Respiratory Quality Improvement Programme - Breathlessness project
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Respiratory Quality Improvement Programme - Breathlessness project, by NHS Improving Quality and Wessex Academic Health Science Network
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Respiratory Quality Improvement Programme - Breathlessness project
- 1. Respiratory Quality Improvement Programme Breathlessness Project Vanessa Brown Rachel Dominey Jayne Longstaff Professor Anoop Chauhan
- 2. Breathlessness project A Respiratory Quality Improvement Project “Breathlessness is a common symptom which can be caused by a number of different conditions. Early diagnosis of the cause of breathlessness can improve outcomes for patients. The aim of this pilot breathlessness project is to test new models of care to facilitate access to diagnostics and accurate diagnosis in an efficient and effective way.”
- 3. Three Test Sites Grange Bordon Wickham Surgery Location (semi-rural) Patient list size (1) Wickham West Hampshire 12,113 (2) Badgerswood South East Hampshire 12,540 (3) The Grange South East Hampshire 6,500
- 4. Ken’s Journey • Age 57 years • Breathless with wheeze (MRC 2) • Worse at work (a life long welder) • Ex-smoker; 10 pack year • Time off work, poor QOL • Spirometry fixed moderate obstruction • Normal cardiac assessment • FeNO 50 ppb • +ve skin prick testing grass, tree and HDM
- 5. GRASP Inclusion Criteria 107 COPD case-finding search Asthma case-finding search Excluded diagnosed conditions related to breathlessness e.g. COPD, heart failure Heart failure case-finding search 972 130 357
- 6. Practice records search - case finding COPD 914 HF 52 Asthma 180 COPD 58 HF 78 Asthma 177 68 6 13 GRASP 87 Patients Manual filter 34 patients Patient attendance 19 Surgery 1&2 20 Surgery 3 GRASP 313 Patients Manual filter35 patients Patient attendance 23
- 7. Patient Journey Full Physiological assessment Clinical Review Self- management and follow-up Follow-up mentorship clinic TESTS PFTs FeNO BMI Skin Tests Cardiac BNP History Exam CXR ECG Bloods MRC RCP Inhaler technique Smoking cessation Self Management Plan Education Education Practice Education/Certification QUESTIONNAIRES Epworth GERD SNOT CAT Nijmegen ACQ
- 8. Results - examples PATIENT 1 3 5 9 Gender M F M F Age (yrs) 77 75 83 86 BMI (Kg/m2) 28 27 28 29 FeNO (ppb) 65 9 18 47 MRC 1 2 1 2 CAT 13 23 15 11 ACQ 1.28 3.4 1.14 1.43 FEV1 % pred 62% 69% 92% 96% O2 Sats 97% 94% 93% 96% Diagnosis ACOS, Nasal Polyps ACOS, Allergic Rhinitis Asbestosis Hypertension Asthma
- 10. 6 month evaluation Patients 12 months Pre clinic 6 months post clinic (Aug – Feb 2016 ) GP non-elective/OOH visits 1 > exacerbations 46 3 1> ED Visits 5 0 1> Hospitalisations 3 0 Deaths - 0 Moved from area - 2 Improved Compliance - 16
- 11. Initial Health Economics • Cost per patient of clinic attendance £142 – Includes GRASP identification, manual search, medical, nursing and admin staff for clinic • National tariff for new patient outpatient appointment – Respiratory multi professional £241 – Cardiology multi professional £189 » excluding market forces factor and additional investigations • Reduction in: – GP (£45) and OOH visits (£114), plus £41 per prescription – ED visit – Hospital admissions
- 12. Ken’s Journey Continued “The team coming to the surgery was beneficial to me. It reassured me having all the tests done and I am so very pleased with what they have done. I am very satisfied and impressed. Thank you!” • Further tests in secondary care • PEFR diary, CT scan and lung function testing • Diagnosed workplace asthma • Bespoke treatment and self-management • Improved quality of life
- 13. Patient Feedback
