Detecting breathlessness and structured assessment in primary care
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Detecting breathlessness and structured assessment in primary care - Dr Noel Baxter, GP and Clinical Commissioner, Southwark CCG and PCRS Executive ...

Detecting breathlessness and structured assessment in primary care - Dr Noel Baxter, GP and Clinical Commissioner, Southwark CCG and PCRS Executive
Presentation from the Breathlessness Symposium held in London on 1 July 2014

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Detecting breathlessness and structured assessment in primary care Detecting breathlessness and structured assessment in primary care Presentation Transcript

  • Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Detecting breathlessness and structured assessment in primary care Dr Noel Baxter, GP & Clinical lead NHS Southwark CCG
  • What works for repeated locally 703,845 population COPD – 7773 Asthma – 31,005 HF – 3,016 LTC & Smoker – 21,077
  • The breathlessness working group Expertise Experts Palliative care & breathlessness support Irene Higginson, Charles Reilly Respiratory Physiotherapy Leyla Osman, Kevin Taylor, Lynn McDonnell Clinical Psychology Janet Wingrove Patients and Carers Breathe Easy Southwark Commissioning Leah Herridge, Ali Young , Alicia Reeves GPs Eric Cajeat, Jonty Heaversedge, Azhar Saleem, Noel Baxter Cardiologist Gerry Carr-White, Jonathan Byrne Respiratory physician Nicholas Hart, Irem Patel Exercise on prescription service Rosie Dalton-Lucas, Agata Roszczynska Diabetes, Metabolic Medicine, Obesity Cardiovascular pharmacist Helen Williams Acute trust service manager Donna Grier
  • How do people with breathlessness present? Daily disabling breathlessness 10% of adults suffer long-term breathlessness. Do they recognise and tell and do we notice and systematically take action?
  • What could it be?
  • Estimating prevalence through coding behaviour All patients ever registered Patients aged over 40 Coded as breathless sex BMI smoking history associated diagnosis diagnosed with COPD diagnosed with heart failure diagnosed with COPD and heart failure
  • Coding for breathlessness SOB: Problem SOB: Measure or finding
  • Southwark – What is the prevalence ? Adult population : 410,868 patients over the age of 40 with an electronic record at one of 40 GP surgeries
  • Characterising the breathless population 44% 35% 28% 20% 9% 4% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Current Smoker COPD Never smoked & BMI <28 BMI>35 Heart Failure COPD & Heart failure
  • COPD Register 2013 – Did we exclude other causes in these patients?
  • Breathlessness activity in 2012 ? Patients continuously registered between 1.1.12-31.12.12 Over 40 Coded as breathless sex age BMI smoking history associated diagnosis COPD asthma asthma and obesity asthma and copd copd and heart failure heart failure none of above Breathlessness coded as problem header sex age BMI Smoking history associated diagnosis asthma COPD Not asthma, COPD, heart failure,
  • Prevalence of breathlessness activity (coding) as a proportion of the over 40s per practice 10x variation
  • Prevalence of breathlessness activity (coding) as a proportion of the over 40s per practice
  • Smoking highly prevalent in people coded as breathless
  • Where breathlessness is recorded as a problem current smoking is less prevalent than population rate
  • Localised breathlessness assessment process NHS Lambeth Clinical Commissioning Group NHS Southwark Clinical Commissioning Group Feeling'Breathless'Guide'for'Patients’' · · · · · · · · · · · · · · · · · · NHS Lambeth Clinical Commissioning Group NHS Southwark Clinical Commissioning Group ( STEP(4(((( ((Tier(2(Investigations(for(presentation(of(chronic(breathlessness Only(order(tests(if(you(would(act(upon(the(results. Common(Causes(of( Breathlessness( Further(Examinations/Tests( Possible(Diagnoses/Reasons( for(Breathlessness( · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ( STEP(5(( Consider(Contributing(Factors(to(Breathlessness( ( · · · Order(each(of(the(possible(contributory(factors(for(the(chronic(breathlessness · · ( (
  • Signposting to services already commissioned
  • Prioritising psychological/dietary/activity interventions
  • Implementing primary care improvement with peer review and support Respiratory referral for Lambeth and Southwark Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group V2 May 2014 This is a referral form for specialist respiratory services provided by King’s Health Partners (KHP) and the Integrated Respiratory Team (IRT). The aim of the referral assessment process is to direct patients to the most appropriate specialist in the most suitable venue. After reviewing the referral criteria please forward this form using the single point of referral email. We will contact you to discuss the referral further or to advise you of the onward pathway within 48 hours Monday to Friday. The service does not handle 2WW, URGENT or TB referrals. Service Description of Service Select required services Smoking cessation for sick smokers This is a specialist stop smoking service for people with any long term condition. The service will provide intensive clinic and home based support in combination with appropriate pharmacotherapy. Please consider patients for this service if they have difficult to treat tobacco addiction and high risk of relapse. Spirometry & Lung Function This service can provide diagnostic standard spirometry if practice case