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Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Detecting breathlessness and
structured assessment in primary care
Dr Noel Baxter, GP & Clinical lead
NHS Southwark CCG
What works for repeated locally
703,845 population
COPD – 7773
Asthma – 31,005
HF – 3,016
LTC & Smoker – 21,077
The breathlessness working group
Expertise Experts
Palliative care & breathlessness support Irene Higginson, Charles Reilly
Respiratory Physiotherapy Leyla Osman, Kevin Taylor, Lynn
McDonnell
Clinical Psychology Janet Wingrove
Patients and Carers Breathe Easy Southwark
Commissioning Leah Herridge, Ali Young , Alicia Reeves
GPs Eric Cajeat, Jonty Heaversedge, Azhar
Saleem, Noel Baxter
Cardiologist Gerry Carr-White, Jonathan Byrne
Respiratory physician Nicholas Hart, Irem Patel
Exercise on prescription service Rosie Dalton-Lucas, Agata Roszczynska
Diabetes, Metabolic Medicine, Obesity
Cardiovascular pharmacist Helen Williams
Acute trust service manager Donna Grier
How do people with breathlessness present?
Daily disabling breathlessness
10% of adults suffer long-term breathlessness. Do
they recognise and tell and do we notice and
systematically take action?
What could it be?
Estimating prevalence through coding
behaviour
All patients
ever registered
Patients aged over
40
Coded as breathless
sex
BMI
smoking
history
associated
diagnosis diagnosed
with COPD
diagnosed with
heart failure
diagnosed with
COPD and
heart failure
Coding for breathlessness
SOB: Problem
SOB: Measure or finding
Southwark – What is the prevalence ?
Adult population : 410,868 patients over
the age of 40 with an electronic record at
one of 40 GP surgeries
Characterising the breathless population
44%
35%
28%
20%
9%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Current Smoker COPD Never smoked & BMI
<28
BMI>35 Heart Failure COPD & Heart failure
COPD Register 2013 – Did we exclude other
causes in these patients?
Breathlessness activity in 2012 ?
Patients continuously
registered between
1.1.12-31.12.12
Over 40
Coded as
breathless
sex
age
BMI
smoking
history
associated
diagnosis
COPD
asthma
asthma and
obesity
asthma and
copd
copd and
heart failure
heart failure
none of
above
Breathlessness
coded as
problem header
sex
age
BMI
Smoking
history
associated
diagnosis
asthma
COPD
Not asthma,
COPD, heart
failure,
Prevalence of breathlessness activity (coding)
as a proportion of the over 40s per practice
10x variation
Prevalence of breathlessness activity (coding)
as a proportion of the over 40s per practice
Smoking highly prevalent in people coded as
breathless
Where breathlessness is recorded as a problem
current smoking is less prevalent than population
rate
Localised breathlessness assessment process
NHS Lambeth Clinical Commissioning Group
NHS Southwark Clinical Commissioning Group
Feeling'Breathless'Guide'for'Patients’'
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
NHS Lambeth Clinical Commissioning Group
NHS Southwark Clinical Commissioning Group
(
STEP(4(((( ((Tier(2(Investigations(for(presentation(of(chronic(breathlessness
Only(order(tests(if(you(would(act(upon(the(results.
Common(Causes(of(
Breathlessness(
Further(Examinations/Tests(
Possible(Diagnoses/Reasons(
for(Breathlessness(
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
· ·
·
·
·
(
STEP(5(( Consider(Contributing(Factors(to(Breathlessness(
(
·
·
· Order(each(of(the(possible(contributory(factors(for(the(chronic(breathlessness
·
·
(
(
Signposting to services already commissioned
Prioritising psychological/dietary/activity interventions
Implementing primary care improvement with peer
review and support
Respiratory referral for Lambeth and Southwark
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
V2 May 2014
This is a referral form for specialist respiratory services provided by King’s Health Partners (KHP) and the Integrated
Respiratory Team (IRT). The aim of the referral assessment process is to direct patients to the most appropriate
specialist in the most suitable venue. After reviewing the referral criteria please forward this form using the single point
of referral email. We will contact you to discuss the referral further or to advise you of the onward pathway within 48
hours Monday to Friday. The service does not handle 2WW, URGENT or TB referrals.
