The Breathing Space Clinic …a multi-disciplinary, inter-organisational hospice-based pilot clinic to support the holistic needs of patients with advanced COPD
The Breathing Space Clinic is a pilot hospice-based clinic that provides holistic support for patients with advanced COPD. It aims to bring together respiratory and palliative care expertise to improve quality of life. Patients are comprehensively assessed physically, psychosocially and spiritually by an interdisciplinary team. The clinic addresses information needs, symptom management, advance care planning and referrals to other support services. It complements existing COPD services and facilitates communication across care pathways. The clinic has received positive feedback and aims to replicate its model of holistic care in the home setting.
Outcome study of pulmonary telerehab - respirehab for post COVID patientsSubodh Gupta
Respirehab's case paper of telerehab of post COVID patients for improving breathing capacity, physical endurance and patient well being. The online pulmonary rehab delivered excellent gains on various parameters like SGRQ, MMRC and SPO2. This would be very helpful for COPD patients suffering from shortness of breath (Dyspnea).
Plenary Sue Hill and Robert Winter - Improving outcomes for people with respi...NHS Improvement
Improving outcomes for people with respiratory disease: Keeping up the momentum
Professor Sue Hill and Dr Robert Winter
Joint National Clinical Directors for Respiratory Disease
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
Stopping over-medication of People with Learning Disabilities
(STOMPLD) 2016.
Reducing Inappropriate Psychotropic Drugs in People with a Learning Disability in General Practice and Hospitals in 2016.
Outcome study of pulmonary telerehab - respirehab for post COVID patientsSubodh Gupta
Respirehab's case paper of telerehab of post COVID patients for improving breathing capacity, physical endurance and patient well being. The online pulmonary rehab delivered excellent gains on various parameters like SGRQ, MMRC and SPO2. This would be very helpful for COPD patients suffering from shortness of breath (Dyspnea).
Plenary Sue Hill and Robert Winter - Improving outcomes for people with respi...NHS Improvement
Improving outcomes for people with respiratory disease: Keeping up the momentum
Professor Sue Hill and Dr Robert Winter
Joint National Clinical Directors for Respiratory Disease
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
Stopping over-medication of People with Learning Disabilities
(STOMPLD) 2016.
Reducing Inappropriate Psychotropic Drugs in People with a Learning Disability in General Practice and Hospitals in 2016.
Pulmonary rehab is part of global standard of care for patients suffering from chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), persistent bronchial asthma and other lung manifestations.
Respirehab makes pulmonary rehab accessible, convenient and cost effective by taking it digital & online.
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
Getting a handle on breathlessness. Case finders and GRASP audit tools for COPD and heart failure - Dr Richard Healicon, Programme Delivery Lead, NHS Improving Quality
Presentation from the Breathlessness Symposium held in London on 1 July 2014
Complementary medical health services: a cross sectional descriptive analysis...home
The clinic attracts people from a wide area in the metropolitan Toronto and surrounding region with
health concerns and diagnoses that are consistent with primary care, providing health education and addressing
acute and chronic health conditions. Further explorations into health services delivery from the broader
naturopathic or other complementary/alternative medical professions would provide greater context to these
findings and expand understanding of the patients and type of care being provided by these health professionals.
Symptom-led diagnostic services for breathlessness: real life examples - Hilary Walker, Head of Programmes, Living Longer Lives, NHS Improving Quality and Wendy Fairhurst, Nurse Partner, Marus Bridge Practice
Pulmonary rehab is part of global standard of care for patients suffering from chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), persistent bronchial asthma and other lung manifestations.
Respirehab makes pulmonary rehab accessible, convenient and cost effective by taking it digital & online.
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
Getting a handle on breathlessness. Case finders and GRASP audit tools for COPD and heart failure - Dr Richard Healicon, Programme Delivery Lead, NHS Improving Quality
Presentation from the Breathlessness Symposium held in London on 1 July 2014
Complementary medical health services: a cross sectional descriptive analysis...home
The clinic attracts people from a wide area in the metropolitan Toronto and surrounding region with
health concerns and diagnoses that are consistent with primary care, providing health education and addressing
acute and chronic health conditions. Further explorations into health services delivery from the broader
naturopathic or other complementary/alternative medical professions would provide greater context to these
findings and expand understanding of the patients and type of care being provided by these health professionals.
