SCFT Chronic Obstructive Pulmonary Disease (COPD) Specialist Team - - PowerPoint PPT Presentation

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SCFT Chronic Obstructive Pulmonary Disease (COPD) Specialist Team & Dolby Vivisol Oxygen Service

Albert Sundararaj, Specialist COPD Physiotherapist, SCFT Jo Hobbs, Clinical manager / Service Lead, Dolby Vivisol

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Crawley, Horsham & Mid Sussex (Central)

Monday to Friday 08.30 – 16.30 Based in Rose Wing, Horsham Hospital

• specialist nurses – 2.8 WTE
• specialist physiotherapists - 2.0 WTE
• pulmonary rehabilitation assistant - 1.0 WTE
• administrator – 1.0 WTE
• Case load: 600 (50/50 clinical management / PR) - 86 receiving oxygen therapy

ULTIMATE AIM: to prevent unplanned hospital admissions

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Referral criteria (via One Call)

Inclusion criteria - aged 18+ Be registered with a Crawley or Horsham & Mid Sussex GP. Have a diagnosis of COPD confirmed by spirometry or a respiratory physician. Clinical assessment:

• POST EXACERBATION - and/or recent hospital admission due to COPD (will be

contacted and triaged within 24 hours and seen within 2 weeks of receiving discharge summary)

• ROUTINE - Patient requires a routine specialist assessment. (will be seen within 12

weeks of referral)

Pulmonary Rehabilitation:

• ROUTINE - Patient would benefit from a 12 session exercise and education

programme (will be assessed and enrolled into a programme within 13 weeks)

• FAST TRACK – Post exacerbation and / or recent hospital admission due to COPD (will

be assessed and enrolled into a programme within 4 weeks)

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Information & supporting documents required with referral

• Specific reason for the

referral

• Known risks regarding a

home visit

• Written evidence of COPD

diagnosis

• Last chest X-ray date &

results

• Last FBC date & results
• Current exacerbation

medication

• If the patient is being

referred due to frequent exacerbations – include 6 months of antibiotic Px

• Recent exacerbation /

hospital admission details

• Current oxygen therapy
• Current nebuliser therapy

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Routine Specialist Assessment

• Assessment of frequent exacerbations of COPD – 2 or more a year.

(Please attach at least 6 months of antibiotic & oral prednisolone prescription history)

• Assessment due to severe disease – FEV1 < 50%
• Already on long term oxygen therapy
• Assessment for long term oxygen therapy (SPO2 <92% at rest, or < 94% if

peripheral oedema, pulmonary hypertension, polycythaemia is evidenced)

• Assessment for ambulatory oxygen assessment (SPO2 <92% on

exertion)

• Assessment for long term nebuliser trial (please ensure therapy is

maximised & inhaler technique assessed & taught) The patient will be required to buy their own should the trial show a positive effect

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Smoking cessation advice COPD Assessment Test Dyspnoea management Bone density FBC Clinical

• bservations

BMI Dietary advice Pulse

• ximetry

Quality of life /symptom assessment Medication review /

• ptimisation.

Inhaler technique Exacerbation management Patient Activation Measure Depression / anxiety management Social support Self management plan Personalised care plan / lifestyle advice Travel advice End of life Immunisation advice Monitor peripheral

• edema

MRC

Specialist Assessment

Chest clearance techniques Exercise advice Oxygen review

Education Inform GP / referrer

SLIDE 7

Oxygen therapy in COPD

A Cochrane review of randomised controlled trials of domiciliary

• xygen therapy for COPD found; (Ref)
• Long-term home oxygen therapy improved survival in a

selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55mm Hg (8.0 kPa)

• Home oxygen therapy did not appear to improve survival in

patients with mild to moderate hypoxaemia or in those with

• nly arterial desaturation at night
• Aim for an SaO2 of 88-92%
• Ref: Cranston JM, Crockett AJ, Moss JR, et al; Domcilliary oxygen for chronic obstructive pulmonary
• disease. Cochrane database Syst Rv. 2005 Oct 19 (4): CD001744

