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Evaluating a community respiratory service

Dorothy Wood
BLF Lead Respiratory Nurse
Community Respiratory Assessment and Management Service
Hartlepool

The Community Respiratory Assessment and Management Service (CRAMS) was launched on 1 October 2007 in Hartlepool. As an example of what can be achieved by moving traditional secondary care-based services out in to the community, it has been very successful.

Although a small team consisting of two British Lung Foundation respiratory nurses, one part-time respiratory physician and a full-time administration officer, it delivered significant savings in its first year of operation alone. The service has gone on to develop further, delivering more than its oxygen assessment and admission prevention remit.

On 1 February 2006, Department of Health guidelines were implemented which demanded the delivery of integrated oxygen services on a 24/7 basis.1 The guidelines recommended that oxygen should be ordered on a home oxygen order form (HOOF) after formal oxygen assessment in a specialist centre. As oxygen assessment had always been provided by secondary care services, a primary care-based oxygen assessment service was a new concept, and a move away from the view that specialist knowledge is available only in a hospital environment.

Studies have shown that this it is not unusual for patients in receipt of oxygen to have no formal review of their oxygen requirements post discharge. Indeed, 60-80% of prescriptions for long-term oxygen therapy (LTOT) are made on blood gases, which are measured at the time of an exacerbation of chronic obstructive pulmonary disease (COPD) and only 35-65% of patients have their blood gases reviewed when they are clinically stable.2 For those patients who were commenced on oxygen therapy in primary care, it was often impossible to ascertain who first prescribed the oxygen, and what follow-up arrangements, if any, had been agreed.3

With the launch of CRAMS came a structured approach to oxygen assessment and follow-up. In Hartlepool the expectation now is that GPs only have to complete a HOOF for palliative oxygen; otherwise the CRAMS team takes care of all the assessments and oxygen orders, including holiday HOOFs.

In addition, the team follow up those patients discharged from hospital on oxygen. Home visits are made at six weeks; complete oxygen reassessment is carried out at three months; and another home visit is performed at six months before an annual assessment date is agreed with the patient. All new referrals for oxygen assessment are seen within 10 working days.

The oxygen assessment itself consists of a comprehensive clinical assessment of the patient, as well as medication review, spirometry, chest X-ray, capillary blood gas analysis, six-minute walk test and full blood count. Other investigations and referrals to other services are arranged as appropriate. All new referrals have to be clinically stable, be on optimal therapy and two assessments are carried out at least three weeks apart before a decision is made about a new oxygen prescription.

The follow-up provided has been invaluable for patients. Experience has identified that patients thought they were on oxygen because they were breathless, and there was little if any understanding of why the oxygen had been prescribed originally. In addition to this, CRAMS have identified patients who recover sufficiently post discharge to a degree that oxygen is no longer recommended. When appropriate, oxygen is discontinued and because our secondary care respiratory colleagues inform patients on discharge that their oxygen use may not be permanent, it comes as no surprise when they are
informed that we recommend its removal.

Of course, there are patients who have had oxygen for many years, using it outside the prescribing guidelines. Often reluctant to surrender ownership of something that may have been kept hidden away in the airing cupboard for years, these are the patients who require the greatest support in the withdrawal of oxygen. Some patients refuse to contemplate relinquishing something that they consider their property, and despite our best attempts at education and support, it is accepted that the oxygen will remain in place. Despite this there are many success stories, as shown below.

Case studies
Mrs A, a 64-year-old lady with moderate COPD, had used her oxygen to treat breathlessness since an admission for an acute exacerbation in 2006. A full assessment was undertaken by CRAMS, and the results indicated that Mrs A did not need any form of oxygen therapy - although she did need help in managing her breathlessness, and increasing her confidence and ability to manage her condition effectively.

Mrs A refused pulmonary rehabilitation but did complete a diary, in which she documented when she used her oxygen, why she used it, what she was doing and how she felt. By exploring these factors we were able to advise her on how to reduce the degree of her breathlessness and manage it more effectively. The oxygen was not removed until she felt confident, and a follow-up visit six weeks after removal identified that she and her husband were getting out more - and had even booked a holiday.

Mr C was a 79-year-old man with moderate COPD. He lived with his dog in a one-bedroom bungalow and was visited by CRAMS because he was in receipt of short burst oxygen, which had been prescribed by his GP without any formal assessment. He undoubtedly considered it a lifeline, and twice a day after meals Mr C and his dog would lie on the bed while he wore his oxygen for half an hour to give him "a boost". This was despite the fact that his oxygen saturations were 96% on air. Mr C wasn't on optimal therapy when we met him, so once we'd changed his inhaled medication he felt a lot better; although he wouldn't relinquish his oxygen, despite all the education he was given. Clearly, we needed to show him that it made no difference. For a week he agreed to lie on his bed as usual, without his oxygen. His oxygen saturations were measured and not once did they fall below 95%. Eventually, Mr C acknowledged that his oxygen didn't make him feel any different and he asked for it to be removed.