Symptom-led diagnostic services for breathlessness: real life examples - Hilary Walker, Head of Programmes, Living Longer Lives, NHS Improving Quality and Wendy Fairhurst, Nurse Partner, Marus Bridge Practice
REG Interstitial Lung Disease Working Group Meeting
Similar to The Breathing Space Clinic …a multi-disciplinary, inter-organisational hospice-based pilot clinic to support the holistic needs of patients with advanced COPD
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
This webinar educates healthcare professionals on interventions for cough, dyspnea, hemoptysis and the “death rattle” in patients with end-of-life respiratory symptoms.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
The goal of this webinar is to educate healthcare professionals on interventions for cough, dyspnea, hemoptysis and the “death rattle” in patients with end-of-life respiratory symptoms.
โรคเรื้อรังเกี่ยวกับระบบทางเดินหายใจ นับว่าเป็นปัญหาสาธารณสุขที่กระทบต่อคุณภาพชีวิตประชาชนมากเป็นอันดับต้นๆ การพัฒนาระบบการดูแลที่เรียกว่า chronic care model นับว่าจะช่วยทั้ง health and well being คนไข้ ครอบครัว และช่วยทางด้าน equity efficiency ระบบบริการสาธารณสุขด้วย
Learning outcome 1The chronicity of COPD allows for self manage.docxaryan532920
Learning outcome 1
The chronicity of COPD allows for self management by sufferers. (Spencer & Barcomb 2014). The self management goal is reduced hospital admissions and improved life quality (Bedra et al 2013). Sufferers should have access to a wide range of skills available from the multidisciplinary team. Those include exacerbation limitation, respiratory failure, chronic productive cough and anxiety and depression.
Symptom Recognition.
Patients discharged from hospital are susceptible to readmission (Bedra et al 2013). Understanding the condition and knowing when they are having an exacerbation is imperative for self management, and what to do in the given circumstances, and when and what medication to take, or realise they need hospital treatment.
Treatment.
The main form of treatments comes from inhaled therapies and explained below would be when they would be administered and their understandings are a major factor in self management.
For breathlessness and exercise limitations: A short acting Beta2 agonist (as required) or short acting muscarinic antagonist (as required).
For exacerbations or persistent breathlessness: A long acting beta2 agonist, long acting muscarinic antagonist, to – long acting beta2 agonist + inhaled corticosteroid (Combination Inhaler) OR a long acting muscarinic antagonist (must discontinue short acting antagonist once this is commenced).
(Remember if using Corticosteroids, this has no evidence of long terms benefits).
If experiencing persistent exacerbations or breathlessness. Long acting Muscarinic antagonist + long acting beta2 agonist and inhaled corticosteroid (combined inhaler).
Niesters et al, (2012) describe how oxygen therapy can also be used, but awareness of inappropriate oxygen therapy with COPD patients is imperative as this can cause respiratory depression.
Self Monitoring.
The British Thoracic Society (BTS) have identified five high impact actions that can improve outcomes for people being discharged after an acute exacerbation of COPD. The form is a quick way of identifying patients need for those interventions, ensuring their needs are met. The aim is for lessened hospital readmission rates with self monitoring patients. The five actions are;
Review of medication and demonstration of inhalers they will be using.
Provide a written Self Management plan and Emergency drug pack.
Asses and offer referral for smoking sensation.
Assess for suitability for pulmonary rehab.
Arrange a follow up call within 72 hours of discharge.
Educational Interventions.
Reardon et al, (2005) explain pulmonary rehabilitation as programs which work with patients to help manage their condition, muscle strength, ability to cope with their disease, help with social requirements as people can become quite isolated.
Test includes incremental shuttle walk a 10 metre course, consecutive runs, each time getting faster, measured how far they got, will give idea of what they can endure on the exercise programme th ...
