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Leicester, Leicestershire, Rutland Breathlessness Pathway (University Hospitals of Leicester NHS Trust)

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Leicester, Leicestershire, Rutland Breathlessness Pathway (University Hospitals of Leicester NHS Trust)

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Leicester, Leicestershire, Rutland Breathlessness Pathway (University Hospitals of Leicester NHS Trust)

  1. 1. Leicester, Leicestershire, Rutland Breathlessness Pathway Dr Rachael Evans PhD Consultant Respiratory Physician Honorary Senior Lecturer, Glenfield Hospital, Leicester, UK
  2. 2. LLR Breathlessness Pathway • Overarching aim ‘to streamline and co-ordinate care to achieve early diagnosis and early treatment for patients suffering from non-acute breathlessness’ • NHS-IQ project - pilot a specialist led cardiorespiratory diagnostic clinic for breathlessness • Part of Leicester, Leicestershire, & Rutland (LLR) project to develop a Breathlessness Pathway across primary, community and secondary care • Better Care Together Health and Social care LLR – Long Term Conditions workstream • LiA UHL NHS Trust project to design the pathway • Patient involvement
  3. 3. Developing integrated symptom-based diagnostic pathways Assessing the current pathway for patients with chronic/non-acute breathlessness
  4. 4. How do adults with breathlessness currently present to secondary care? Outpatient survey All primary care referrals to cardiology and respiratory outpatients during March 2015: • 63/174 (36%) were for breathlessness • 38 had unexplained symptoms prior to referral • 35% had ≤1 investigations prior to referral Investigations performed prior to referral: Respiratory Cardiology Both 0 10 20 30 40 50 60 70 80 Investigation CXR Spirometry BNP Echo Hb ECG CT thorax
  5. 5. Duration to diagnosis and treatment Mean [SD] time: • to be seen was 13 [8] weeks • to diagnosis from referral was 16 [7] weeks • for respiratory physiotherapy was 19 [13] weeks • to PR was 28 [7] weeks • There were no inter-speciality referrals
  6. 6. How do adults with breathlessness currently present to secondary care? Admissions unit survey • 67/156 adult admissions were for breathlessness. • 33/67 had unexplained symptoms, of which 17 were discharged within 24 hrs (>75% required only simple investigations interpreted, 70% EWS ≤1). • Of the 33, 61% required simple investigations only and 50% had an EWS of ≤1 on arrival. • The median [IQR] duration of breathlessness was 3 [1 - 14] days. All admissions to CDU in 96 hours during July 2015
  7. 7. Comparison of the diagnoses between the two settings Diagnoses for adults with unexplained breathlessness presenting to secondary care OPD Diagnoses (n=38) Frequency Acute CDU Diagnoses (n=33) Frequency COPD 9 Pneumonia 8 ILD 6 LRTI 4 Asthma 5 AF 3 Dysfunctional Breathing 4 MSK chest pain 3 Bronchiectasis 3 Bronchitis 2 OSA 2 Asthma 2 Bronchitis 2 Other Respiratory 7 Other Respiratory 4 Other Cardiology 4 Other Cardiology 3 *separate heart failure clinic
  8. 8. Conclusions • Simple investigations are not fully utilized prior to OPD referral for breathlessness. • Nearly a quarter of patients presenting with undifferentiated breathlessness have COPD • Only 30% had spirometry prior to referral • Identified need for three different approaches to breathlessness services: 1) a diagnostic pathway for primary care 2) an ambulatory same day service with simple investigations including chest radiograph, blood tests and electrocardiography readily available with interpretation 3) a diagnostic combined speciality outpatients with earlier appointments Submitted abstract to ERS 2016
  9. 9. Developing a LLR Breathlessness Pathway
  10. 10. Bringing a Leicestershire team together County and City GPs Respiratory Consultants Cardiology Consultants Public Health Community providers - LPT Diagnostics Therapies (OT/PT) Cardiology Specialist Nurses Exercise Rehabilitation Specialists (Community and UHL) NCSEM - EM Respiratory Specialist Nurses UHL Managers CCG representatives PATIENTS Pharmacists
  11. 11. “PHEW!” We designed a Leicestershire Breathlessness Pathway • Glenfield Patient Cardio-Respiratory Group • Presented to 15 members of the group • Patient volunteers continue to support the project Preference for less visits even if meant longer appointments “Happy to travel to see the experts” Experience of delayed diagnosis and treatment “I wish I had been referred to PR earlier”
  12. 12. All pathways to include lifestyle changes • Exercise programmes • Smoking cessation • Dietary advice Nijmegen questionnaire
  13. 13. Echo
  14. 14. Pilot of a specialist led cardiorespiratory diagnostic breathlessness clinic