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Oxygen assessment for LTOT

• Definitive diagnosis
• Patient clinically stable
• Medically optimised
• SPO2 <92% at rest, or < 94% if peripheral oedema, pulmonary

hypertension, polycythaemia is evidenced

• Risk assessment
• Smoking status
• Patient understands implications and process
• Gain verbal and written consent (IHORM, HOCF, HOOF)

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Capillary blood gases assessment

• If PO2 ≤ 7.3kPa – repeat in 3 weeks – if result same – Px LTOT
• If PO2 = 7.31 - 8kPa with no clinical evidence of secondary

conditions - LTOT is not required

• If PO2 = 7.31 – 8kPa with clinical evidence of secondary

conditions - Px LTOT

• Titrate O2 in 1Litre increments at 20 min intervals
• Once stabilised at SPO2 >90% – perform blood gas to confirm

pO2 = 8.1 – 9kPa Update HOOF and consider all equipment required and the need for ambulatory oxygen

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Follow up after LTOT initiation

• 1 week – telephone call
• 4 weeks - Reinforce education and check SPO2 on O2 /

Symptoms of hypercapnia / Adherence / Smoking status / Equipment

• 3 months - reassessment and blood gas
• 12 monthly blood gases for normocapnic patients
• 6 monthly blood gases for hypercapnic or concerning patients

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Nebuliser Trial – 3 weeks

Nebuliser trial should consider:

• A reduction in symptoms
• An increase in the ability to undertake activities of daily living
• An increase in exercise capacity
• An improvement in lung function

If the trial is positive, we will recommend the patient rents or purchases a device from a reputable company.

We provide written information:

• Buying a Nebuliser Guide
• Details of nebuliser Suppliers
• Care of your nebuliser booklet
• Price list for rental or purchase agreements (£70 - £100 & £5 - £6)

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Nebuliser Trial:

• Check inhaler technique
• Consider use of spacer device
• Assess the individual and / or carer’s ability to use and clean etc
• Only continue treatment if there is an improvement during trial
• Offer choice of mask or mouthpiece
• Consider which drugs require mouth piece only
• Always provide education / written instructions / technical

support details

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Nebulised medications in COPD

• Salbutamol 2.5mg / 5mg up to QDS

Patients admitted with acute exacerbations of COPD requiring nebulised therapy should be considered for 2.5mg nebulised Salbutamol in place of 5mg (Ref)

• Ipratropium Bromide 250mcg/1ml or 500mcg/2ml up to QDS
• Saline solution - Sodium Chloride 0.9% w/v up to QDS
• Colomycin antibiotic therapy 1 or 2 Million International Units

(MIU) mixed with 4ml sterile water BD

Ref: Nair S. A randomised controlled trial to assess the optimal dose and effect of nebulised Albuterol in acute exacerbations of COPD. Chest 2005; 128; 48 - 54

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Pulmonary Rehabilitation

• Programme of exercise and education
• Individually designed
• Benefits – improve muscle strength, cope better with

breathlessness, improve fitness, improve mental health

• 6 sessions a week – 3 centres
• Commitment – 2 sessions week for 6 weeks
• May need to be assessed for ambulatory oxygen

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Pulmonary Rehabilitation pathway

Initial assessment (History taking from patient, medical and drug history, Quality of Life Questionnaire, Incremental shuttle walk test) Included in Pulmonary Rehabilitation (Cardiovascular Training + Strength training+ Education) Final assessment (Quality of Life Questionnaire, Incremental shuttle walk test – improvement of 47.5m ) Patient discharged form the service

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PR Venue and timings

• Crawley – Physiotherapy gym, Crawley Hospital

Time - Wed: 2.45pm Fri: 2.00pm

• Mid Sussex – Dolphins Leisure centre, Haywards Heath

Time – Tue: 1.30pm Thu: 1.30pm

• Horsham – Physiotherapy gym, Horsham Hospital

Time – Mon: 10.00am Wed: 11.45am

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Time for a challenge

Sit to Stand test Aim to stand up and sit down for 1minute.

