I have been the Lead Nurse for a growing team of nurse specialists since 1997 and in 2005 I developed my role further to become Respiratory Nurse Consultant, completing my MSc in respiratory care in 2008. I embarked on a part-time PhD in September 2014 with the University of Edinburgh, which I completed in spring 2021. My research interests are telemedicine and teleconsultation in sleep medicine service delivery.
NHS Dumfries and Galloway is a remote and rural health board in south-west Scotland and our Integrated Respiratory Team (IRT) provides a region-wide service covering 2500 square miles, a population of 149 500 with 45% of the population living remotely from the largest settlement of Dumfries. The Respiratory Managed Clinical Network developed a ‘spend to save initiative’ that was approved by the Integrated Joint Board in April 2018 with funding to expand the existing respiratory nurse specialist and pulmonary rehabilitation teams. We wanted to provide more same-day early supported discharges (ESDs), reduce lengths of stay, develop admission avoidance (AA) and provide better access to pulmonary rehabilitation (PR) across the region.
Geography is particularly challenging when delivering ESD and AA in the more remote parts of the region. The PR service had long waiting times to attend the six regional sites' programmes, with no service provision in the west of the region owing to low physiotherapist staffing levels. The service was also was heavily supported by the community respiratory nurses, to the exclusion of other work.
Aims and objectives
Within the first 18 months of the implementation of the project plan, we aimed to provide same-day ESD with up to a 7-day follow up in the community for people with chronic obstructive pulmonary disease (COPD) and other respiratory conditions. We also aimed to develop an AA service for GP referrals and patient self-referrals, by introducing novel technology.
Method
I was released from some of my clinical role in 2018 to project manage the further development of the IRT and the respiratory action plan, which initially included 19 workstreams (Table 1).
We recruited two additional respiratory nurse specialists (RNSs), two respiratory physiotherapists and two respiratory healthcare support workers to expand the existing team to 10 members of staff across our IRT, working across both primary and secondary care. Three hospital-based RNSs provided in-reach to both the combined assessment unit (CAU) and the emergency department (ED), supported by the respiratory senior medical team. We increased the IRT community-based staff by six in October 2018. The additional PR service recruitment was completed in 2019 with the specialist physiotherapy team and their healthcare support workers based in Stranraer and Dumfries to provide a region-wide accessible service for those referred for PR and to increase capacity and reduce waiting times.
We also introduced Morse, a secure app that allows the user to upload electronic healthcare records to an iPad and there are specific electronic forms that are used to record the IRT's activity and clinical assessments when they conduct home visits, virtual visits or telephone reviews. The Morse app then allows the user to synchronise their electronic records directly back to the electronic healthcare record in the clinical portal using secure wi-fi. This is immediately available to GP practices and all clinicians who may need access to these records, allowing implementation of a paperless system.
Results
We initially anticipated the IRT would only see people with COPD. However, the service has evolved and now supports people with interstitial lung disease, people with ventilatory failure who use oxygen and nocturnal non-invasive ventilation, and complex cases, where people may need high-flow humidification/oxygen therapy at home.
The team has also developed additional skills to address all of the respiratory action plan projects outlined in Table 1, such as undertaking inhaler technique training for all team members, and successful completion of the Association for Respiratory Technology and Physiology (ARTP) spirometry course by three team members. Other skills developed are arterial blood gas sampling and transcutaneous CO2 monitoring, both in primary and secondary care settings, fitting of masks and troubleshooting for the continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) service users and the provision of humidified oxygen therapy and delivery of home nebulised antibiotic therapies where appropriate.
Conclusion
The Scottish Atlas of Variation 2019 (https://tinyurl.com/jvew2rsb) demonstrated that between 2016 and 2019 NHS Dumfries and Galloway had lower admission rates for asthma and COPD and also lower 28-day readmission rates for COPD and asthma compared with national rates. This trend fits with our local experience and health informatics data. The PR service now provides rapid access for people who are referred post-discharge, and the waiting list to attend PR had been reduced significantly to less than 4 months, with a greater than 80% increased capacity delivered across multiple regional hubs. Our mean length of stay reduced consistently up to 2019; it now stands at 7 days.
Table 1. Respiratory action plan workstreams
| Project | Measurable benefit |
|---|---|
| 1. Early supported discharge | Increase in number of same-day discharges from CAU/ED. Increase in number of patients discharged within 5 days |
| 2. Improve communication with CAU | Increase in number of same day discharges from CAU/ED. Increase in number of patients discharged within 5 days |
| 3. Referral to the IRT from primary and secondary care for IRT review | Increase in the number of respiratory patients discharged home with support from the IRT team. Increase in the number of appropriate referrals to the community IRT team |
| 4. Admission avoidance service | Admission avoidance rates. Attendance rates |
| 5. Home CPAP/NIV service | People who are admitted/discharged from secondary care who are using CPAP/NIV have a timely review by the IRT |
| 6. Home oxygen service | People who require home oxygen therapy will have their oxygen therapy prescribed and delivered as per guidelines. Where LTOT therapy is not being used as prescribed or there are safety issues identified oxygen therapy may be removed |
| 7. Complex respiratory case management | Increase in number of people who can be safely managed outside of the hospital setting Reduction in hospital admission and length of stay in this patient group |
| 8. Pulmonary rehabilitation | Increase in the number of patients being referred to and completing PR. Decrease in waiting time for PR |
| 9. Outpatient specialist physiotherapist review | Increase in number of people receiving specialist treatment which may result in increased care at home |
| 10. Technology enabled care provision | More efficient use of IRT time. More efficient data recording. Reduced travel time. Reduced carbon emissions/fuel consumption |
| 11. CREWS/self-management | People with COPD will be enabled to recognise early signs of exacerbation and seek earlier intervention to avoid hospital admission |
| 12. Respiratory medicine prescribing | Improve quality of guideline-based respiratory medicine prescribing. Reduction in respiratory medicine prescribing costs |
| 13. Scottish ambulance service/out-of-hours engagement with IRT | The number of patients referred to the IRT where admission to hospital is avoided |
| 14. Stakeholder engagement | Good communication between stakeholders ensures that people are aware of the IRT and what they can offer to support people living safely with respiratory conditions to be managed at home or in a homely environment |
| 15. Patient satisfaction with IRT service | Implementation of service improvement measures where needed |
| 16. Anticipatory care planning (ACP) | Increase in the number of people living with severe lung disease who are given the opportunity to discuss their ACP |
| 17. Reduced length of stay in respiratory ward | Length of stay reduction. 7 day and 28-day re-admission rate. Patient satisfaction |
| 18. BTS/COPD/asthma and PR audit | Ongoing service improvement |
| 19. National Respiratory Health Care Action Plan | National improvement work to drive local service improvement |
Key: BTS=British Thoracic Society; CAU=combined assessment unit; COPD=chronic obstructive pulmonary disease; CPAP=continuous positive airway pressure; ED=emergency department; IRT=integrated respiratory team; LTOT=long-term oxygen therapy; NIV=non-invasive ventilation; PR=pulmonary rehabilitation
Investment in the IRT has certainly contributed to this success and we were continuing to explore new options of delivering technology-enabled care such as remote monitoring solutions in COPD and other respiratory conditions prior to the advent of COVID-19. The pandemic has accelerated the implementation of technology enabled care solutions. The respiratory action plan is a working document and has evolved to include innovative and safer ways of working with the advent of the SARS-CoV-2 pandemic that include wider use of teleconsultation with NHS Near Me, or telephone reviews where people do not have suitable technology, and also to protect both our patients and the IRT from the risk of contracting COVID-19.