Fit for the Future: a holistic approach to respiratory care

A report from the Primary Care Respiratory Society 2016 conference14-15 October, Telford International Centre

A holistic approach to respiratory care was the focus of the PCRS-UK 2016 conference. The event covered both high quality clinical care and the wider issues that impact on lung health such as air pollution, quitting smoking, the value of exercise, the special needs of teenagers and end of life care.

The patient’s perspective was a key theme of the conference. ‘We need to move away from thinking about QOF and ticking boxes and go back to really listening to our patients, having the right conversations and focusing on what matters to them,’ said PCRS-UK conference chair Dr Noel Baxter.

He explained that the conference was called ‘Fit for the Future’ to encourage delegates to think about whether the organisation they worked in was fit for the future and to ask, ‘Am I as an individual fit for the future, am I able to have the right conversations with people, am I able to work in a positive way with other professionals and the environment so that our organisations can really make a difference?’

Professor Simon Gregory, Director and Dean of Education and Quality, Health Education England Midlands and East, and a GP in Northampton, said although general practice was struggling with an increasingly heavy workload it was more important than ever to move back to a culture of patient centred medicine.

He urged healthcare professionals to concentrate more on patient decision aids rather than guidelines and targets. Personalised plans and technology-supported medicine could be used to help healthcare professionals to understand the person and their disease.

Primary care was undergoing transformation and general practice had to get used to working with new members of the workforce such as pharmacists, physicians associates and paramedics. GPs needed to become better employers of practice nurses and to value and support them, said Professor Gregory.

Stephen Wibberley, Chief Operating Officer of the British Lung Foundation (BLF), said it was important for healthcare professionals to engage with the patient in shared decision-making and to help them access the information they needed to develop the skills and confidence to take control of their diseases.

Dr Samantha Walker, Deputy Chief Executive and Executive Director for Research and Policy at Asthma UK, said patient organisations and technology could help educate patients about self-management. ‘Do it in partnership. Send your patients to the BLF or Asthma UK and tell them; learn as much as you can about self-management and I'm here to support you when you need it. There is community online support and on people’s phones to help them and if they do this they are likely to visit the surgery less often.’

Monica Fletcher, Chief Executive of Education for Health, said that patient activation measures, the concept of the patient’s readiness for managing their own health, had been used in the US for 15 years and provided simple ways for patients and health care professionals to work together to find ways to help them better engage in health behaviour change cycles.

‘This is something that I hope will transform the NHS. Helping people to manage their disease well is about looking at the holistic issues,’ she said.

KEY LEARNING POINTS FROM THE CONFERENCE

PERSONALISING CARE FOR THE BREATHLESS PATIENT

The ‘Living with Breathlessness’ Study, involving 500 patients with COPD, provides new evidence on the care needs and preferences of patients with COPD and their carers. Completed in 2015, the study was conducted by a multidisciplinary team in the Primary Care Unit at the University of Cambridge.

Research lead, Dr Morag Farquhar, set out the six key recommendations from the study, explaining that they all had patient centred care at their heart:

• Stop focusing on the challenge of prognosis and unpredictability of trajectories as barriers to meeting needs.
• Change targets to incentivise person centred care within existing services.
• Enable identification in response to patient support needs (through evidence-based tools and approaches)
• Identify and support patients’ informal carers
• Identify and respond to psychological morbidity
• Change societal attitudes and understandings of COPD, breathlessness, palliative care and informal care support.

HOLISTIC MANAGEMENT OF CHRONIC BREATHLESSNESS

Miriam Johnson, Professor of Palliative Medicine, Hull York Medical School, explained how management of breathlessness stems from holistic assessment:

• Breathlessness is not just a signpost to diagnosis - assess and treat in its own right.
• Base assessment and management on the model of ‘breathing, thinking and functioning’.
• Evidence based non-drug and drug interventions can modify the perception of breathlessness and help to
  • improve self-efficacy
  • physical re-conditioning.
• Cognitive approaches can modify the emotional response to breathlessness.
• Exercise and other ways can maximise function to maintain
  • quality-of-life
  • reduce social isolation
  • improve breathlessness

RESPIRATORY DISEASE IN ADOLESCENCE

Dr Louise Fleming, Clinical Senior Lecturer in Respiratory Paediatrics, National Heart and Lung Institute, said teenage years were a time of great change that presented unique challenges and opportunities particularly around risk taking behaviour, adherence to medication and smoking. Teenagers should be equipped and empowered to manage their asthma with appropriate support

‘It is vital that we listen to young people and ensure their voice is heard,’ she said.

