For someone who has a terminal illness every moment is precious. But for those with recurrent pleural effusions, all too often that time is spent in hospital, distressed, in pain and apart from their families. It was the plight of these patients that inspired Ram Gulrajani, a respiratory nurse specialist and respiratory project manager at West Essex PCT, to develop the UK’s first service to manage recurrent pleural effusions in the community.
Ram’s efforts have made an enormous contribution to the quality of life of his patients and the service looks set to be repeated across the UK. His work has also been recognised by his peers who judged him winner of the Innovation in your Specialty category at the 2007 NT Awards.
Ram, a nurse for 25 years, trained in Gibraltar. He came to the UK in 1985, working mainly in acute care and specialising in paediatrics and A&E. Eventually, however, he chose to focus on respiratory care.
‘I had a special interest in the area, coming from a family with a long history of asthma,’ he explains. He put his understanding and insight to good use, working for several years as a respiratory nurse specialist at Princess Alexandra Hospital in Harlow, before taking his current role at West Essex PCT two years ago.
‘Primary care seemed to offer more scope to improve the quality of care,’ he recalls.
Charged with wanting to develop respiratory services in the community, he was determined to reduce admissions wherever possible so that patients could be treated in the comfort of their own homes. But it was witnessing the distress of two patients, who were terminally ill and had to stay in hospital twice a week to have their effusions drained, that prompted him to come up with the idea of managing pleural effusions at home.
‘The experience was causing them anxiety, trauma and pain at a stage when they just wanted to be at home with their families,’ he explains.
He also felt the service was ‘more protracted than it should be’ leaving much room for improvement.
‘You have to find hospital beds, which are not always available, as well as staff to care for the patients and transport to get them to hospital.’
Ram decided it would be worthwhile trying to find an alternative way of treating these patients. Then Dr Douglas Newbury, a consultant chest physician at Princess Alexandra Hospital, contacted him about reducing admissions and they decided to look at how a service could manage patients’ pleural effusions in the community.
There were barriers, he admits, such as the cost of equipment and concern as to whether the service would really be safe.
‘This had never been done before so it was new territory for the PCT and the hospital,’ Ram remembers.
Then the director of nursing for West Essex PCT gave the go-ahead to trial the service with two patients. Partial funding was agreed and a team of district nurses was trained to carry out the necessary procedures required to manage pleural effusions in a home setting. Once a chest physician has inserted a Pleurx pleural drainage catheter into the patient’s pleura (under local anaesthetic as a day-case procedure), the pre-vacummed Pleurx bottle can then be attached as needed at home to drain the effusion. Treatment is usually completed within half an hour.
The benefits of the trial were immediate, Ram says. ‘The pleural effusions were easy to manage and the patients found the procedure less painful and distressing than their hospital experience.’
Since then, the service has expanded to neighbouring areas within the PCT. It is self-funding thanks to the number of admissions that have been avoided since its inception – nearly 200 during the past 18 months, resulting in a saving of around £3,000 per admission.
Reducing the number of admissions also means that fewer patients are exposed to the risks of healthcare-associated infections. And the initiative has other advantages – not only is it helping to forge closer working relationships between primary and acute care and giving those nurses who are involved new skills, it is also extending the boundaries of nursing practice.
However, there is no denying that it is the patients who have really benefited most. The scheme has enhanced their quality of life and improved their quality of care. Patients have reported less pain as well as reduced shortness of breath and nausea, and say they feel less anxious and distressed.
‘The general feedback is that they love the service,’ says Ram. ‘One patient even talked about the service on their local radio station. And people tell us that they feel a lot better, more controlled and reassured, and are grateful for being able to spend more time with their families.’
Firas Sarhan, a senior lecturer at Buckinghamshire New University and judge for the awards, says he is ‘very impressed’ with Ram’s efforts to improve patient care.
‘Ram stood out because no one else was doing anything like this. The whole focus of his work was the patient and ensuring they were receiving the maximum treatment without distress for them. Ram has also built up great links between primary and secondary care. This is extremely innovative work.’
Ram is ‘delighted’ to have won the award and says he will use the winnings to develop the service further. He hopes it will catch on nationwide and, to this end, has given a talk about it to health professionals at a cancer study day in Bury. Hospitals in Basildon and Chelmsford have also shown an interest in developing the work.
Ram believes that, in the future, the service will prove even more valuable, allowing health professionals to effectively manage the growing number of people with pleural effusions – a consequence of an ageing population.
‘This service has made such a difference to patients and yet it is so simple, as these initiatives so often are,’ he says. ‘You just need the drive to change things.’
His drive has created a service that is helping people to live the best way they can in the short time that they have left. In some cases that time has been prolonged beyond expectations, augmenting the service’s importance and even causing Ram to wonder to what extent the scheme may have played a part.
‘I know of one individual who has lived beyond their three-month prognosis. I would like to think we are helping patients to live longer because they don’t have the added stress of going to hospital.
‘Another of our terminally ill patients used to have to arrange transport two days every week. Now she is using that time to go shopping and be with her family. It is stories like these that make this service invaluable.’