Breadth of the service
A previously unidentified cohort of patients has also been discovered: those who do not meet the criteria for long-term oxygen therapy or ambulatory oxygen, but exhibit worsening hypoxaemia during sleep, unrelated to obstructive sleep apnoea. The introduction of overnight oximetry has assisted in the identification and treatment of these patients, ensuring the service delivered is comprehensive and patients receive quality care.

CRAMS also delivers a reactive service for acutely ill respiratory patients. The aim is to manage patients in their own homes, when appropriate, and reduce inappropriate reliance upon secondary care. The team visits the patient within three hours of a call; they are clinically assessed, and if it is considered safe to manage the patient at home, the appropriate treatment is prescribed, and support throughout the exacerbation provided. As the team does not have an electronic database, an encounter report is requested from the surgery before any home visit is made. This ensures the team have some insight in to the patient's medical history before they visit. It is never assumed that because a patient has a respiratory diagnosis this is the cause of the problem they present with.

Referrals for the reactive element of the service mainly come from GPs and patients themselves, and contribute to a reduction in hospital admissions, as well as a reduction in GP home visits. The advantage of meeting these patients is that we are able to deliver the education and support so many require, and to identify any social issues that, once addressed, can improve their quality of life and ability to manage.

The respiratory consultant delivers a clinic once a week and patients are referred to him for a multitude of reasons: patients unresponsive to treatment; patients with symptoms that far outweigh their disease severity; and those whose diagnosis is in doubt. Monthly patient satisfaction surveys reveal the high value patients place upon having a consultant available in the community, as well as indicating that they are happy with the service they receive from nursing staff and that they would recommend the service to others.

Pushing the boundaries of care
A year after its launch, the team set up a pulmonary rehabilitation class in a local gym. With the help of a secondary care-based respiratory physiotherapist, this class is now delivered twice a week, and each course runs for eight weeks.
The class has recently introduced an optional educational element addressing end-stage disease and end-of-life discussion. Delivered with the support of a palliative care nurse consultant, the benefits have yet to be evaluated; although, anecdotally, the majority of patients report this to be a beneficial element of the programme.

A telehealth pilot is also currently under way. Although only small - involving 20 units - early indications are that it has been successful. Patients feel safe knowing that someone is monitoring their condition. Some use the equipment as reassurance that their breathlessness is not associated with hypoxaemia and, therefore, feel more in control.

When the first year of the service was evaluated, savings for oxygen assessments amounted to £83,876 of which £48,895 was from preventing unnecessary prescriptions of oxygen from primary care. Interestingly, inappropriate referral dropped dramatically after the first year. The reactive service for exacerbations of COPD saved £268,442 attributable to the avoidance of hospital admission. Further service evaluation is required but as the team do not yet have a database and all information is held in a paper-based system this would be so time-consuming as to be almost impossible. Imminent introduction of a web-based data system will rectify this.

Conclusion
Undoubtedly, a specialist community based service such as this requires confident practitioners with skill and expertise to ensure service delivery is safe and evidence based. Making an autonomous decision in primary care is completely different to making similar decisions in the ward environment, and if we expect nurses to take on these extended roles the support, supervision and opportunity to develop with confidence should
be ensured.

Access to clinical supervision and ongoing professional development is essential and having a respiratory physician available to question and to mentor the team has been a valuable resource. The benefits of being a British Lung Foundation nurse are also incalculable. The study days the organisation provides for its nurses every three months, and the immediate access to a peer group with their combined skill and experience, is of huge benefit. These additions to our own efforts at professional development are of significant value.

Ensuring that equipment is reliable is of particular importance. The blood gas analysers are registered with an external agency (www.weqas.co.uk) who provide analyte on a monthly basis so the team can examine and ensure the accuracy of the equipment and provide independent evidence of the same. In addition, the team has undertaken accredited training in capillary blood gas sampling.

Although today's health economy presents many challenges, integrated working between primary, secondary and tertiary care colleagues means the CRAMS team are confident that patients will receive the best care possible, despite the pressures upon their limited resources.

References
1. NHS Modernisation Agency. Home Oxygen Therapy Service. Available from: www.natpact.info/uploads/2005_Feb/HOTS_board_briefing.pdf
2. MacNee W. Prescription of oxygen: still problems after all these years. Am J Respir Crit Care Med 2005;172:517-22.
3. Pali A, Hungin S, Chinn DJ, Convey B, Dean C, Cornford CS, Russell A. The prescribing and follow up of domiciliary oxygen - whose responsibility? A survey of prescribing from primary care. Br J Gen Pract 2003;53:714-15.