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COPD: From Acute Trust to Community

COPD: From Acute Trust to Community . A Seamless Service. Where come from . Recognition that COPD and asthma a significant problem for our health economy Data: 1800 admissions in 1996 1995: COPD and asthma GL Across economy, DPH’s involved Revised 1998 after first BTS GL

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COPD: From Acute Trust to Community

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  1. COPD: From Acute Trust to Community A Seamless Service.

  2. Where come from • Recognition that COPD and asthma a significant problem for our health economy • Data: 1800 admissions in 1996 • 1995: COPD and asthma GL • Across economy, DPH’s involved • Revised 1998 after first BTS GL • 1996-8 COPD education project • 1998 – pathway working

  3. Where come from (2) • 1997: open access spirometry with report • 2000: Hosted BTS early discharge course • 2001 SED: 1200 reviewed, 300 at home • Activity across hospital, LOS 9 to 3 days • 2006-8: SAM. Economy sign off • 4 then 2 PCTs, now 2 CCGs • Different speeds of development • 2008 – community services • UHNS, commissioners, provider units • Clinics, PR, nebuliser……

  4. UHNS • SED still functions to identify patients for community service integration • SED reviews patients for oxygen prior to discharge • Education & Self Management as an inpatient. • Tier 4 oxygen clinics • T4 COPD clinics

  5. Acute ventilation service • NIV since early 1990’s • Takes place on a bespoke 12 bedded respiratory HDU • Nurse led initiation and setting change • 24/7 consultant support • Go beyond boundaries (pH of 7) • 10% mortality

  6. Communityteam • Quality assured spirometry • Supported in practices by community physiologist • UHNS outreach • PR a success with low drop outs • T3 oxygen service • Specific community nursing team • COPD focused, do SED follow ups / step-up • x6 consultant community clinics per week • x1 consultant MDT per week

  7. Pulmonary Rehab • 1200 places offered across North Staffordshire per year • 8 venues across the locality – 2 sessions per week for 8 weeks • High level of satisfaction from questionnaires • Multi-disciplinary team input and signposting to wider community services

  8. PatientJourney Patient admitted to AMU Daily review by team. Education, self management plans, rescue meds given & inhaler technique checked Medically fit for discharge Loan nebuliser issued (if needed ) Referral to Community respiratory team faxed Assessed by team Transferred to ward

  9. Patient Journey • Referral from : • Single point of Care • ‘Potteries Way’ • GP / Practice Nurse Home visit Triage by Nurse Specialist Discussion with or review by Consultant Clinic Appointment • Referral from • Acute or Community Hospitals • Step down post exacerbation • follow up Oxygen review Discharge to GP & / or Lead Health Professional with Action Plan Follow up at Acute Hospital for further investigation

  10. Contact details • Dr Martin Allen: Martin.Allen@uhns.nhs.uk Tel Number 01782 675753 (Alison Jessop Secretary). • Karen Leech: karen.leech@uhns.nhs.uk Tel Number 01782 674069 • Vicky Campbell: Victoria.Campbell@ssotp.nhs.uk Tel Number 0300 1230995 ext 4538

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