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The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD) and the value of advance care planning (ACP) for end-of-life patients.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Chronic Obstructive Pulmonary Disease (COPD):
Post-Acute and Long-Term
Healthcare Setting
Presentation to Executive Leadership
1
Introduction: Major of Study
Master’s of Science in Nursing Generalist (MSN)
Analyze, Design, Implement, and Evaluate Nursing Care
Simplify the Complexity of Transitions in Care
Post-Acute /Long-Term Care Rehabilitation
Community Services/Dwelling
Clinic – Preventive and Palliative Care
Acute – Reducing Readmission Rates for Exacerbation of Chronic Illness
MSN competencies allow for a full analysis of design, implementation, and evaluation of nursing care to diverse populations and cohorts of patients, in clinical and community-based systems, (American Association of Colleges of Nursing [AACN], 2011).
As a Director of Nursing within the long-term care continuum, having a MSN degree will allow for the integration of findings from across the sciences and humanities, and will facilitate continuous improvement of nursing care at the unit, clinic, home, and program level (AACN, 2011).
The DON who acquires their MSN provides for a strong background in healthcare leadership, assessment, pharmacology, and pathophysiology in preparation to understand how the systems and organizational sciences can blend to meet the healthcare needs of a diverse population (AACN, 2011). This blending of core components will provide the knowledge necessary for transitioning patients with Chronic Obstructive Pulmonary Disease (COPD) safely through their continuum of healthcare needs, within the micro-, meso-, and macrosystems of healthcare.
2
Introduction: Chronic Disease
COPD
Characteristics
Dyspnea
Exercise Intolerance
Shortness of Breath
Chronic Cough
Expiratory Exertional Effort – Force or Time
Sputum Production
Wheezing
Exposure to Risk Factors for the Disease
COPD is characterized by exertional effort, force or time, needed during the expiratory phase of the respiratory cycle, with the central symptoms being dyspnea, exercise intolerance, shortness of breath, chronic cough or sputum production, and/or exposure to risk factors for the disease, with the central sign being wheezing (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2018; McCance, & Huether, 2014).
3
Introduction: COPD
Pathophysiology of COPD
Insult to Respiratory System
Airway Inflammation
WBC Enter Bronchial Wall
Pulmonary Edema
Enlarged Mucous Glands & Goblet Cells
Ciliary Impairment
Inability to Clear Airway
The pathophysiology of COPD involves the inspired agent resulting in airway inflammation, white blood cells enter the bronchial wall, leading to edema and enlarged mucous glands and goblet cells, which in turn impairs ciliary function, which results in the body being unable to clear the lungs of debris (McCance, & Huether, 2014).
4
Introduction: COPD
Risk Factors
Primary: Tobacco Use
Air Pollution
Genetic Factors
Abnormal Lung Development
Respiratory Infections
The primary risk factor for COPD is tobacco use, with other risk ...
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This presentation will share the results of a Rapid Process Improvement Workshop (RPIW) event that focused on reducing defects in plan of care (admission through to discharge) for hospital patients with chronic obstructive pulmonary disorder (COPD). The RPIW team was the first in Saskatchewan to pilot new tools (standard orders, care maps, discharge education) designed to provide more consistent, collaborative care for COPD patients.
Better Teams
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Mahdi Hemmat
PEDS PICU Respiratory fellowship material :)
Similar to The Breathing Space Clinic …a multi-disciplinary, inter-organisational hospice-based pilot clinic to support the holistic needs of patients with advanced COPD (20)
Presentation delivered by Dr Jason Chan, Highly Specialised Clinical Psychologist at the Acute COPD Early Response Service (ACERs) at the Homerton Hospital, at the Pan London Airways Network Winter Meeting 2015
Keynote presentation delivered by Dr Irem Patel, Integrated Consultant Respiratory Physician, Kings Health Partners, at the Pan London Airways Network Summer Meeting 2016
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One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
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CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
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Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
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The Breathing Space Clinic …a multi-disciplinary, inter-organisational hospice-based pilot clinic to support the holistic needs of patients with advanced COPD
1. The Breathing Space Clinic
…a multi-disciplinary, inter-organisational hospice-
based pilot clinic to support the holistic needs of
patients with advanced COPD
Dr. Ellie Hitchman
Specialty Doctor St Joseph’s Hospice, Hackney
Kim Barlow
Specialist Physiotherapist St Joseph’s Hospice, Hackney
DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily represent
the views and policy of PLAN(Pan London Airways Network).