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Part A HOOF training

• Jo Hobbs
• Service Lead/ Clinical Manager
• Dolby Vivisol

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Dolby Vivisol Supporting Patients and Health Care Professionals 24/7 365 days a year

• Major Home Healthcare provider in the UK
• 20,000 active Patients across the UK
• 250 Employees in the UK (all CRB checked & “Patient

Ready”)

• Long term contracts with the NHS – Home Oxygen –

Scotland, South East Coast & South Central

• Partner with all main manufacturers…

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Guides

• British Thoracic Society
• National Home Oxygen Safety Group
• NHS Improvement

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Clinical assessment

• Clinical assessment for correct home
• xygen requirement with appropriate

equipment

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Forms!

• Initial Home Oxygen Risk Mitigation

(IHORM) form completed (National form)

• Home Oxygen Consent Form (HOCF)

completed

• Home Oxygen Order Form (HOOF)

completed

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IHORM

• National form from 1st August 2017
• “It is the responsibility of the registered health care

professional who is gaining consent to complete and add the IHORM with the HOOF and HOCF to the patient’s notes. If all documents are not confirmed as being completed in full the Home Oxygen Order cannot be fulfilled”

• “If a High Risk is identified (shaded box), It is highly

recommended that oxygen is not requested without referral to Home Oxygen Assessment and Review Service (HOS-AR) or support services e.g. falls team, stop smoking service”

Initial Home Oxygen Risk Mitigation Form (IHORM) and Home Oxygen Consent Form (HOCF) for new patients only .

BOTH FORMS MUST BE COMPLETED AND SIGNED BEFORE OXYGEN CAN BE INSTALLED. DO NOT SEND FORMS TO SUPPLIER FORMS WILL BE PLACED IN PATIENT NOTES THERE ARE CONFIRMATION BOXES ON THE HOME OXYGEN ORDER FORMS. Oxygen can pose a risk of harm to the user and others in the event of fires, falls and inability to use complex equipment. The initial identification and onward communication of these risks is the responsibility of the health care professional ordering the oxygen and remains so until that prescription ceases or is superseded. The table below reflects risk factors that are based on evidence of real life serious and untoward incidents, 90% of which are smoking and e-cigarette/charger related. The Initial Home Oxygen Risk Mitigation (IHORM) is to be completed in conjunction with the Home Oxygen Consent Form (HOCF) prior to oxygen being ordered from the oxygen supplier via the Home Oxygen Order Form (HOOF). It is the responsibility of the registered health care professional who is gaining consent to complete and add the IHORM with the HOOF and HOCF to the patient’s notes. If all documents are not confirmed as being completed in full the Home Oxygen Order cannot be fulfilled. If the risks identified on the IHORM indicate significant levels of risk the patient should be discussed directly with the local Home Oxygen Service or Clinical Oxygen Lead for a full risk assessment prior to oxygen being ordered as recommended in the British Thoracic Home Oxygen Guidelines June 2015. Regardless of risk or diagnosis all adult patients should be referred the Home Oxygen Assessment and Review Service (HOS-AR) for the team to determine next steps if deemed relevant. If any responses below fall within a shaded box, please refer to the Required Action column and supporting notes. All actions should be explained to the patient and why they are being taken in line with service contracts. Ensure that both verbal and written information has been given to the patient or their representative Patient Name DOB Address Oxygen requested? Yes - Sending HOOF No - Risk is too high Recorded at Please indicate:- Hospital / Clinic / Home / other location NHS No Risk Level Risks No Yes Required Action HIGH Does the patient smoke cigarettes / e-cigarettes? If a High Risk is identified (shaded box), It is highly recommended that

• xygen is not

requested without referral to Home Oxygen Assessment and Review Service (HOS-AR) or Respiratory Specialist or support services e.g. falls team, stop smoking service, Have they smoked in the last 6 months? Quit date. Does anyone else smoke at the patients premises? A recent history of drug or alcohol dependency? Patient reported they have had a fall in the last 3 months? Have they had previous burns or fires in the home? Does the person have identified mental capacity issues? MODERATE Can the patient leave their property un-aided? If 3 or more risks are identified (shaded box), It is highly recommended that