Service Description of Service Select
required
services
Smoking
cessation for
sick smokers
This is a specialist stop smoking service for people with any long term condition.
The service will provide intensive clinic and home based support in combination
with appropriate pharmacotherapy. Please consider patients for this service if
they have difficult to treat tobacco addiction and high risk of relapse.
Spirometry &
Lung Function
This service can provide diagnostic standard spirometry if practice case finding
and microspirometry suggests asthma and COPD. Practices with a neighbourhood
spirometry service in place should not use this service unless more detailed lung
function has been recommended by a respiratory specialist.
Pulmonary
Rehabilitation
Any patient with COPD and MRC3 breathlessness or more should be offered
referral to pulmonary rehabilitation. The service will also accept people with MRC
2 scores and accepts breathless people with any respiratory disease as long as any
cardiac disease is stable.
HOSAR –
Home oxygen
assessment
and review
Any patient requiring long term oxygen therapy needs to be seen by a specialist in
oxygen therapy. This service will see any new patient who you feel may benefit
from oxygen and would also like to see patients currently on oxygen who haven’t
had a review in the last year. When referring it is useful to provide at least one
pulsoximetry reading.
Respiratory
Specialist
opinion
This option includes chest clinic and/or Integrated Respiratory Team assessment
(GSTT and KCH only). The referral pathway will forward your patient to the most
appropriate respiratory specialist and venue. In housebound patients causing
diagnostic concern or with advance care planning needs we can offer a joint
home visit with a clinician from your practice. If you would like advice before
referral please also use this service.
Please check below to see where services are available and select any preference. For oxygen reviews or assessment
we can liaise with neighbouring borough teams.
Kings College Hospital – Lung function, HOSAR, Pulmonary rehab, COPD, pleural disease, cough, asthma, general chest
clinics
Guy’s Hospital – COPD, asthma, interstitial lung disease, Sarcoid, general chest, HOSAR
St Thomas’ Hospital – Pleural disease, general chest, Pulmonary rehabilitation, Ambulatory HOSAR
St Georges Hospital / Wandsworth community team - HOSAR
Mayday Hospital / Croydon community team – HOSAR
Dulwich Leisure Centre (Crystal Palace Road SE22 9HB) - Pulmonary rehabilitation
Brixton Recreation Centre (Brixton Station Road SW9 8QQ) - Pulmonary rehabilitation
Lambeth Walk (Chandler Community Hall, Lambeth Walk SE11 6DU) - Pulmonary rehabilitation
Date of referral: 01-Jul-2014 Referrer Name: BAXTER, Noel (Dr)
Surgery: Surrey Docks Health Centre, Downtown Road, London, Greater London, SE16 6NP
Tel: 020 30497444 E-mail:
Southwark*Respiratory*single*point*of*referral*activity*October9March*201391
!
*
Conditions*referred**
!
99!
57!
21!
15!
12!
8!
5!
4! 3!3!
2!
2!
1!1!
1!
1!
COPD!
Breathlessness!
Cough!
Asthma!
Pulmonary!Fibrosis!
Unknown!
Bronchiectasis!
Cough!&SOB!
COPD!&!Heart!Failure!
Recurrent!chest!infections!
Pleural!Effusion!
Sarcoid!
Cluster!Headache!
Palliative!
Pulmonary!Hypertension!
ABCs for breathless people!
!
This%guide%was%developed%with%our%clinical%partners%at%Guy’s%and%St%Thomas’s%NHS%Foundation%Trust%and%King’s%
College%Hospital%NHS%Foundation%Trust.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Page 1 of 3%
NHS Lambeth Clinical Commissioning Group
NHS Southwark Clinical Commissioning Group
Taking'Charge'of'Your'Breathlessness'
Patient Information –what you can do to help with breathlessness
!We!have!developed!this!guide!to!support!people!experiencing!breathlessness.!This!advice!may!not!be!suitable!for!
everyone.!!If!you!need!further!advice,!please!contact!your!GP!or!health!professional.!