When treating teenagers, healthcare practitioners should:

• Respect privacy, confidentiality
• Address the young person
• Involve them in decision-making/consent
• Give the young person the opportunity to have time alone in the consultation
• Promote self-advocacy versus parental/doctor advocacy
• Understand the teenager’s health needs

AIR POLLUTION

Professor Frank Kelly, Chair in Environmental Health, King’s College, London, and an international expert on air pollution, said there were invisible pollutants that people did not realise could be harmful. Both patients and healthcare professionals needed to understand what the impact of air pollution could be on patients with respiratory disease. He advised healthcare professionals to start a conversation with their patients and find out if air pollution was making their condition worse, then they could help them to identify opportunities to minimise their exposure.

THE VALUE OF EXERCISE

Dr William Bird, a GP with a special interest in the promotion of physical activity, said that exercise could help prevent and improve symptoms of at least 23 long term conditions, including respiratory disease. COPD patients who walked regularly were 50% less likely to be admitted to hospital, however healthcare professionals should be aware that most patients with respiratory conditions feared the breathlessness associated with exercise.

Practices could become ‘fully active’ by:

• Discussing exercise at every consultation and giving brief advice on the benefits of exercise routinely to patients.
• Training all staff on the health benefits of physical activity and encouraging staff to set an example by being active themselves.
• Ensuring patients are signposted to external activities.
• Organising a health walk every week from the practice, led by staff.
• Putting up posters and leaflets promoting the benefits of exercise in the waiting room.

THERAPEUTIC OPTIONS TO REDUCE TOBACCO DEPENDENCY

Darush Attar, Respiratory Lead Pharmacist Barnet CCG and a public health trainer, said healthcare professionals needed to encourage patients to use the many different forms of smoking cessation therapy available to overcome tobacco dependency. He urged healthcare professionals should use all the tools available including a carbon monoxide monitor to support smoking cessation. The most effective option was pharmacotherapy combined with behavioural support.

LIVING AND DYING WITH PROGRESSIVE LUNG DISEASE

Dr Elin Roddy, consultant physician and Lead Clinician for End of Life Care at the Royal Shrewsbury Hospital, said advanced care planning could be difficult in respiratory disease but everyone, including primary care clinicians, could get better at it.

She said patients with respiratory conditions were much more likely to die in hospital than at home or in a hospice, and were much less likely than patients with cancer to access palliative care. Collaboration between primary, secondary and tertiary care and across professional hierarchies was critical, and care and support should be driven by patients’ self-identified support needs.

‘Patients with lung disease may have faced disadvantage and discrimination throughout their lives – they shouldn’t face it at the end too,’ she said.

• Don’t miss Professor Keri Thomas and colleagues’ article, End of Life care: doing it better Practice Nurse November 2016;46(11):36-42

INTERACTIVE WORKSHOPS

A series of interactive workshops, run in conjunction with Education for Health providing updates in practical skills

Templates in respiratory care – for or against?

Delegates debated the use of templates in the consultation. The arguments in favour included that templates could be used to guide the consultation, help novices with their educational needs and for collecting data for audit purposes. Arguments against were that they could lead to a tick-box-mentality, and could impact on the patient’s experience.

The group concluded that templates are useful, they’re here to stay, and speed up data entry, but that it is nurses’ all-round consultation skills that are important – templates should only be used as an aid to consultation and not become its focus.

Chest examination

This workshop covered the principles of how to examine the chest. Nurse practitioner Beverley Bostock-Cox stressed the importance of thorough history taking prior to the examination in order to form a provisional diagnosis. The chest examination findings could then help to support or refute this provisional diagnosis.

Key Learning Points:

• A structured approach to chest examinations is crucial – A useful acronym to use is HIPPO: History, Inspection, Palpation, Percussion and (O)auscultation.
• Findings must be recorded - both positive and negative.
• As with any new skill, practice is vital to become accomplished. Attendees were encouraged to work with a mentor in practice.

Simplifying spirometry interpretation

‘Spirometry does not make a diagnosis and must be interpreted in the light of the clinical history’ was the main take home message from the workshop on interpretation of spirometry results.

