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Innovation

Using specialist teams to diagnose breathlessness in primary care

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Partnership working between general practice and specialist respiratory teams can improve the management of patients with undiagnosed breathlessness. This project was shortlisted for the HRH Prince of Wales Award for Integrated Approaches, Nursing Times Awards 2016

Citation: Longstaff J et al (2017) Using specialist teams to diagnose breathlessness in primary care. Nursing Times [online]; 113: 10, 52.

Authors: Jayne Longstaff is respiratory quality improvement nurse; Claire Roberts and Ellie Lanning are quality improvement fellows; Anoop Chauhan is director of research and innovation; all at Portsmouth Hospitals Trust; Rachel Dominey is associate director, wealth and enterprise, Wessex Academic Health Science Network.

Introduction

Shortness of breath is a common reason for patients presenting at emergency departments. This distressing symptom can be caused by a range of conditions (Box 1).

Early diagnosis of the cause of breathlessness can improve outcomes by reducing a patient’s risk of deteriorating into a spiral of recurrent exacerbations, frequent GP visits and secondary care admissions. More needs to be done to develop and implement referral pathways and services.

Wessex Academic Health Science Network’s respiratory quality improvement team designed a programme to allow earlier diagnosis and treatment for people experiencing breathlessness. It was funded by NHS England’s Improving Quality Longer Lives team. It began in April 2015 and the evaluation was completed in March 2016.

Box 1. Common causes of unexpected breathlessness

  • Obesity or inactivity
  • Uncontrolled asthma
  • Chronic obstructive pulmonary disease
  • Anaemia
  • Heart failure
  • Cardiac arrhythmia

Method

Breathless patients without a diagnosis were identified in a Wessex locality and breathlessness clinics were held in two GP practices, involving specialists from secondary care and undertaking investigations on a single day. The key aims were to:

  • Empower patients with the knowledge to manage their condition effectively;
  • Reduce spirals of recurrent exacerbations and secondary care admissions;
  • Reduce days of work lost to ill health and maintain patient independence;
  • Educate primary care staff to manage breathlessness;
  • Achieve early and accurate diagnosis.

Results

As a result of the project:

  • Using GRASP data interrogation tools and manual screening of patients’ notes, 42 patients were identified with undiagnosed breathlessness, who were invited to attend a breathlessness clinic;
  • GPs and practice nurses were encouraged to participate and learn about breathlessness;
  • Investigations, assessments and accurate diagnosis were provided on the same day to 42 patients;
  • Patient experience and engagement was improved through rapid, detailed specialist assessments;
  • Patient and health professional concerns around diagnosis and treatment were addressed;
  • Specialists were integrated much earlier in the patient pathway.

The clinics resulted in:

  • All patients (n=42) receiving a definitive diagnosis explaining their breathlessness;
  • A 100% reduction in hospital admissions and A&E attendance in the six months after the clinic compared with the previous 12 months.

Overall, the majority of patients were highly satisfied with the service, including the booking process (83%), information given (91%) and the team that welcomed them (100%). Patients provided positive comments including:

This is a very good idea, all the clinical staff I saw were very professional. All in all a very worthwhile visit.”

“I thought everyone was very informative and professional, I even had an allergy test done, which was interesting. It was also useful having someone explain why I’m taking inhalers, how it works properly and how to take it correctly.

Conclusion

This new model of care for early diagnosis was possible because of an effective partnership between primary and secondary care across Wessex. Efficiencies were created through inter-organisational working and collaboration of resources and skills across service boundaries.

Implications for practice

  • An accessible integrated respiratory service should include primary and secondary care
  • The skill mix of the specialist clinical team should reflect respiratory and cardiac conditions
  • GP practices and clinical commissioning groups need more consistent coding of breathlessness
  • General practice staff benefit from mentorship of an experienced specialist respiratory teams
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