!
The of breathlessness:
ACTIVITY – it is important to remember to stay as active as you can.
Avoiding activities that make you breathless weakens your muscles and can actually
lead to an increase in the feeling of breathlessness over time. Instead of avoiding
activities, try using planning and pacing to help:
· Planning: Think about which activities make you feel breathless. Plan in advance
for these activities, and spread them throughout the day. Be sure to rest in between
activities if you need to. If there is an activity that makes you feel especially
breathless, for example hoovering or changing the bed covers, take it slowly, and
ask for help if you need it.
· Pacing: Pace yourself and take breaks if you start feeling breathless. You can use
the ‘50% rule’ to help. For example, if climbing a flight of stairs leaves you feeling
very breathless, try climbing 50% of the way up and taking a break to catch your
breath before continuing up the rest of the stairs. This will help you to manage the
stairs without feeling like you are gasping for breath.
BREATHING – You can learn to control your breathing when you feel breathless using
a technique that singers use called diaphragm breathing (also known as tummy breathing).
Before you start
• Relax your shoulders and arms as this saves energy.
• Place both hands on your tummy, just above your belly button
• Let your elbows rest in by your sides.
Spend as long as you need on each of the following points:
• Feel the rise and fall of your tummy and hands
· As you breathe in, allow your tummy to swell.
!
!
This%guide%was%developed%with%our%clinical%partners%at%Guy’s%and%St%Thomas’s%NHS%Foundation%Trust%and%King’s%
College%Hospital%NHS%Foundation%Trust.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Page 3 of 3%
Relaxation'Poem''
For'use'when'feeling'breathless'
!
!
!
Be!Still...!Be!calm....!
Drop!the!shoulders!
Slowly!sigh!Out...and...Out!
Hear!the!sigh!Haaah....!!!
...soft!and!quiet!
Feel!control!returning!
Peaceful!and!safe!
!
!
%
%
With%thanks%to%Jenny%Taylor,%%
Physiotherapist,%St.%Christopher’s%Hospice%%
EQUIP = Effecting Quality in
Practice

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Detecting breathlessness and structured assessment in primary care

  • 1. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Detecting breathlessness and structured assessment in primary care Dr Noel Baxter, GP & Clinical lead NHS Southwark CCG
  • 2. What works for repeated locally 703,845 population COPD – 7773 Asthma – 31,005 HF – 3,016 LTC & Smoker – 21,077
  • 3. The breathlessness working group Expertise Experts Palliative care & breathlessness support Irene Higginson, Charles Reilly Respiratory Physiotherapy Leyla Osman, Kevin Taylor, Lynn McDonnell Clinical Psychology Janet Wingrove Patients and Carers Breathe Easy Southwark Commissioning Leah Herridge, Ali Young , Alicia Reeves GPs Eric Cajeat, Jonty Heaversedge, Azhar Saleem, Noel Baxter Cardiologist Gerry Carr-White, Jonathan Byrne Respiratory physician Nicholas Hart, Irem Patel Exercise on prescription service Rosie Dalton-Lucas, Agata Roszczynska Diabetes, Metabolic Medicine, Obesity Cardiovascular pharmacist Helen Williams Acute trust service manager Donna Grier
  • 4. How do people with breathlessness present? Daily disabling breathlessness 10% of adults suffer long-term breathlessness. Do they recognise and tell and do we notice and systematically take action?
  • 6. Estimating prevalence through coding behaviour All patients ever registered Patients aged over 40 Coded as breathless sex BMI smoking history associated diagnosis diagnosed with COPD diagnosed with heart failure diagnosed with COPD and heart failure
  • 7. Coding for breathlessness SOB: Problem SOB: Measure or finding
  • 8. Southwark – What is the prevalence ? Adult population : 410,868 patients over the age of 40 with an electronic record at one of 40 GP surgeries
  • 9. Characterising the breathless population 44% 35% 28% 20% 9% 4% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Current Smoker COPD Never smoked & BMI <28 BMI>35 Heart Failure COPD & Heart failure
  • 10. COPD Register 2013 – Did we exclude other causes in these patients?