finding and microspirometry suggests asthma and COPD. Practices with a neighbourhood spirometry service in place should not use this service unless more detailed lung function has been recommended by a respiratory specialist. Pulmonary Rehabilitation Any patient with COPD and MRC3 breathlessness or more should be offered referral to pulmonary rehabilitation. The service will also accept people with MRC 2 scores and accepts breathless people with any respiratory disease as long as any cardiac disease is stable. HOSAR – Home oxygen assessment and review Any patient requiring long term oxygen therapy needs to be seen by a specialist in oxygen therapy. This service will see any new patient who you feel may benefit from oxygen and would also like to see patients currently on oxygen who haven’t had a review in the last year. When referring it is useful to provide at least one pulsoximetry reading. Respiratory Specialist opinion This option includes chest clinic and/or Integrated Respiratory Team assessment (GSTT and KCH only). The referral pathway will forward your patient to the most appropriate respiratory specialist and venue. In housebound patients causing diagnostic concern or with advance care planning needs we can offer a joint home visit with a clinician from your practice. If you would like advice before referral please also use this service. Please check below to see where services are available and select any preference. For oxygen reviews or assessment we can liaise with neighbouring borough teams. Kings College Hospital – Lung function, HOSAR, Pulmonary rehab, COPD, pleural disease, cough, asthma, general chest clinics Guy’s Hospital – COPD, asthma, interstitial lung disease, Sarcoid, general chest, HOSAR St Thomas’ Hospital – Pleural disease, general chest, Pulmonary rehabilitation, Ambulatory HOSAR St Georges Hospital / Wandsworth community team - HOSAR Mayday Hospital / Croydon community team – HOSAR Dulwich Leisure Centre (Crystal Palace Road SE22 9HB) - Pulmonary rehabilitation Brixton Recreation Centre (Brixton Station Road SW9 8QQ) - Pulmonary rehabilitation Lambeth Walk (Chandler Community Hall, Lambeth Walk SE11 6DU) - Pulmonary rehabilitation Date of referral: 01-Jul-2014 Referrer Name: BAXTER, Noel (Dr) Surgery: Surrey Docks Health Centre, Downtown Road, London, Greater London, SE16 6NP Tel: 020 30497444 E-mail: Southwark*Respiratory*single*point*of*referral*activity*October9March*201391 ! * Conditions*referred** ! 99! 57! 21! 15! 12! 8! 5! 4! 3!3! 2! 2! 1!1! 1! 1! COPD! Breathlessness! Cough! Asthma! Pulmonary!Fibrosis! Unknown! Bronchiectasis! Cough!&SOB! COPD!&!Heart!Failure! Recurrent!chest!infections! Pleural!Effusion! Sarcoid! Cluster!Headache! Palliative! Pulmonary!Hypertension!
  • ABCs for breathless people! ! This%guide%was%developed%with%our%clinical%partners%at%Guy’s%and%St%Thomas’s%NHS%Foundation%Trust%and%King’s% College%Hospital%NHS%Foundation%Trust.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Page 1 of 3% NHS Lambeth Clinical Commissioning Group NHS Southwark Clinical Commissioning Group Taking'Charge'of'Your'Breathlessness' Patient Information –what you can do to help with breathlessness !We!have!developed!this!guide!to!support!people!experiencing!breathlessness.!This!advice!may!not!be!suitable!for! everyone.!!If!you!need!further!advice,!please!contact!your!GP!or!health!professional.! ! The of breathlessness: ACTIVITY – it is important to remember to stay as active as you can. Avoiding activities that make you breathless weakens your muscles and can actually lead to an increase in the feeling of breathlessness over time. Instead of avoiding activities, try using planning and pacing to help: · Planning: Think about which activities make you feel breathless. Plan in advance for these activities, and spread them throughout the day. Be sure to rest in between activities if you need to. If there is an activity that makes you feel especially breathless, for example hoovering or changing the bed covers, take it slowly, and ask for help if you need it. · Pacing: Pace yourself and take breaks if you start feeling breathless. You can use the ‘50% rule’ to help. For example, if climbing a flight of stairs leaves you feeling very breathless, try climbing 50% of the way up and taking a break to catch your breath before continuing up the rest of the stairs. This will help you to manage the stairs without feeling like you are gasping for breath. BREATHING – You can learn to control your breathing when you feel breathless using a technique that singers use called diaphragm breathing (also known as tummy breathing). Before you start • Relax your shoulders and arms as this saves energy. • Place both hands on your tummy, just above your belly button • Let your elbows rest in by your sides. Spend as long as you need on each of the following points: • Feel the rise and fall of your tummy and hands · As you breathe in, allow your tummy to swell. ! ! This%guide%was%developed%with%our%clinical%partners%at%Guy’s%and%St%Thomas’s%NHS%Foundation%Trust%and%King’s% College%Hospital%NHS%Foundation%Trust.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Page 3 of 3% Relaxation'Poem'' For'use'when'feeling'breathless' ! ! ! Be!Still...!Be!calm....! Drop!the!shoulders! Slowly!sigh!Out...and...Out! Hear!the!sigh!Haaah....!!! ...soft!and!quiet! Feel!control!returning! Peaceful!and!safe! ! ! % % With%thanks%to%Jenny%Taylor,%% Physiotherapist,%St.%Christopher’s%Hospice%%
  • EQUIP = Effecting Quality in Practice