- 14. Summary • Specialist secondary care case-finder breathlessness clinics in primary care can: • Identify at risk patients and accurately confirm diagnosis • Optimise treatment and improve management • Specialists clinics allow for: • Tailored HCP education and mentorship clinic • Reduction in secondary care referrals • Early diagnosis and improved patient outcomes • ‘Joined up’ care
- 15. What next? Modern Innovative Solutions Improving Outcomes in Asthma, Breathlessness and COPD
- 16. Patient Journey 1 2 3 4 5 6 7 8 9 10 11 12 13 14 GP visit Diagnosis Assessme nt Drug treatment s i.e. relievers/a ntibiotics Practice Nurse Visit Review 2 weeks after diagnosis GP Visit PF Spirometr y Drug treatment Chest X- ray at hospital GP Visit Review & Treat PN Visit Review & Treat ED Visit Review & Treat: Nebs Steroids GP Visit Within 7 days Step up treatment Hospital Admissi on MAU LOS X-ray Drugs Tests i.e. BT/PF/etc Outpati ent visit (1) Spir/LFT X- ray/BT Rxs/Ass/ Sats/Histo ry/comorb idities/refl ux Outpati ent visit (2) Rx/Treatm ent escalated GP Visit 1 or 2 visits to GP Could have 2nd admission GP or consulta nt referral to severe asthma clinic Consult ants and specialis ts X 7 visits 1 GP Visit (1st) £ 2 PN Visit (2nd) £ 3 GP Visit (3rd) £ 4 Chest X- Ray £ 5 GP Visit (3rd) £ 6 PN Visit (4th) £ ED Visit 7 £ 8 GP Visit £ 9 Admission to hospital £ 1 0 £ 1 1 Outpatient visit (2) £ 1 2GP Visit £ 1 3 Consultant /GP Referral £xx Respiratory Clinic 1 4 • There could be up to 14 steps in a 12 month patient journey prior to referral to a respiratory clinic. • The patient may have had more than one admission into hospital (50% of all asthma admissions are severe asthmatics) Factor in x 2 Admissions PBR Tariff Outpatient visit (1)
- 17. Patient Identification Practice records Asthma & COPD Breathless with no known diagnosis ASTHMA BREATHLESS GRASP MISSION ABC Clinics COPD
- 18. Patient Education Action Stations! Self management Plans Bespoke 1:1s Skin Tests, FeNO Teamwork Working with Surgeries Questionnaires Protocol Assessments Integration between primary and secondary care
- 20. Diagnosis Treatment Maintain Control Flo-Tone • Eclipse Live • GRASP Pharmacists Nurses Community Respiratory Integrated Services • Niox FENO • Thorasys “Mini” Mission Clinic Rapid Mission Clinic GP Practice Specialist Consultant Primary Care Clinic Severe Mission Clinic Acute Care Provider Airsonett ESMENA • Education/ Training • BLF • Asthma UK Innovator Core Respiratory Specialist Team ProviderLegend: Comorbidity and Medicines Optimisation myAsthma/ myCOPD/CLINITOUCH Message Dynamics mGAGE Change Improvement Fellows
- 21. Innovators
- 22. 5 Reasons 1. Improving the lives of patients with breathlessness 2. High quality ‘breathlessness’ investigations in the right place at the right time 3. Innovative and integration approach of diagnostic tools, clinical teams and digital platforms leading to exceptional health outcomes in patients with breathlessness 4. Flexible service personalised for each patient, empowering self-management 5. Leaving a legacy of education and strong networks
- 23. Winner of HSJ Value Award in Use of Diagnostics 2015! “Our winner has a fantastic multidisciplinary team approach. The impact is excellent, well evaluated and it works with high risk patients, which in the longer term will reduce death rates.”
Notes de l'éditeur
- Improving in disease control, quality of life, optimisation of medication and self-management
- Manual reviewed for – ED visits, ooh visits and hospital admissions and excluded other known diagnosed conditions relating to SOB e.g. respiratory, cardiac, thyroid conditions GP reviewed
- Patient Review – physiologist – medical consultant review and respiratory nurse review Developed breathlessness CRF Mentorship clinics with nurses and G.P’s Education sessions – differential diagnosis and spirometry interpretation Respiratory nurse follow -up
- There are some causes of SOB that we just can’t do anything about!