The Hull and East Yorkshire Hospitals NHS Trust Physiotherapy Acute Respiratory COPD Service (PARCS) was commissioned to enable patients with acute COPD exacerbations to have rapid access to physiotherapists with specialist respiratory skills, in their own homes. Patients are seen within one working day of a referral from primary and secondary care service providers, or from the patients themselves, in fulfilment of recommendations 220.127.116.11 and 18.104.22.168 of NICE Clinical Guideline 101 and statement 7of Quality Standard 10. The team commence chest clearance, provide reassurance to reduce anxiety, teach problem solving strategies and provide the patient with individualised advice on how to manage their symptoms.
Aims and objectives
The aim of the service is to prevent avoidable hospital admissions and improve patient’s quality of life through education to recognise early signs of an exacerbation and to encourage timely referral, or self referral, to specialist physiotherapy 7 days a week when an exacerbation is suspected.
Reasons for implementing your project
The City of Kingston upon Hull has a population of 257,000 of which more than the national average are smokers. As a high proportion of smokers tend to have COPD, it is unremarkable that smoking related deaths in Hull were worse than the average for England in 2014. At the time that the service commenced in 2011, acute exacerbations of COPD were the second most common cause of Accident and Emergency admissions in the City. Patient feedback indicated that they often did not wish to be admitted to hospital because this put them at increased risk of contracting other infections which then prolonged hospital length of stay. Nationally, 15% of COPD patients who are admitted to hospital die within 3 months (DH, 2011).
Local commissioners recognised that an effective COPD pathway would reduce the need for such patients to have to access the Accident and Emergency department to initiate timely exacerbation management. Prior to the introduction of the PARCs team, COPD patients would be admitted to hospital for medical management and to access specialist physiotherapy. Hence, provision of specialist physiotherapy in the home would also reduce bed pressures in the hospital and reduce the risk of a patient contracting another infection whilst in hospital. The views of service users and other members of the medical and nursing teams were sought to inform the development of the initial business case.
How did you implement the project
In 2011, the Hull Clinical Commissioning Group were looking to enhance the existing COPD pathway which consisted of a community oxygen therapy service, community matron team, respiratory nurses and the Acute respiratory assessment team. The Physiotherapy Acute Respiratory COPD service was proposed as a means of delivering specialist physiotherapy to patients within their own home who have an acute exacerbation of COPD. The service offered extended hours Monday to Friday to reduce out of hour admissions, and had to be capable of responding to a call within one working day of receiving a referral.
In June 2012 the service extended to include a targeted 7 day service. The team comprised of 2 band 7 and 3 band 6 Physiotherapists with acute respiratory experience. This level of seniority reflected the fact that patients were acutely unwell, had more advanced disease and potentially more comorbidities. Hull Clinical Commissioning Group agreed to fund the service including provision of a base, access to mobile phones, laptops and an evening driver because the service was provided by a lone worker. Patients preferred daytime appointments, so uptake for the evening service was limited. As a result in August 2014 the service was reconfigured to increase daytime hours by stopping the evening service.
As patients had identified a desire for this service, the main barrier was the need to raise awareness of the service to the Respiratory Consultants, General Practitioners and Paramedics and the need to be integrated into existing services. New Physiotherapy team members spent time with each of the aforementioned services, and attended G.P. training forums to raise awareness of the service.
Referrals are received by telephone to a central phone in the team office. When not in the office the team can check for messages via their mobile phones. The team use a secure electronic record system so they can access clinical information remotely. Patients are seen on average 4 to 5 times during an acute exacerbation. Interventions include reassurance, chest clearance techniques, and patient and carer education in:
- management of breathlessness,
- anxiety management through trigger recognition and strategies to enhance self control.
- effective inhaler and nebuiliser techniques
- provision of aids and advice to enhance mobility or movement
- energy conservation techniques
The Physiotherapy team initially monitored effectiveness using the MRC dyspnoea scale, COPD assessment Test (CAT) and the Clinical COPD Questionnaire (CCQ). Table 1 in the supplementary information illustrates the initial presentation and degree of change achieved on each of these scales during the period of the PARCs team intervention. Mean scores demonstrated improvement in all domains. Due to considerable overlap in the measures, the MRC and CAT were discontinued. The CCQ and EQ-5D-5L were adopted as this was licensed for use by the Chartered Society of Physiotherapy at the time. Mean change in CCQ achieved in this second service evaluation was consistent with the previous findings. A small median improvement was recorded in total EQ-5D in two annual audits (tables 3 and 4). The service was therefore able to identify standards against which they could assess their on-going effectiveness.
Patient satisfaction data was collated quarterly. The team were consistently rated ‘excellent ‘in time spent with patients, care shown, personal manner, quality of help given, amount, appropriateness and clarity of information given and utility of the self management advice provided. Free text comments received indicate that the team, as part of the wider pathway, are managing to prevent hospital admission in many cases:
“Having breathing problems for years I have dreaded having a cold which always develops into chest infections hence admission to hospital, then to pneumonia. With the long term conditions team, and now the COPD physiotherapists visiting me on a regular basis, my fears have been alleviated. There’s been no hospital admission too. With this support my COPD is under control. This service is brilliant.”
Patient feedback has suggested that the service has prevented avoidable hospital admissions in some cases. It has improved patients quality of life in terms of symptom burden, psychological impact and improved functional ability to a limited extent, which was an unexpected achievement considering the amount of physical limitations that this patient group experience. Patients are very satisfied with the service and it is valued by the rest of the COPD pathway providers. The initial contract was for three years and has recently been renewed and enhanced.
Key learning points
Patients did not want visits after 4pm as they were too fatigued, and did not want physiotherapy after their evening meal. Hence the hours of the service were altered to provide more contacts between 8.30 am and 4.30pm Monday to Friday.
The team continually needs to market their service to ensure that they receive new patient referrals in a timely manner.
Most advanced COPD patients have “just in case” medication boxes. As established patients self - refer to the Physiotherapy team as soon as they feel an exacerbation commencing, it was identified that the service could be more responsive if Physiotherapy staff could initiate administration of the required medication. Hence a case has been made to fund one of the Physiotherapy staff to undertake the non-medical Independent prescribing course.
Exercise has been shown to be beneficial in COPD, but approximately 50% of patients seen by this team are unable to access community pulmonary rehabilitation programmes due to the severity of their disease. A Senior Physiotherapy Assistant post has been created within the team to deliver a tailored post exacerbation exercise programme in the home. This will aim to improve muscle power and cardiovascular endurance so that mobility does not become further compromised.