• xygen is not

requested without referral to HOS-AR or Respiratory Specialist or support services e.g. stop smoking service, Is the patient or any dependents/ in the property vulnerable? E.G. disabilities/ children Do they live in a home that is joined to another? Patient reports they have working smoke alarms at home? (if unknown please state no) Do they live in a multiple occupancy premises (Bedsit/flat) Mitigation actions taken e.g. contacted falls team Referred to Fire and Rescue Declaration I confirm that I am the healthcare professional responsible for the care of this patient. I have discussed the risks listed

• n this form with the patient/carer/ guardian (delete as necessary) and from the responses given Oxygen can/cannot (delete as

necessary) be requested at this time. Clinicians Signature Profession Print Name HOS team Yes / No Contact No. Date Lead Consultant is (Hospital Discharge only)

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Home Oxygen Consent Form

• Consent to sharing of information

with:

• The home oxygen supplier (us) and

to allow us access to deliver, service, refill and remove the equipment.

• Local Fire and Rescue Service
• Electricity supplier (if electrical

equipment ordered)

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Home Oxygen Order Form

Part A HOOF Part B HOOF- Specialist teams

HomeOxygen Order Form (HOOF)

Part B (After Specialist / Paediatric Oxygen Assessment)

All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed

• 1. Patient Details

1.1 NHS Number* 1.7 Permanent address* 1.9 Tel no. 1.2 Title 1.10 Mobile no. 1.3 Surname*

• 2. Carer Details (if applicable)

1.4 First name* 2.1 Name 1.5 DoB* 2.2 Tel no. 1.6 Gender

 Male  Female

1.8 Postcode* 2.3 Mobile no.

• 3. Clinical Details
• 4. Patient’s Registered GP Information

3.1 Clinical Code* 4.1 Main Practice name:* 3.2 Patient on NIV/CPAP

 Yes  No

4.2 Practice address: 4.3 Postcode* 4.4 Telephone no. 3.3 Paediatric Order

 Yes  No

• 5. Assessment Service (Hospital or Clinical Service)
• 6. Ward Details (if applicable)

5.1 Hospital or Clinic Name: 6.1 Name: 5.2 Address 6.2 Tel no.: 5.3 Postcode: 5.4 Tel no: 6.3 Discharge date: / /

• 7. Order*
• 8. Equipment*

For more than 2 hours/day it is advisable to select a static concentrator

• 9. Consumables*

(select one for each equipment type) Litres/Min Hours/Day Type Quantity Conserving Device Nasal Cannula Mask % and Type 8.1 Static Concentrator Back up static cylinder(s) will be supplied as appropriate 8.2 Static Cylinder(s) A single cylinder will last for approximately 8hrs at 4l/min 8.3 Self Fill Concentrator Same as static concentrator and can fill ambulatory cylinder(s) (8.5/8.6) 8.4 Transportable Concentrator (trolley based) Can be used in place of a static concentrator and / or for ambulatory use 8.5 Standard Ambulatory Cylinder(s) Cylinders for use outside of a home setting 8.6 Lightweight Ambulatory Cylinder(s) Lighter than the standard ambulatory cylinder 8.7 Portable Concentrator (carry over shoulder) Lighter weight than transportable concentrator and limited to pulse dose 8.8 Liquid Oxygen (LOX) Dewar Please select number of flasks required below 8.9 Liquid Oxygen (LOX) Flask To be used in conjunction with the LOX Dewar

• 10. Additional Equipment

10.1 Humidification (not usually indicated for less than 4l/min)

 Yes  No

10.2 Tracheostomy (mask only)  Yes  No

• 11. Delivery Details*

11.1 Standard (3 Business Days)  11.2 Next (Calendar) Day  11.3 Urgent (4 Hours) 

• 12. Temporary Secondary Supply (e.g. Holiday Order with different modality)
• 13. Contact Details (if applicable)

12.1 Address: 13.1 Name: Postcode: 13.2 Tel no.

• 14. Additional Patient Information
• 15. Clinical Contact (if applicable)

15.1 Name: 15.2 Tel no. 15.3 Mobile no.

• 16. Declaration*

I declare that I am the registered healthcare professional responsible for the information provided, the information given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false information, I may be liable to prosecution or civil proceedings *I’ve completed/ or confirm there is a previously signed copy of the Home Oxygen consent form HOCF  AND an Initial Home Oxygen Risk Mitigation Form IHORM  Name: Profession: Signature: Date: Fax back no. or NHS email address for confirmation / corrections:

Home Oxygen Order Form (HOOF)

Part A (Before Oxygen Assessment – Non-Specialist or Temporary Order)

All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed

• 1. Patient Details

1.1 NHS Number* 1.7 Permanent address* 1.9 Tel no. 1.2 Title 1.10 Mobile no. 1.3 Surname*

• 2. Carer Details (if applicable)

1.4 First name* 2.1 Name 1.5 DoB* 2.2 Tel no. 1.6 Gender

 Male  Female

1.8 Postcode* 2.3 Mobile no.

• 3. Clinical Details
• 4. Patient’s Registered GP Information

3.1 Clinical Code* 4.1 Main Practice name:* 3.2 Patient on NIV/CPAP

 Yes  No

4.2 Practice address: 4.3 Postcode* 4.4 Telephone no 3.3 Paediatric Order

 Yes  No

• 5. Assessment Service (Hospital or Clinical Service)
• 6. Ward Details (if applicable)

5.1 Hospital or Clinic Name: 6.1 Name: 5.2 Address 6.2 Tel no.: 6.3 Discharge date: / / 5.3 Postcode: 5.4 Tel no:

• 7. Order*
• 8. Equipment*

For more than 2 hours/day it is advisable to select a static concentrator

• 9. Consumables*

(select one for each equipment type) Litres / Min Hours / Day Type Quantity Nasal Canulae Mask % and Type 8.1 Static Concentrator Back up static cylinder(s) will be supplied as appropriate 8.2 Static Cylinder(s) A single cylinder will last for approximately 8hrs at 4l/min

• 10. Delivery Details*

10.1 Standard (3 Business Days)  10.2 Next (Calendar) Day  10.3 Urgent (4 Hours) 

• 11. Additional Patient Information
• 12. Clinical Contact (if applicable)

12.1 Name: 12.2 Tel no. 12.3 Mobile no.

• 13. Declaration*

I declare that I am the registered healthcare professional responsible for the information provided; the information given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false information, I may be liable to prosecution or civil proceedings. * I have completed/or confirm there is a previously signed copy of the Home Oxygen Consent Form HOCF  AND the Initial Home Oxygen Risk Mitigation Form IHORM  Follow the link for more help https://www.pcc-cic.org.uk/article/home-oxygen-order-form Name: Profession: Signature: Date: Referred for assessment:  Yes  No Fax back no. or NHS email address for confirmation / corrections:

• 14. Primary Clinical Code

CODE Condition CODE Condition 1 Chronic obstructive pulmonary disease (COPD) 11 Neuromuscular disease 2 Pulmonary vascular disease 12 Neurodisability 3 Severe chronic asthma 13 Obstructive sleep apnoea syndrome 4 Interstitial lung disease 14 Chronic heart failure 5 Cystic fibrosis 15 Paediatric interstitial lung disease 6 Bronchiectasis (not cystic fibrosis) 16 Chronic neonatal lung disease 7 Pulmonary malignancy 17 Paediatric cardiac disease 8 Palliative care 18 Cluster headache 9 Non-pulmonary palliative care 19 Other primary respiratory disorder 10 Chest wall disease 20 Other If no other category applicable

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Static Concentrator

• Most cost effective for LTOT use
• Standard 1 to 5 litres/min
• Back up cylinder provided for up to

8 hours usage, in case of power failure or equipment fault

• High flow up to 9 litres/min
• Low flow 0.1 to 2 litres/min
• Low low flow 0. 1 to 0. 8 litres/min

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Static Cylinder

• Commonly used for paediatrics

LTOT- low flow regulators can be attached to reduce flow rate and enable weaning off oxygen. (Can be secured to the wall if requested).

• Usually for orders of less than 2

hours per day in adults, i.e. Cluster headaches.

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Safety

• A field based risk assessment is carried out

by the technician to ensure it is safe to install oxygen

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Thank you

Good HOOF guide Jo.hobbs@nhs.net COPD Team – 01403 620459 J.kilgarriff@nhs.net a.sundararaj@nhs.net