VOL: 98, ISSUE: 12, PAGE NO: 53
Annette Pilling, SEN, RGN, BSc, DipAsthma, DipCOPD, Advanced COPD Cert, Dip HE, is COPD specialist nurse;Roger Wolstenholme, BSc, MB, BS, FRCP, DTM&H, Dip Sports Med, is chest consultant physician, Royal Albert Edward Infirmary, Wigan
One in four acute hospital admissions is caused by respiratory problems, and more than half of these are due to complications of chronic obstructive pulmonary disease (British Thoracic Society, 2001). Currently ranked as the third most common cause of death in the UK, and the only common cause of death that is increasing (Barnes, 1999), COPD accounts for 20% of respiratory mortality (British Thoracic Society, 2001).
One in four acute hospital admissions is caused by respiratory problems, and more than half of these are due to complications of chronic obstructive pulmonary disease (British Thoracic Society, 2001). Currently ranked as the third most common cause of death in the UK, and the only common cause of death that is increasing (Barnes, 1999), COPD accounts for 20% of respiratory mortality (British Thoracic Society, 2001). Compared with other regions in England, Wigan has a higher than average mortality and morbidity resulting from respiratory disease. In the north west of England 30% of adults aged over 16 are smokers, which is higher than the national average. Coupled with the high numbers of former miners and cotton mill workers, this has resulted in significant prevalence of COPD (General Household Survey, 1999). As a result of the high COPD prevalence in the area, it was felt that there was an urgent need to supplement existing services to cope with the increasing pressures from emergencies. A nurse-led COPD acute assessment service was therefore developed in which specialist nurses are responsible for performing the patients’ full assessment and investigation. The nurses prescribe a full treatment package for patients on discharge and a six-week follow up assessment, providing patients with a seamless service.
A significant number of patients with COPD were attending the medical admissions unit (MAU) and would potentially benefit from an acute assessment service. It was thought that this would reduce the number admitted to inpatient beds. It was also suggested that a rapid access service for GPs would draw a sizeable number of additional patients. In August 1998 the health authority allocated funds for a COPD acute assessment service at Wrightington, Wigan and Leigh NHS Trust. A steering group was set up, which included a chest physician, GP, nursing, rehabilitation and primary care representatives, to determine the best means of developing the service. The steering group decided to model the service on one used in Glasgow (Gravil et al, 1998), which combines initial hospital assessments with subsequent home treatment for patients with acute exacerbation of COPD. In the absence of a service specification from the health authority the team could develop guidelines and outline the resources and equipment required for the service. When undertaking a needs assessment, it was important to be clear about the aims and objectives of the service and to consider pragmatic solutions and set realistic goals. It was also necessary to identify resources and negotiate with the ambulance service and other members of the multidisciplinary team who would be affected by the new service. In August 1999 two COPD specialist nurses and a secretary were appointed to establish the COPD acute assessment unit at the Royal Albert Edward Infirmary. Secretarial support was necessary to provide coordination and adequate communication with the multidisciplinary team, along with the development of teaching and training programmes. Very early on in the development of the service the need for a third nurse and extra clerical support was identified. This was to allow time to develop and implement respiratory teaching programmes for all staff members in the trust and further development of the service. The specialist nurses’ need for continuing professional development was acknowledged in the planning of the service. They also had clinical support from a senior respiratory physician, giving them rapid access for medical advice and guidance.
It was envisaged that expenditure on drugs and investigations would increase with the expansion of the service. It was also thought that additional follow-up in the outpatients department would be necessary, which would have cost implications. In fact, all patients accepted by the service had their chest X-ray and echocardiograph (ECG) reviewed in the unit by a senior chest physician. This avoided inappropriate referrals to chest clinics. While it is difficult to quantify savings made by the service, other authors have reported that acute respiratory assessment and home care services provide a cost-effective and efficient service for selected patients with chronic respiratory disease (Haggerty et al, 1991). Skwarska et al (2000) stated that there was no evidence to suggest that supporting patients at home leads to increased costs.
