Setting up a spirometry hub

Spirometry is recognised by many as an essential part of the diagnostic process in respiratory disease.¹ During the pandemic all testing was ceased in the belief it was an aerosol-generating procedure (AGP). The waiting lists for diagnostic spirometry following this led to delayed and missed diagnoses of many respiratory conditions.¹

The cessation of services also raised awareness of the funding for, and commissioning of, the spirometry services in general practice, with many practices realising that they were not being funded via any contract.

This was an opportunity for many forward-thinking services to provide patient care in a different way. Northwest Surrey integrated care service (NICS) is a primary care federation serving 370,000 patients across North West Surrey. NICS already delivers an extended access service to provide additional GP appointments on weekdays and over the weekend to improve access to health care.They also have an ambition to ‘provide new and innovative services that will benefit patients and practices’.²

By providing additional payments (over and above the extended access payments that practices were currently paid), funding was made available for a service to be established to supply a spirometry service for 37 practices. The main hub of this service was the local Urgent Treatment Centre (UTC) at a centrally sited hospital, which was the base for a GP-led service open from 8am – midnight every day. The UTC treats minor injuries and illnesses that need immediate treatment and was able to provide the clinical areas needed to undertake spirometry, particularly after the COVID-19 pandemic, when further infection control processes were needed. This centre was the base for the administrative team for NICS.

The Federation covers three localities, Woking, Thames Medical and SASSE (Stanwell, Ashford, Staines, Shepperton, Egham). The Extended Access Service hubs are based at Woking Community Hospital, St Peters and Ashford Hospital, and satellite GP practices ensuring that all patients in North West Surrey have equal access to services within their own locality.

THE TEAM

Although there was agreement for the service provision there were no local clinicians with free time to assist with clinics. A medical agency was therefore employed, and staff requested with a training certificate e.g. Rotherham Respiratory performing and interpreting course or ARTP equivalent. It was apparent – as with many such services – staff with the required training were not available. However, two clinicians, a registered nurse and a paramedic, were interested in diversifying their careers and supporting a new service. They undertook and successfully completed an online training course (Simply Spirometry: Performing and Interpreting – Rotherham Respiratory LTD). During this training period contact was made with the author, who is the nurse tutor for that course, and as an independent consultant she agreed to mentor and support the team in both their training and later in the overall interpretation.

The service initially started with one clinic in the Spelthorne locality on a Saturday morning in December 2021. The advice and guidance for infection prevention (COVID-specific) at this time in relation to restarting spirometry was still generic and therefore interpretation of this guidance was well ventilated room, screens and fallow time with all patients screened pre-testing for COVID-specific symptoms. As in many respiratory clinics this was a time-consuming process given cough is a common respiratory presentation.³ It is interesting to note retrospectively that no clinician since the service has been performing spirometry (over two years) has ever contracted COVID or tested positive from a work contact.

A second clinic was later added in January 2022 on Tuesdays and Fridays, run by the paramedic, with a third clinic on a Monday afternoon supported by a local respiratory nurse. Further clinics have been added as practices recognised the value of the service. There are now 28 practices which commission 11 clinics, 6 days per week.

The overall leadership for the service was provided by Claire Laing, who with support from the nurse consultancy, was able to adapt the service as it progressed, with expert vision and insight into the needs of the population and unwavering support for the team. Administrative support was led by Denise Wiggens, who created a video clip to be sent to patients to enable them to find difficult venues and advises on parking and any issues with attendance.

The main role of screening applications for contraindications has fallen to the administrative team with the support of the clinical team via a WhatsApp group. Significant responsibility was being deferred to this team and the appropriateness of this is to be reviewed, as the ultimate responsibility for patient safety is the referrer and then ultimately the person undertaking the test. This ongoing education of the person referring, and the practice responsibility is a theme of ongoing education which has been provided by sponsored lunch time events and regular review and training meetings.

TRAINING, PROTOCOLS AND ARTP ACCREDITATION

The initial training was an online course (two months to complete) which was designed by Rotherham Respiratory with a pragmatic approach and no academic requirement.⁴ The final assessment is to report/interpret a trace to ensure that training had been transferred into practice. In agreement with the service lead and medical director a consultant nurse was employed to mentor the team (which had now increased to five staff) and a period of mentorship was instigated with every clinic and health care professional visited and ‘signed off’ after observing their practice within a clinic setting with patient tests undertaken. One staff member (who had not started seeing patients) agreed they did not have required competency and left with another leaving as they could not commit to the clinic’s timings. The initial team therefore consisted of a nurse, paramedic, and retired midwife. Over time support health care staff were added as health care support workers (having previously worked in COVID vaccination clinics) and another nurse joined the service on a sessional basis.