2. Aim of presentation
This presentation will outline the development and
function of the Breathing Space Clinic, focusing on
the referral criteria and pathway including
introduction to ACERS team
3. Establishing need
oLocal policy drivers
Strategic Plan (2007) - St Joseph’s Hospice, Hackney
Creation ACERS (COPD) Team - Homerton University
Foundation
NHS Trust
oNational policy drivers
End of Life Care Strategy (2008)
NICE Management of chronic obstructive pulmonary disease
in adults in
primary and secondary care (2010)
COPD clinical outcomes framework (strategy) (2011)
4. Hackney specific… COPD 1
o31% of the adult population smoke
oEthnically diverse – over 100 languages
spoken
oHackney residents are four times as likely to
die from COPD before the age of 75 years as
people living in the local authority with the
lowest premature COPD death rate
1. London Health Programmes (2011)
5. Palliative care needs of COPD patients
oHeavy burden of symptoms 2, 13
oSymptoms at least as severe as lung cancer 2,3
oImpaired quality of life and emotional well being
compared to lung cancer 4
oInformation needs also great
- lack of awareness of progressive nature and that they may die of COPD
- fear that both of these are true 2, 5 – 8
oCarers’ needs 9 - 12
6. Palliative care needs of COPD patients
Patients who died from COPD lacked
surveillance and received inadequate
services from primary and secondary care in
the year before they died. The absence of
palliative care services highlights the need for
research into appropriate models of care to
address uncontrolled symptoms, information
provision and end of life planning in COPD 14
7. Breathing Space Clinic
Holistic Assessment
Undertake a comprehensive multi-professional
assessment of physical, psychosocial, spiritual
wellbeing by
oPalliative Care Specialty Doctor
oCOPD Clinical Nurse Specialist
oPalliative Care Physiotherapist
oPalliative Care Health Care Assistant
8. ACERS Service
Acute COPD Early Response Service
24 hrs day specialist advice
Main focus exacerbation management – community focussed
Assessment, treatment and intervention
MDT including medical, psychological and nursing/physiotherapist
Other services
Pulmonary rehabilitation
Ward
Education
Home oxygen service
Palliative care
Contact 0208 510 5107
Email: homertoncopd@nhs.net
9. Clinic aims
1. A flexible hospice-based clinic for patients with
advanced chronic obstructive pulmonary disease
(COPD)
2. Assessment, facilitation and treatment
bringing together respiratory and palliative care expertise in order to
maximise the quality of life for people with respiratory conditions
who may be towards the end of life
complement existing services and improve communication and joint
working across pathway
to improve access to specialist palliative care
10. Clinic function
Information
oProvide access to information about both the
underlying respiratory disease and the
patient’s physical and emotional response to
it, including issues of disease progression
and prognosis
oIntroduce and assist with advance care
planning, including documentation of CPR
status
11. Clinic function
Physical
oOptimise symptom control through non-
pharmacological and pharmacological means as
necessary via access to relevant disciplines internally
and externally to the hospice
Psychosocial and spiritual
oIntroduce patients to specialist palliative care
oReferral to other services including social work,
benefits, complementary therapy, psychological
therapies and chaplaincy
oAccess to respite service
12. Keys to success
Recognising that the clinic would not operate in isolation
oSmall steering group of interested and enthusiastic
professionals
Representing hospice and hospital specialist palliative care
local community respiratory specialist staff
oBuy-in from other key personnel
General practice
Respiratory medicine
oWide-ranging consultation
Including patients
oA focus on transport issues
and replicating the service at home
13. Patient example: Mary
oMary is a 78 year old lady
oreferred to the Breathing Space Clinic by the local
ACERS team
ooptimised medically for a number of years
orecent exacerbation requiring hospital admission
discharged with home oxygen
ohousebound and frightened to leave the house due to
breathlessness
oseverity of COPD: Very Severe FEV1 29 %
oMRC Scale: 4
main symptoms: breathlessness on exertion, anxiety,
low mood, reduced exercise tolerance
14. Clinic referral criteria