  15. 15. Aims (other than initiating the clinic) • Achieve earlier diagnosis by systematically assessing the ‘panel of investigations’ for all patients • Reduce time to be seen from referral (aim for < 4 weeks) • Integrate cardiopulmonary exercise tests into the diagnostic pathway • Aim for ‘one stop approach’ as far as possible • Keep number of follow-ups to a minimum • Reduce need to refer on to the other speciality e.g cardiology or respiratory • Reduce waiting time for chest physiotherapy • Increase referral to exercise programmes • Improve patient experience • Estimate how many referrals could have been avoided if all ‘the panel of investigations’ had been performed in primary care prior to referral • Estimate how many needed specialist opinion (but could have been occurred in the community) • Estimate how many patients required specialist tests • Integrate a MDT discussion between the cardiologist and respiratory physician at the end of the clinic and capture any outputs Overarching aim to improve quality of care for patients suffering from non-acute breathlessness
  16. 16. Developing the clinical team The clinic team Consultant Cardiologist - Dr Will Nicolson Respiratory Physiotherapist – Ms Shaazia Khatri. Consultant Respiratory Physician – Dr Rachael Evans Respiratory physiologists (performing spirometry at clinic, cardiopulmonary exercise tests, PC20, PFTs) Integrated Care Clinical Fellow, HEEM, UHL NHS Trust - Dr Irene Valero-Sánchez Clinic Co-Ordinator: Kirti Odedra Healthcare Assistant: Julian Bursnall Outpatient Nursing Team – Sadie Hall Secretaries – Julie Spence/Sarah Sayer CMG managers – Clare Rose/ Sam Leak
  17. 17. Clinic process Implementation • Started August 2015 • 2- 5pm 1st and 3rd Friday afternoon • Consultants reviewed referral letters into the department for patient selectio • Blood test requested via letter prior to clinic • Other investigations would be performed same day as clinic – spirometry, ECG, CXR, MRC, Nijmegan score, HADS, BMI, Activity Q • MDT occurred 4.30 – 5pm Barriers • Finding a clinic slot • Admin staff time • Outpatient nursing staff time • Clinics were booked on an adhoc basis for 3 months therefore less patients were able to be seen than if the clinic was a regular occurrence • Difficult to maintain a process of getting patients seen <4 weeks with this adhoc nature
  18. 18. Results • 54 new cardiorespiratory patients • 50% male, mean [SD] age 66.6 [15.4] yr, Body Mass Index 31 [7] kg/m2) were seen over six months • 25/54 referrals either had no diagnosis specified or diagnosis was uncertain • Investigations documented on the GP referral letter were: • Hb 26% • BNP 28% • ECG 17% • CXR 54% • Spirometry 27% • BMI <2% • Smoking history 31% • Echocardiogram 18.5% 1 4% 2 29% 3 36% 4 24% 5 7% MRC dyspnoea grade 0 5 10 15 20 25 30 35 40 Frequency Respiratory Cardiology
  19. 19. Outcome – usual OPD pathway vs breathlessness clinic • % discharged back to GP was higher in the ‘Breathlessness Clinic’ compared to usual outpatient pathway • 87% back to GP with max 1 follow up within < 2 months vs 35% within 6 months • N = 6 were referred to either respiratory (n=3) or cardiology (n=3) outpatients for ongoing follow up; • interstitial lung disease (n=2), • severe OSAS (n=1), • primary pulmonary hypertension vs HFpEF (n=1) • severe valvular heart disease (n=2) Usual outpatient pathway Breathlessness clinic P value Time to be seen 13 [8] 5 [3] <0.001 Time to diagnosis 16 [7] 5 [8] <0.001 Time to physio 19 [13] 1 [1] <0.001 New to follow up ratio 2:10 8:2 DNA % 18% 4% Breathlessness Clinic • 48% discharged after single visit • 39% discharged after 1 follow up • 2% (n=1) had 2 follow ups • 9% referred to specialist clinics
  20. 20. Outcome …continued • 16/54 (29.6%) further outpatient referrals were avoided to the other speciality by having the MDT • 11% (n=6) mod-severe COPD, n=1 severe bronchiectasis and respiratory failure, referred to cardiology • 7.4% (n=4) HFpEF/AF/Valvular heart disease referred to respiratory • 10 (18.5%) were diagnosed due to systematically having simple investigations for breathlessness rather than clinician preference • 18.5% could have been diagnosed in primary care (judged by need for simple investigations only and no complex co-morbidity) • Only a third of patients required specialist tests needing a secondary care setting
  21. 21. Diagnoses and Investigations Primary Diagnosis Frequency Arrhythmia 2 Asthma 8 Bronchiectasis 2 COPD 8 Dysfunctional Breathing 11 HFpEF 6 HFrEF 1 Valvular Heart Disease 2 Interstitial Lung Disease 4 Mixed Heart Disease 1 Obesity 4 Physical Deconditioning 3 Sleep disordered breathing 1 Co-existing Obesity and Physical deconditioning 20 • Multi-morbidity of breathlessness 0 5 10 15 20 25 30 Frequency No. of Diagnoses 1 2 3 4 5HADS>9 Anxiety Depression 7 10
  22. 22. Other investigations performed: 0 2 4 6 8 10 12 14 16 Investigations CPET CTPA Cardiac MRI Echo HRCT thorax 24hr ECG PC20 PFT R heart catheter
  23. 23. Patient experience Outpatient feedback questionnaire - http://www.nhssurveys.org/ • 10 consecutive patients Dec 15 – Jan 16 • Did you have enough time to discuss your health or medical problem with the doctor? • 10 Yes, definitely • Did the doctor explain your condition and the reasons for any treatment or action in a way that you could understand? • 10 Yes, definitely • Was the main reason you went to the Outpatients Department dealt with to your satisfaction? • 10 Yes, completely • Overall, how would you rate the care you received at this Outpatients Department? • 10 Excellent • Would you recommend this clinic to your family and friends? • 10 Yes, definitely
