Regional Breathlessness Audit - Case Note Survey. 1. Introduction. Regional Breathlessness Audit - Case Note Survey. 2.

Transcription

1 Regional Breathlessness Audit - Case te Survey 1. Introduction Please complete this form for your case note review. Cases used may be PROSPECTIVE AND/OR RETROSPECTIVE. Please log as many cases as you can. If you have any questions about how this form should be completed please contact Joanna.roberts5@nhs.net Regional Breathlessness Audit - Case te Survey 2. Demographics Please complete the patient's demographic details. If you have any questions about how this form should be completed please contact YOUR ADDRESS. * 1. Patient s Specialist Palliative Care Service Group (SPCSG) * 2. Patient s SPCSG Location & Service * 3. Age * 4. Sex: Female Male * 5. Patient s Place of Care Home Nursing Home Hospice Hospital Regional Breathlessness Audit - Case te Survey 3. Initial Assessment by Palliative Care Professional 1

2 1. What is the diagnosis? Cancer (lung primary) Cancer (not lung primary) Heart failure COPD Pulmonary fibrosis Renal failure Hepatic failure Neurological condition 2. Was a reversible cause for breathlessness identified and documented? 3. If yes, was this treated? reversible cause documented t possible or appropriate to treat 4. On initial assessment was there documentation of: A chest examination Fluid volume status Oxygen saturations at rest Oxygen saturations post exertion Full blood count Chest X-ray 5. On initial assessment was there evidence of documentation of: Exercise tolerance Functional ability e.g. ADLs Associated panic 6. Has the cause of breathlessness been clearly documented? Regional Breathlessness Audit - Case te Survey 4. n Pharmacological Management 2

3 1. n Pharmacological management. Was there documentation of use of: Handheld fan Pacing/energy conservation Breathing techniques Relaxation Exercise Complimentary therapies Education Positioning 2. Was there documentation that the patient was referred to? Physiotherapy Occupational therapy Complimentary therapies t appropriate for therapy referral (please expand) Regional Breathlessness Audit - Case te Survey 5. Benzodiazepines 1. Was it documented the patient had anxiety or panic? 2. If yes, was the patient commenced on anxiolytics (e.g. a benzodiazepine) 3. How is it prescribed? Regular use PRN basis Both Benzodiazepine not prescribed 3

4 4. If a benzodiazepine was used, which one? Lorazepam Diazepam Temazepam Clonazepam Other (please state) Benzodiazepine not prescribed Regional Breathlessness Audit - Case te Survey 6. Opioids 1. On initial assessment was the patient already prescribed an opioid for breathlessness? 2. If no, on initial assessment was an opioid commenced for breathlessness? Already prescribed opioid for breathlessness 3. If opioid prescribed, what opioid was commenced for breathlessness management? Morphine (instant release) Morphine (modified release) Morphine (via syringe driver) Oxycodone (instant release) Oxycodone (modified release) Oxycodone (via syringe driver) Diamorphine (via syringe driver) Alfentanil (via syringe driver) Hydromorphone Other (please state) Regional Breathlessness Audit - Case te Survey 7. Nebulised Medication 4

5 1. Have nebulised medication been used in the management of breathlessness in this patient? 2. If yes, which nebulised medications? (please tick all that apply) Saline Salbutamol Ipatropium bromide Nebulised opioids Nebulised antibiotics Nebulised medication not prescribed Other 3. Was any adverse reaction to nebulised medication recorded? Regional Breathlessness Audit - Case te Survey 8. Steroids 1. Was the patient commenced on steroids during the care episode? 2. If yes, was the indication for steroids documented? Fatigue Appetite stimulant Pain Superior vena cava obstruction Metastatic spinal cord compression Cerebral oedema Lymphangitis Nausea Bowel obstruction Indication not documented Other 5

6 Regional Breathlessness Audit - Case te Survey 9. Other Treatment 1. During the care episode was the patient having any other concurrent treatment for the management of breathlessness? Antibiotics Radiotherapy Low molecular weight heparin Diuretics Blood transfusion Inhalers Oxygen Other Regional Breathlessness Audit - Case te Survey 10. Thank You Thank you for completing the survey. If you wish to submit more examples click on the Done button and enter this address again: ENTER SURVEY WEB ADDRESS HERE 6