Download - 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
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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
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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
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Case Review pilot ( continued)
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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
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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??