the greatest pleasure in life is doing what people say you cannot do. anonymous. (health first)

The greatest pleasure in life is doing

what people say you cannot do. Anonymous

Wendy FairhurstNurse Partner Marus Bridge Practice

Clinical Director Health FirstALW Community Interest Company

Approximately 15-20% patients misdiagnosed

Local projects (COPD Salford and Blackburn) 40-60% admissions prevented

RCT (COPD USA) 41% admissions prevented CHD NSF ( Heart Failure) 50% admissions

preventable Asthma UK – 75% of admissions avoidable

EVIDENCE

3

Deprivation Diet, ObesitySmoking , Alcohol

COPD CVD -HF

Admissions and Mortality

Why breathlessness?• LOW QUALITY• POOR EXPERIENCE|• HIGH COST

High rates of

admissio

ns and re-

admissions

Misdiagnosis

Common

Respiratory

disease accounts for 21% excess deaths

Wide PracticeVariation

QoF process rather than

outcome

5

Case Review pilot 2007

Problems with diagnosis between cardiac and respiratory causes of breathlessness

Multiple pathologies managed individually not holistically

Limited post-exacerbation follow-up in practice teams – many factors

No detailed personalised management plans

COPD diagnosis covering other causes of worsening Breathlessness

Haphazard medication regimes – medication not optimised

Limited follow-up of patients on o2 therapy Poor servicing and technical problems

identified with home nebulisers Patients who might benefit from o2 not being

identified 

6

Case Review pilot ( continued)

7

Feedback from Primary Care

Difficulties in the management of patients with multiple pathology

Patients referred to multiple hospital consultants and specialist nurses – inconvenience and confusing for patients – delays in appropriate treatment

Difficulties for some patients in accessing services Travelling is difficult for this group of breathless

patients There are a high number of follow-up out-patient

appointments. These are inconvenient for patients result in a high level of DNAs and costly for the PCT

8

Health Equity Audit -Heart Failure

The recorded prevalence of heart failure in ALWPCT is remarkably low

1.under-reporting2.under-diagnosis

3. effect of increased cardiovascular mortality.

The poor detection rates, and conceivably treatment rates, will have implications on healthcare resource utilisation and therefore requires further scrutiny and intervention.

The reported proportion of heart failure patients in receipt of ACE-inhibitor or angiogenesis II antagonist therapy compares favourably with regional and nationalFigures.

For patients with asthma, COPD and heart failure in Ashton, Leigh and Wigan there is:-◦ Mortality levels above national and SHA average◦ Admission levels above national and SHA average◦ Under diagnosis◦ High levels of multiple long term conditions◦ Fragmented services with lack of co-ordination

Evidence from other projects

Why is the Service Needed?

Enhanced on-going care/case management

Current Journey to Diagnosis

524 pts in PF and AL

Reflection of working within the Breathlessness service

Sam Lacey Senior Practice Nurse Maurus Practice Respiratory Nurse Practitioner – Breathlessness Service

Practice Nurse Ultimate aims

◦ To be a practice nurse

◦ Prevent hospital admissions

◦ Improve patient care

My Journey Developed more as specialist nurse Patient advocate Worked with CLAHRC (HFSN)

◦ Work published Developed as educator

Sandra Burns Lead Nurse PractitionerBreathlessness Service

Case study – Terence 54 year old Retired senior Police officer Lives with wife, has 2 children and 1

grandson Never smoked Goes to gym reg, very fit, cycles and play

golf PMH Sinusitis Nil other

GP consultations Feb 14 cough – px abx March 14 cough – px abx December 14 cough/sinusitis – px abx Jan 15 cough – px abx Feb 15 cough – px abx March diagnosed with chronic rhinitis (GP) PX abx and omeprazole April 15 Chronic Rhinitis – px Beconase nasal spray (stopped

Omeprazole) May 15 Cough – px gaviscon May 15 cough/wheeze/breathlessness

◦ Referred to ENT ◦ Started Omeprazole for ?GORD

Consultations – continued…. June 15 cough and breathlessness,

◦ Px abx and referred to the breathlessness clinicJune 15 seen by respiratory nurse in clinic

investigations – BNP neg, sputum NAD, CXR NAD

Spirometry normalreferred to chest physician within community July 15 cough – px more abxAugust 15 worsening breathlessness. Now unable

to go to the gym, struggling even playing with grandson, wheezy at night, started salbutamol

Consultations -continued August 15 seen by chest physician Spirometry normal O/E had global expiratory wheeze, no crepes FENO 198ppb….. Started Fostair / Montelukast Jan 16 “Feels marvellous” ! Only required 2 consultations within the

breathlessness service

Thank you for listening

Any Questions??