Protocols had been created and were amended as the service progressed. Pre and post bronchodilator testing was a requirement of the practices who has commissioned the service and although a financial quality and outcomes framework (QOF) requirement – not a clinical need – this required the service to have a patient group directive (PGD) for the administration of salbutamol. The service also had to purchase salbutamol inhalers with single use disposable spacers for individual patient use. Evidence for repeat use of salbutamol inhalers in this clinic settings is not available therefore a pragmatic approach of 20 patient use was incorporated as at no time was the inhaler touched by the patient and the spacer disposable. It was interesting to note the number of patients who stated they did not know spacers were available for metered dose inhalers (MDI) and requested them to use with their inhalers. An advisory note was sent to the surgery as part of the discharge summary to support improved inhaler technique.

The service specification required the team to be ARTP accredited. This was delayed until after a period of consolidation as the assessment process is very intensive and the team needed time to embed their skills into the service before they were able to translate this into the needs of the ARTP assessment process.

The nurse consultant undertook remote interpretation of the spirometry within the patients EMIS record and was therefore able to quality assure all spirometry traces that had been undertaken before clinical interpretation was completed. All staff undertaking the test completed a template which revisited contraindications, recorded smoking pack years (https://www.smokingpackyears.com/) and undertook a brief respiratory history (why the patient was presenting). They also record how the test was performed e.g. the patient coughed throughout the test with a clear wheeze heard pre bronchodilator improving after administration of the salbutamol; post bronchodilator cough resolved and wheeze less apparent. This overview enabled the interpreter to report the test in the context of how it was performed in relation to the clinical history within the patient’s notes. The ability to review tests (eosinophils, FeNO) investigations (CXR and CT scans) also supported the ongoing advice to the practice. All of this was recorded within the patient records.

The equipment

All the clinics taking part in the service either had or were provided with a spirometer. All clinics had the Spiro Connect connected to the EMIS system, enabling the tests to be opened within the patient record, and reported remotely. The uniformity of the equipment was useful in ongoing support and updates, especially between clinics when common errors could be addressed. The team has a WhatsApp group to enable group discussion at any time, so staff members do not feel isolated. This provides clinical support within clinics e.g., patients presenting with symptoms not previously disclosed on the contraindication checklist or equipment support (important to note that patient details are never disclosed) i.e., the machine won’t switch on or more mouthpieces are needed at such-and-such a clinic. Any specific patient discussion is via NHS email if needed. The team routinely works within established clinics and therefore becomes familiar with equipment, staff, and the support within that environment.

Numbers and outcomes

By August 2023, 2163 spirometry patients had been seen, and FeNO testing for 1,280 patients has been undertaken. All tests were undertaken and reported for technical acceptability as well as guidance on next steps. No diagnosis is made, as this is the individual practice/referrer’s responsibility as they know the patient and the reason for referral. Advice and suggestions as to next steps and provided with the discharge summary. There may be an understandable time delay from referral to test, and further signs, symptoms or investigations may have been undertaken in the intervening period.

The template used for reporting was designed to be systematic and promote learning within the practice (as the report is available in the patient records for all health care professionals to see). The examples below show significant reversibility and demonstrate the advice and guidance the team provides. The actual clinical interpretation is left to the practice/referrer as are the next steps in management. Advice is sometimes given to retest after a trial of treatment. It should be noted that it is not the service responsibility to make a diagnosis, but only to report the findings and suggest next steps.

In some cases, the traces are not technically acceptable and as such should not be reported. In some instances, they will be reported ‘with caution’ where it is apparent that the patient will be unlikely to ever perform an adequate test. However, in most situations the advice is to repeat the test.

CASE 1

• 40-year-old female, never smoker. Referred with suspected asthma. History of atopy and family history of asthma. No inhalers currently. Positive FeNO result of 102ppb.
• Pre- and post-bronchodilator (BD) spirometry performed, meeting ARTP criteria with good reproducibility and repeatability. Patient made good effort, no cough or wheezing reported. Patient reported her breathing felt much better post-BD.
• Pre-BD, FVC higher than VC, indicating poor technique. FEV1/FVC ratio of 78%, above LLN of 73%. No obstruction.
• Post-BD (diagnostic), FVC remains higher than VC. FEV1/FVC ratio of 77%, above LLN of 75%. No obstruction.
• Positive reversibility of 370ml (14%) shown.
• With patient’s history of atopy, strong family history of asthma and positive FeNO result of 102ppb, results support a diagnosis of asthma for this patient. Suggest trial of ICS treatment, with education around importance of concordance, and review of symptoms 6/52.

CASE 2

• 57-year-old female non-smoker. Referred with suspected asthma. Ongoing cough, wheeze and breathlessness, now impacting on quality of life. Family history of asthma. Salamol inhaler prescribed but no ICS.
• Pre- and post-bronchodilator spirometry performed, meeting ARTP criteria with good reproducibility and fair repeatability. Chesty cough and loud wheeze heard throughout testing.
• Pre-BD, FVC and VC similar. FEV1/FVC ratio of 59%, below LLN of 68%. With FEV1 of 54% - moderate obstruction present. VC, FVC and FEV1 all below LLN – possible restriction or poor technique.
• Post-BD, FVC and VC remain similar. FEV1/FVC ratio of 74%, above LLN of 68%. No obstruction and restriction no longer present with patient commenting on significant improvement noted.
• Positive reversibility of 560ml (42%) shown. Given strong FH asthma suggest FeNO and trial of ICS or combination inhaler with peak flow diary to monitor impact and inform diagnosis. Repeat spirometry in 4-6 weeks may further support diagnosis.