  24. 24. Case history 1 • 63 yr old man -increasing breathlessness over two months • Ex-smoker and hypertensive. • ET now only 50yds - had been able to walk miles until May 2015. GP requested urgent appointment • Weight gain of three stone since being prescribed steroids for polymyalgia rheumatica. • swelling of his ankles and orthopnoea. No cough or LRTIs. • O/E breathless on minimal exertion, SpO2 98% on air, sweaty and tachycardic 120 (SR). His JVP was visible at 4cm. BMI 47. Bilateral pitting oedema to knees • CXR – cardiomegaly • ΔΔ heart failure (2⁰IHD/HT) - speed of deterioration, risk factors and clinical examination. • The cardiologist performed a screening Echo, which reassuringly showed normal LV function but RV dilatation. • His spirometry showed severe airflow obstruction compatible with COPD and restriction due to his obesity • He hadn’t had the blood test for BNP as he thought he’d have it at the same time as the clinic – normal • On direct questioning he was a snorer, with daytime somnolence, un-refreshing sleep and awoke choking at night. He was a lorry driver but had been off work because of the shoulder problem. • He had a sleep study which confirmed very severe OSAS and he was started on CPAP within two weeks • DVLA contacted • He has since lost 1.5 stone and is attending Pulmonary Rehabilitation. He has been weaned completely off the steroids. Joint approach led to discharge to the sleep clinic after a single appointment Usual OPD - referred urgently to the heart failure clinic
  25. 25. Case history 2 • 73 yr old female , non-smoker, - symptoms of breathlessness for the last couple of months. CXR - cardiomegaly and signs of “congestion”. Normal BNP. Diagnosis of possible heart failure. Referred for an appointment to cardiology clinic. • Further report of CXR comes back. Radiologist suggests further characterisation of images with high resolution CT scan (HRCT). Therefore HRCT requested in primary care. • Referral was reviewed by cardiologist and selected for the breathlessness clinic. • HRCT recently performed but images not reported. HRCT Images reviewed by respiratory physician during clinic preparation and radiological diagnosis of interstitial lung disease (ILD) made • Patient seen by respiratory physician, eosinophila, high dose steroids started, requests additional blood tests for further characterisation, refers to the ILD team, who take over for follow up. • Diagnosis – likely Cryptogenic organising pneumonia Estimated time to diagnosis on old pathway 6 months Time to diagnosis and Rx - 1 month due to cardiorespiratory option
  26. 26. Case history Exclude COPD • Spirometry at work • Good clinical history for COPD but spirometry showed restrictive deficit • Poor quality spirometry • Poor interpretation Asthma • Good history for asthma - no therapeutic trial of inhaled steroid performed
  27. 27. Conclusions • There is a need to increase the utilization of simple tests for the diagnosis of non-acute breathlessness in primary care • 18.5% of specialist referrals could have been avoided if these had been employed • The diagnostic clinic achieved a significantly earlier diagnosis, fewer follow up visits, compared to ‘usual pathway’ (quality and efficiency improved even without the panel of Ix being performed prior to clinic) • Earlier physiotherapy was achieved by having a physiotherapist present • Joint cardiorespiratory working was valuable and avoided 30% of the cohort having inter-speciality referrals • This was higher than for the ‘usual OPD pathway’ due to the ‘panel of investigations’ being systematically performed • Secondary care referrals for breathlessness outside of the ‘breathlessness clinic’ should utilise the ‘simple panel of investigations’ • The ‘panel of investigations’ led to a more comprehensive assessment of the causes of breathlessness leading to multiple co-morbidities being diagnosed • A joint specialist clinic in the community would have been possible in nearly two-thirds as long as the ‘panel of investigations’ were available • Improved stratification of patients referred to secondary care is needed to ensure resource is ‘best used’
  28. 28. Further work • Successful application to supervise an Integrated Care Fellow through Health Education East Midlands to further this work • Dr Ire Valero is piloting the implementation of the LLR breathlessness pathway in primary care (utilising the information from this project) • The clinic is due to be commissioned from April 2016 – we will find out end of March. • Utility of cardiopulmonary exercise tests has not been evaluated - ongoing • Waiting time for the exercise programmes has not been assessed. It took a few months to find out what community programmes were available and they have different referral forms • Ongoing evaluation and mapping of exercise services is being performed by the ‘health and innovations’ team of Better Care Together Long Term Conditions • A generic exercise rehabilitation programme has been set up at the NCSEM-EM so we will now refer the majority of new patients there • We aim to move the clinic to NCSEM-EM • Dissemination

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