  • 11. Breathlessness activity in 2012 ? Patients continuously registered between 1.1.12-31.12.12 Over 40 Coded as breathless sex age BMI smoking history associated diagnosis COPD asthma asthma and obesity asthma and copd copd and heart failure heart failure none of above Breathlessness coded as problem header sex age BMI Smoking history associated diagnosis asthma COPD Not asthma, COPD, heart failure,
  • 12. Prevalence of breathlessness activity (coding) as a proportion of the over 40s per practice 10x variation
  • 13. Prevalence of breathlessness activity (coding) as a proportion of the over 40s per practice
  • 14. Smoking highly prevalent in people coded as breathless
  • 15. Where breathlessness is recorded as a problem current smoking is less prevalent than population rate
  • 16. Localised breathlessness assessment process NHS Lambeth Clinical Commissioning Group NHS Southwark Clinical Commissioning Group Feeling'Breathless'Guide'for'Patients’' · · · · · · · · · · · · · · · · · · NHS Lambeth Clinical Commissioning Group NHS Southwark Clinical Commissioning Group ( STEP(4(((( ((Tier(2(Investigations(for(presentation(of(chronic(breathlessness Only(order(tests(if(you(would(act(upon(the(results. Common(Causes(of( Breathlessness( Further(Examinations/Tests( Possible(Diagnoses/Reasons( for(Breathlessness( · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ( STEP(5(( Consider(Contributing(Factors(to(Breathlessness( ( · · · Order(each(of(the(possible(contributory(factors(for(the(chronic(breathlessness · · ( (
  • 17. Signposting to services already commissioned
  • 19. Implementing primary care improvement with peer review and support Respiratory referral for Lambeth and Southwark Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group V2 May 2014 This is a referral form for specialist respiratory services provided by King’s Health Partners (KHP) and the Integrated Respiratory Team (IRT). The aim of the referral assessment process is to direct patients to the most appropriate specialist in the most suitable venue. After reviewing the referral criteria please forward this form using the single point of referral email. We will contact you to discuss the referral further or to advise you of the onward pathway within 48 hours Monday to Friday. The service does not handle 2WW, URGENT or TB referrals. Service Description of Service Select required services Smoking cessation for sick smokers This is a specialist stop smoking service for people with any long term condition. The service will provide intensive clinic and home based support in combination with appropriate pharmacotherapy. Please consider patients for this service if they have difficult to treat tobacco addiction and high risk of relapse. Spirometry & Lung Function This service can provide diagnostic standard spirometry if practice case finding and microspirometry suggests asthma and COPD. Practices with a neighbourhood spirometry service in place should not use this service unless more detailed lung function has been recommended by a respiratory specialist. Pulmonary Rehabilitation Any patient with COPD and MRC3 breathlessness or more should be offered referral to pulmonary rehabilitation. The service will also accept people with MRC 2 scores and accepts breathless people with any respiratory disease as long as any cardiac disease is stable. HOSAR – Home oxygen assessment and review Any patient requiring long term oxygen therapy needs to be seen by a specialist in oxygen therapy. This service will see any new patient who you feel may benefit from oxygen and would also like to see patients currently on oxygen who haven’t had a review in the last year. When referring it is useful to provide at least one pulsoximetry reading. Respiratory Specialist opinion This option includes chest clinic and/or Integrated Respiratory Team assessment (GSTT and KCH only). The referral pathway will forward your patient to the most appropriate respiratory specialist and venue. In housebound patients causing diagnostic concern or with advance care planning needs we can offer a joint home visit with a clinician from your practice. If you would like advice before referral