Participants were also reminded that a systematic approach to interpretation was essential, to ensure nothing was omitted, and that reproducibility and technical acceptability of the trace must be assured before moving on to full interpretation of the results.

Helping patients live with breathlessness

A workshop addressing issues of breathless culminated in top tips to help patients deal with this disabling symptom

• Positions of ease (such as forward lean sitting) can help to reduce breathlessness
• Breathing control exercises help people feel more in control of symptoms.
• Using a hand-held fan or opening a window or door to create air movement across the face helps to reduce symptoms
• A 'square breathing'* approach regulates breathing and acts as distraction
• Simple techniques can be used to clear sputum from the chest.

*Breathe in for a count of 4, hold for a count of 4, breathe out for a count of 4, exhale for a count of 4

RESEARCH

In the research stream prizes were awarded for the best Research and Best Practice abstracts

The winning research abstract

Maintain standard ‘blue’ colour for bronchodilator inhalers

Maintaining the convention for blue cases for bronchodilator inhalers is essential to avoid patient confusion, ease communication with healthcare professionals, and in an emergency could prove life saving.

This was the conclusion of the UK Inhaler Group (UKIG), a coalition of not-for-profit organisations and professional societies with a common interest in promoting the correct use of inhaled therapies, following its survey of patients and HCPs.

Short acting beta 2 agonist inhalers used for rapid relief in an asthma attack have traditionally been coloured blue. However, with a rapidly changing market for inhaled therapy for COPD and asthma and a growing number of devices becoming available there has been concern that this is resulting in the erosion of traditional colour conventions. This could cause confusion among patients about the role of different therapies, and UKIG is concerned this could mean patients reach for the wrong inhaler during an emergency.

So the research team, led by Monica Fletcher, Chief Executive of Education for Health, conducted an online survey of 3,000 patients and healthcare professionals to assess the importance of inhaler colour and to determine whether there was a requirement to formalise colour schemes.

The survey found:

• Only 11.3% of patients never referred to the colour when referring to their inhaler
• Nearly all (95%) of healthcare professionals felt colour conventions were important when referring to reliever medication
• Healthcare professionals often referred to inhalers by colour when talking to patients

Following this survey, the UK Inhaler Group (UKIG), has launched a campaign calling for an official industry-wide colour-code system to be introduced for inhaled reliever medication. This would mean that in the future it would not be possible for a blue inhaler to obtain a licence unless it is a reliever and inhalers not used for rapid symptom relief will not be licensed if they are blue.

The full paper has been published in the journal npj Primary Care Respiratory Medicine: http://www.nature.com/articles/npjpcrm201681

The winning Best Practice abstract

Integrated case finding project improves diagnosis of the breathless patient

This project brought the expertise of secondary care specialists into primary care to improve the skills of primary care healthcare professionals in diagnosing patients with symptoms of breathlessness.

The rationale for the initiative was that many patients with breathlessness lack a correct diagnosis yet the condition results in more than one in four acute hospital admissions.

The multidisciplinary team, led by Jayne Longstaff, a Respiratory Quality Improvement Nurse, employed by Portsmouth Hospital Trust, used the GRASP suite of case finding tools to identify patients with breathlessness symptoms in primary care who lacked a diagnosis.¹ These patients were then invited to attend ‘carousel’ clinics run by the teams working in partnership with the practice. Patients were given same day accurate diagnoses and education about their condition.

Of 42 patients reviewed:

• 97.2% were given a confirmed respiratory diagnosis
• There was an 89% reduction in exacerbations
• There was a 100% reduction in hospital admissions, out of hours and emergency department visits
• Patients gained greater confidence in managing their symptoms
• All the patients said they would recommend the clinics

The lessons learned:

• Case finding by symptoms rather than condition yields a high rate of diagnosis and health benefits for patients.

The initiative saved money – the cost per patient of running a specialist clinic in primary care was £142 compared with £242 for a respiratory multi-professional outpatient appointment.

• The skills of primary care healthcare professionals in accurately diagnosing patients with breathlessness symptoms were improved after working alongside the specialist multidisciplinary teams.

This work is now being incorporated into an initiative to identify patients with poorly controlled asthma and COPD and undiagnosed patients with breathlessness symptoms, and is being rolled out across South East Hampshire CCG.

REFERENCES

1. University of Nottingham. GRASP-COPD audit tool. https://www.nottingham.ac.uk/primis/tools-audits/tools-audits/grasp-suite/grasp-copd.aspx