUR); an existing commissioned service. The SCCP would provide an outreach service to these pharmacies in managing the complex respiratory patient.

32 Service Streams

33 Ref Description Current position Currently funded RA1 Q&P pathway LTOT Assessment live 2013/14 Y QOF RA2 Q&P pathway Bronchiectasis management live 2013/14 Y QOF RA3 Q&P pathway Chronic Cough Pathway-Adult live 2013/14 Y QOF RA4 Q&P pathway Pulmonary Rehabilitation live 2013/14 Y QOF RA5 Q&P pathway Sleep Apnoea live 2012/13 Y QOF RA6 QOF Asthma, COPD, Smoking Live Y QOF Funding Source RB1 Self Management live + Proposed P Current core Trust funding + TBD RB2 Smoking Cessation - Trust & PHA live Y Core RB3 Smoking Cessation - QOF live Y QOF RB4 Support Groups live + Proposed P Current core Trust funding + TBD

34 Ref Description Current position Currently funded Funding Source RB5 Pulmonary Rehab live + Proposed P Current core Trust funding + 14/15 IPT RB6 Trust Core - Social Worker/ OT/Physio/ Reablement / Palliative Care / Dietetics live Y Current core Trust funding RB7 Psychology/Psychiatry proposed N IPT 14/15 RC1 Community Hub proposed N IPT 14/15 RC2 Physiotherapy (ESD) planned Y ICP IPT 13/14 RC3 Home Oxygen Assessment planned Y ICP IPT 13/14 RC4 Clinical Co-ordinator for transition proposed N IPT 14/15 RC5 GP Education to support new pathway proposed N IPT 14/15 RC6 Clinical coding development for transition proposed N IPT 14/15 RD1 Virtual Clinic planned Y Trust IPT 13/14 RD2 Pharmacy proposed P Trust IPT 13/14 + IPT 14/15

35 Activity Information Respiratory Acute Hospital Information Respiratory QOF Information Total Outpatient Referrals (New) Unscheduled Respiratory Admissions Unscheduled Admissions by Primary Diagnosis. Bed Capacity Asthma, COPD, Smoking Total Outpatient Waiting List Discharges (Non-Elective) Average Length of Spell for Respiratory Discharges (Non-Elective)