please also use this service. Please check below to see where services are available and select any preference. For oxygen reviews or assessment we can liaise with neighbouring borough teams. Kings College Hospital – Lung function, HOSAR, Pulmonary rehab, COPD, pleural disease, cough, asthma, general chest clinics Guy’s Hospital – COPD, asthma, interstitial lung disease, Sarcoid, general chest, HOSAR St Thomas’ Hospital – Pleural disease, general chest, Pulmonary rehabilitation, Ambulatory HOSAR St Georges Hospital / Wandsworth community team - HOSAR Mayday Hospital / Croydon community team – HOSAR Dulwich Leisure Centre (Crystal Palace Road SE22 9HB) - Pulmonary rehabilitation Brixton Recreation Centre (Brixton Station Road SW9 8QQ) - Pulmonary rehabilitation Lambeth Walk (Chandler Community Hall, Lambeth Walk SE11 6DU) - Pulmonary rehabilitation Date of referral: 01-Jul-2014 Referrer Name: BAXTER, Noel (Dr) Surgery: Surrey Docks Health Centre, Downtown Road, London, Greater London, SE16 6NP Tel: 020 30497444 E-mail: Southwark*Respiratory*single*point*of*referral*activity*October9March*201391 ! * Conditions*referred** ! 99! 57! 21! 15! 12! 8! 5! 4! 3!3! 2! 2! 1!1! 1! 1! COPD! Breathlessness! Cough! Asthma! Pulmonary!Fibrosis! Unknown! Bronchiectasis! Cough!&SOB! COPD!&!Heart!Failure! Recurrent!chest!infections! Pleural!Effusion! Sarcoid! Cluster!Headache! Palliative! Pulmonary!Hypertension!
  • 20. ABCs for breathless people! ! This%guide%was%developed%with%our%clinical%partners%at%Guy’s%and%St%Thomas’s%NHS%Foundation%Trust%and%King’s% College%Hospital%NHS%Foundation%Trust.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Page 1 of 3% NHS Lambeth Clinical Commissioning Group NHS Southwark Clinical Commissioning Group Taking'Charge'of'Your'Breathlessness' Patient Information –what you can do to help with breathlessness !We!have!developed!this!guide!to!support!people!experiencing!breathlessness.!This!advice!may!not!be!suitable!for! everyone.!!If!you!need!further!advice,!please!contact!your!GP!or!health!professional.! ! The of breathlessness: ACTIVITY – it is important to remember to stay as active as you can. Avoiding activities that make you breathless weakens your muscles and can actually lead to an increase in the feeling of breathlessness over time. Instead of avoiding activities, try using planning and pacing to help: · Planning: Think about which activities make you feel breathless. Plan in advance for these activities, and spread them throughout the day. Be sure to rest in between activities if you need to. If there is an activity that makes you feel especially breathless, for example hoovering or changing the bed covers, take it slowly, and ask for help if you need it. · Pacing: Pace yourself and take breaks if you start feeling breathless. You can use the ‘50% rule’ to help. For example, if climbing a flight of stairs leaves you feeling very breathless, try climbing 50% of the way up and taking a break to catch your breath before continuing up the rest of the stairs. This will help you to manage the stairs without feeling like you are gasping for breath. BREATHING – You can learn to control your breathing when you feel breathless using a technique that singers use called diaphragm breathing (also known as tummy breathing). Before you start • Relax your shoulders and arms as this saves energy. • Place both hands on your tummy, just above your belly button • Let your elbows rest in by your sides. Spend as long as you need on each of the following points: • Feel the rise and fall of your tummy and hands · As you breathe in, allow your tummy to swell. ! ! This%guide%was%developed%with%our%clinical%partners%at%Guy’s%and%St%Thomas’s%NHS%Foundation%Trust%and%King’s% College%Hospital%NHS%Foundation%Trust.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Page 3 of 3% Relaxation'Poem'' For'use'when'feeling'breathless' ! ! ! Be!Still...!Be!calm....! Drop!the!shoulders! Slowly!sigh!Out...and...Out! Hear!the!sigh!Haaah....!!! ...soft!and!quiet! Feel!control!returning! Peaceful!and!safe! ! ! % % With%thanks%to%Jenny%Taylor,%% Physiotherapist,%St.%Christopher’s%Hospice%%
  • 21. EQUIP = Effecting Quality in Practice