The nurses and medical staff involved in the service were aware of the ethical and professional indications of their practice. Consideration was therefore given to the ethical issues, protocols, documentation, accountability and training needs before the service started. Documentation had to be clear and cover all relevant areas, including evidence of adherence to clinical guidelines and protocols and any advice given to patients. Initially, comprehensive protocols were developed to allow the nurses to use their professional judgement while providing a safety net for any decisions made. A COPD acute assessment care pathway was devised to provide standardised, evidence-based care, and the trust’s care pathway facilitator helped to design patients’ hospital and hand-held home records. The British Thoracic Society (1997) guidelines on the management of COPD emphasise the provision of care in the community and on the use of outreach services to bridge the gap between primary and secondary care. Our service is based on the recognition that many patients with an uncomplicated exacerbation of COPD do not require intensive or complex investigations and therapy (Gravil et al, 1998), yet they are major users of hospital beds, accounting for approximately one-third of medical admissions. The COPD acute assessment service aims to provide a high quality of service for patients with acute exacerbation of COPD. This involves educating patients and their carers on the causes and progress of COPD and agreeing management plans that will keep patients functioning in their family setting for as long as possible. Before the launch of the service educational plans were developed to increase the self-management abilities of patients and their families. Pharmaceutical companies provided useful literature, videos and educational material both for patients and staff. A short pilot scheme was undertaken, which involved the lead chest physician being on call for the MAU and initiating referrals to the service. Individual meetings were arranged with a number of GPs, followed by an official launch to all GPs in the area in January 2000. Referrals are made by contacting the COPD specialist nurses directly by pager or by contacting the secretary at the unit. Patients are assessed as soon after referral as practicable.
The nurses consider a range of patient factors in the assessment (Box 1). They can order chest X-rays and ECGs and have the appropriate training to perform capillary blood gases and spirometry. Other investigations include the following: - Blood pressure; - Pulse; - Respiratory rate; - Temperature; - Random blood sugar; - Full blood count; - Urea and electrolytes; - Sputum sample for culture and sensitivity; - Routine urine test; - Visual analogue score to assess the patient’s perceived level of breathlessness on assessment (Noseda et al, 1992); - Medical Research Council score, based on the patient’s condition when stable.
Patients meeting the criteria for the service are given an individual treatment package and care plan. The senior house officer is informed about the patient’s supported discharge and reviews chest X-ray and ECG. The specialist nurses prescribe the appropriate individual medication within patient group directions. Patients are treated with antibiotics - usually tetracycline but occasionally trimethoprim, chosen on the advice of our microbiology unit. These are supplemented by high-dose bronchodilator therapy and a standardised prednisolone regimen. Some may require a compressor and nebuliser during this period and a loan agreement is arranged for them. Patients needing further support due to poor social circumstances or nursing needs are referred to our rapid response multidisciplinary team. This also offers support, if required, at the weekend. Patients are visited the day after assessment and for a two-week period by the nurse to continue treatment and support as indicated. The majority require four or five visits in this initial acute phase of their illness (Fig 1). The nurses are on call from 9-5, Monday to Friday to give advice and support or revisit patients as required. If a patient’s condition is deteriorating they have the authority to admit him or her to the MAU.
Two-week discharge assessment
After two weeks patients are assessed for discharge from the service into the day-to-day care of their GP. This assessment includes the following: - Temperature; - Pulse; - Blood pressure; - Pulse oximetry; - Spirometry; - Inhaler technique; - Medication compliance; - MRC score and visual analogue. Any abnormalities or suggested changes in treatment and follow-up appointments are forwarded to the patient’s GP by fax, together with a record of all observations.
A further assessment is undertaken at six weeks, at which patients with hypoxia at initial assessment have blood gases repeated and, according to the results, are referred to the appropriate members of the respiratory team for further management. At this final assessment patients are advised to contact their GP if they experience any future problems with their condition.
The way forward
Estimates of the potential workload by the chest physician and GP representative made before the service was initiated indicated that demand could vary from 20 to 80 new cases per month (average 41), with up to 500 cases per year. However, to date this has not been the case. During the first 12 months of the service (to November 2000), 257 patients were assessed. This was significantly fewer than predicted and reflects the need to increase the number of appropriate referrals, and possibly an initial lack of understanding of the service among colleagues. Most patients have been referred via A&E and the MAU, with the MAU being the main source (Fig 2). Approximately 55% of referrals were suitable for discharge under the cover of the service, while 45% did not meet the criteria for the service and were unsuitable. Due to the low number of referrals from GPs we are looking at ways of increasing this. The nurses suggested that MAU and A&E staff could advise GPs about the patients who fit the criteria for direct referral to the service. Changes in senior house officers and house officers every three months also affect the referral rate. To address this problem we now try to make contact with new doctors at their induction course and supply written information about the service. Following a critical review of patients assessed by the COPD team it became evident that nurses and medical staff frequently misunderstood the use of oxygen. It was also observed that the correct guidelines were not always adhered to when administering oxygen to COPD patients. This led the respiratory team to develop a trust-wide protocol for the administration of oxygen, along with patient-held oxygen alert cards. We are also currently developing a teaching package for medical and nursing staff. Due to increasing numbers of patients eligible to use the service and the unmet need identified within clinical areas, the service needs additional staff if it is to continue to offer a good standard of care. Some patients cannot go home immediately because they need a step-down service in order to enable them to cope independently or with support. An early discharge service was suggested as a way of supporting them, which would enable them to be safely discharged with a good standard of support and home monitoring by respiratory nurses. This will be launched shortly.