CASE 3

• Spirometry screening of an 84-year-old male with 30 smoking pack years. Referred with existing diagnosis of COPD. Patient unaware of diagnosis. Macrocytic anaemia. Longstanding history of atopy. Family history of asthma. No inhalers.
• Pre- and post-bronchodilator spirometry performed, meeting ARTP criteria with good reproducibility and fair repeatability. Patient made good effort; mild wheeze heard throughout.
• Pre-BD, FVC higher than VC. FEV1/FVC ratio of 67%, above LLN of 59%. No obstruction.
• Post-BD, FVC remains higher than VC. FEV1/FVC ratio of 71%, above LLN of 59%. No obstruction.
• Positive reversibility of 250ml (13%) shown.
• With no obstruction, COPD is excluded.
• Positive reversibility and history of atopy may support diagnosis of asthma for this patient in view of presentation.
• Consider referral for FeNO with trial of ICS treatment and review.

FRACTION OF EXHALED NITRIC OXIDE (FeNO) PROVISION

In June 2022 further transformation money enabled the service to start delivery of FeNO testing. An advert to support the service resulted in 30 applications from health care assistants, who were required to complete the national care certificate6 before they could be employed. Five were employed and trained. Some are dual trained and undertake spirometry and FeNO (FeNO tested first) while others only perform FeNO. The availability of FeNO testing has further added to the diagnostic capability of the service.

NEXT STEPS

With national funding being made available for the establishment of diagnostic hubs and community diagnostic centres (CDC),⁷ the service should be seen as an exemplar of this type of provision. What is fundamental is the service availability to patients (several venues and days) and the feedback that is received. Patient feedback is exceptional and is collated to support the ongoing commissioning of the service.

Recent funding has enabled the service to include children and young people. This has required further training for the team and support in reporting and interpretation will be sought from paediatric trained staff until confidence has improved and competence assessed by the ARTP. Three members of the team have successfully completed the ARTP assessment and are on the register.⁸

Practices are encouraged to provide feedback on the service and initially there were requests for the reports to be shorter and more concise but the service felt that it was important to maintain the level of reporting to support ongoing education/training of the clinical staff.

A lunchtime training session around interpretation and next steps was attended by nurses and GPs, but as is the case in many of these events, those who attended were already well informed. A further date is planned this year to support the new practices that have commissioned the service for the first time in 2024.

As with any commissioned service there are changing numbers with 38 practices commissioned in 21/22 and 28 practices in 22/23. In October 2022, one Primary Care Network (PCN) decided to provide the service themselves but recommissioned the service in April 2023. However, two further PCNs and two practices decided to provide their own services and train their own staff from April 2023. The main reason given for the change was funding, with some PCNs thinking they could provide the service more cost effectively – however, one of these PCNs has a 9 week wait for an appointment. Other limitations are that although spirometry performance is of a good standard the GPs have to do their own interpretation.

CONCLUSION

This service has shown itself to be resilient in both restarting spirometry post-COVID and maintaining a service when commissioning requirements and budgets have changed. While this is not put forward as a mandate to how a service should be created, it is an exemplar of good practice and the team should be congratulated on their innovative thinking.

REFERENCES

1. Asthma + Lung UK. Diagnosing the problem – right test right time report;2023 https://www.asthmaandlung.org.uk/diagnosing-problem-right-test-right-time

2. Northwest Surrey integrated care service (NICS). GP Improved Access https://www.nicsfed.co.uk/services/patient-services/

3. Morice AH, Kasteli JA. Chronic cough in adults. Thoraz 2003;58:901-907. https://thorax.bmj.com/content/thoraxjnl/58/10/901.full.pdf

4. Rotherham Respiratory Performing and Interpreting Spirometry Course Simply Spirometry: Performing and Interpreting (Online). https://rotherhamrespiratory.com/lungs-courses/simply-spirometry-performing-and-interpreting-online/

5. Smoking pack years calculator https://www.smokingpackyears.com/

6. Health Education England. Care Certificate https://www.hee.nhs.uk/our-work/care-certificate

7. Department of Health and Social Care. New diagnostic centres deliver nearly three-quarters of a million tests; 2022. https://www.gov.uk/government/news/new-diagnostic-centres-deliver-nearly-three-quarters-of-a-million-tests

8. Association for Respiratory Technology and Physiology (ARTP) register. https://www.artp.org.uk/spirometry-register

Chris Loveridge
RGN BSc (Hons)
Respiratory nurse,
Director Inspirometry
Training and Consultancy Limited
Practice Nurse 2024;54(3):12-15