Disease severity
oPatients will have very severe disease – FEV1 <30% predicted (this can
be greater if uncontrolled breathlessness – flexible approach)
Necessity
oUncontrolled physical symptoms (related either directly to the COPD)
that are having a significant impact on their quality of life despite
optimised medical management
oThree or more admissions to hospital with respiratory failure and/or
infective exacerbations of their COPD in the preceding 12 months (Those
requiring more intensive home management would be referred to
CHPCT)
House keeping
oMedical management optimised
oKnow that they have a diagnosis of COPD
oKnow about, and agree to the referral
15. Referral pathway
All patients referred through the Homerton
Hospital’s respiratory medicine MDT
This ensures optimal management of the patient’s
COPD prior to referral to palliative care
16. Role of HCA
• ‘First face of the hospice’ – ‘meet and greet’
• Introduces patient and carer to the clinic
• Assists them to complete outcomes measures
questionnaires
• Assists with taking observations
• Provides information about hospice, shows
them the respite ward, day hospice
• Supports carers
17. Physiotherapist
Initiate specialist physiotherapy assessment in clinic
Gain subjective history of how breathlessness impacts on
individual and carer
Objective assessment to screen mobility, transfers and level of
SOB
Action referrals – wheelchair service, community or SS OT,
Provide hand held fan and advice sheet on Breathlessness
techniques
Arrange for 1:1 appointment with physio to complete
assessment and consider intervention options
- Refer back to PR
-Refer to MFRG
-Consider appropriateness for ICon
18. ICON - In Control of my Breathing
• 6 sessions out patient programme at St Joseph’s
• Open to patients from C&H, TH and Newham, regardless of
diagnosis, who are palliative and where breathlessness is key
symptom
• Have attended Pulmonary Rehab (or a comparable input) to
maximise physical fitness in their locality
• Main aim is to empower patients to self manage their
breathlessness more effectively
• Educational and practical aspects in every session
• Based on Breathlessness Toolkit - Dorothy House Hospice
• Enables patients to become familiar with the hospice and it’s
range of services
• Patients can also access rehabilitation alongside the
programme by attending physiotherapy gym sessions/ ELT in
Newham
20. Medical input
• Overview of general medical condition
• Pharmacological management
• Management of Breathlessness
• Advance care planning
• Optimisation of COPD treatment:
• Inhaled steroids and long acting bronchodilators
• Theophylline
• Carbocysteine
• Oxygen assessment
21. Opioids for breathlessness management
• Cochrane review (2011) found evidence to support use of
oral or parenteral opioids for breathlessness in advanced
disease or terminal illness
• Safe for use in COPD if slowly and carefully titrated
Rocker et al, Thorax (2009)
• No impact on respiratory depression
• Side effects and perception of risk can put patients and
(doctors) off
23. Advance care planning
• Often patients have not had the opportunity to
discuss the future with anyone
• Focus on Preferred Place of Care and
Preferred Place of Death
• Resuscitation status and ceilings of care
• Can be challenging – special considerations
eg need for non invasive ventilation
• We use Coordinate My Care but hard to
capture all angles of patients preferences
24. Conclusion… lessons learnt
oExcellent and positive feedback from patients
referred to the clinic
oCurrent metrics do not support the perceived benefits
that patients are expressing
oInter-organisation partnership working can and does
work
oClinical leadership across specialist palliative and
respiratory medicine was key
oIncrease awareness of advanced care planning and
CMC recording
26. References
1. Fan et al. Arch Intern Med 2007
2. Habraken et al. J Pain Symptom Manage 2009
2. Gardiner et al. Respir Med 2009
3. Edmonds et al. Palliat Med 2001
4. Gore et al. Thorax 2000
5. Curtis et al. Chest 2002
6. Curtis et al. Eur Respir J 2008
7. Caress Journal of Clinical Nursing 2009
8. Gardiner et al. Palliat Med 2009
9. Bergs. Journal of Clinical Nursing 2002
10. Booth et al. Supportive and Palliative Care 2003
11. Gysels and Higginson. Supportive and Palliative Care 2009
12. Pinto et al. Resp Medicine 2007
13. Fletcher CM, Elmes PC, Fairbairn MB et al. (1959)
14 Elkington et al Pall Med 2005