SCFT Chronic Obstructive Pulmonary Disease (COPD) Specialist Team & Dolby Vivisol Oxygen Service
Albert Sundararaj, Specialist COPD Physiotherapist, SCFT
Jo Hobbs, Clinical manager / Service Lead, Dolby Vivisol
Crawley, Horsham & Mid Sussex (Central)
Monday to Friday 08.30 – 16.30
Based in Rose Wing, Horsham Hospital
• specialist nurses – 2.8 WTE
• specialist physiotherapists - 2.0 WTE
• pulmonary rehabilitation assistant - 1.0 WTE
• administrator – 1.0 WTE
• Case load: 600 (50/50 clinical management / PR) - 86 receiving oxygen therapy
ULTIMATE AIM: to prevent unplanned hospital admissions
Referral criteria (via One Call)
Inclusion criteria - aged 18+ Be registered with a Crawley or Horsham & Mid
Sussex GP. Have a diagnosis of COPD confirmed by spirometry or a respiratory
physician.
Clinical assessment:
• POST EXACERBATION - and/or recent hospital admission due to COPD (will be
contacted and triaged within 24 hours and seen within 2 weeks of receiving discharge
summary)
• ROUTINE - Patient requires a routine specialist assessment. (will be seen within 12
weeks of referral)
Pulmonary Rehabilitation:
• ROUTINE - Patient would benefit from a 12 session exercise and education
programme (will be assessed and enrolled into a programme within 13 weeks)
• FAST TRACK – Post exacerbation and / or recent hospital admission due to COPD (will
be assessed and enrolled into a programme within 4 weeks)
Information & supporting documents required with referral
• Specific reason for the
referral
• Known risks regarding a
home visit
• Written evidence of COPD
diagnosis
• Last chest X-ray date &
results
• Last FBC date & results
• Current exacerbation medication
• If the patient is being referred due to frequent exacerbations – include 6 months of antibiotic Px
• Recent exacerbation / hospital admission details
• Current oxygen therapy
• Current nebuliser therapy
Routine Specialist Assessment
• Assessment of frequent exacerbations of COPD – 2 or more a year. (Please attach at least 6 months of antibiotic & oral prednisolone prescription history)
• Assessment due to severe disease – FEV1 < 50%
• Already on long term oxygen therapy
• Assessment for long term oxygen therapy (SPO2 <92% at rest, or < 94% if peripheral oedema, pulmonary hypertension, polycythaemia is evidenced)
• Assessment for ambulatory oxygen assessment (SPO2 <92% on exertion)
• Assessment for long term nebuliser trial (please ensure therapy is maximised & inhaler technique assessed & taught)
The patient will be required to buy their own should the trial show a positive effect
Smoking
cessation
advice
COPD
Assessment
Test
Dyspnoea
management
Bone
density
FBC
Clinical
observations
BMI
Dietary
advice
Pulse
oximetry
Quality of life
/symptom
assessment
Medication
review /
optimisation.
Inhaler
technique
Exacerbation
management
Patient
Activation
Measure
Depression /
anxiety
management
Social
support
Self
management
plan
Personalised
care plan /
lifestyle advice Travel
advice
End of
life
Immunisation
advice
Monitor
peripheral
oedema
MRC
Specialist
Assessment
Chest
clearance
techniques
Exercise
adviceOxygen
review
Education
Inform GP /
referrer
Oxygen therapy in COPD
A Cochrane review of randomised controlled trials of domiciliary oxygen therapy for COPD found; (Ref)
• Long-term home oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55mm Hg (8.0 kPa)
• Home oxygen therapy did not appear to improve survival in patients with mild to moderate hypoxaemia or in those with only arterial desaturation at night
• Aim for an SaO2 of 88-92%
• Ref: Cranston JM, Crockett AJ, Moss JR, et al; Domcilliary oxygen for chronic obstructive pulmonary disease. Cochrane database Syst Rv. 2005 Oct 19 (4): CD001744
Oxygen assessment for LTOT
• Definitive diagnosis
• Patient clinically stable
• Medically optimised
• SPO2 <92% at rest, or < 94% if peripheral oedema, pulmonary
hypertension, polycythaemia is evidenced
• Risk assessment
• Smoking status
• Patient understands implications and process
• Gain verbal and written consent (IHORM, HOCF, HOOF)
Capillary blood gases assessment
• If PO2 ≤ 7.3kPa – repeat in 3 weeks – if result same – Px LTOT
• If PO2 = 7.31 - 8kPa with no clinical evidence of secondary
conditions - LTOT is not required
• If PO2 = 7.31 – 8kPa with clinical evidence of secondary
conditions - Px LTOT
• Titrate O2 in 1Litre increments at 20 min intervals
• Once stabilised at SPO2 >90% – perform blood gas to confirm
pO2 = 8.1 – 9kPa
Update HOOF and consider all equipment required and the need
for ambulatory oxygen
Follow up after LTOT initiation
• 1 week – telephone call
• 4 weeks - Reinforce education and check SPO2 on O2 /
Symptoms of hypercapnia / Adherence / Smoking status /
Equipment
• 3 months - reassessment and blood gas
• 12 monthly blood gases for normocapnic patients
• 6 monthly blood gases for hypercapnic or concerning patients
Nebuliser Trial – 3 weeks
Nebuliser trial should consider:
• A reduction in symptoms
• An increase in the ability to undertake activities of daily living
• An increase in exercise capacity
• An improvement in lung function
If the trial is positive, we will recommend the patient rents or purchases a device from a reputable company.
We provide written information:
• Buying a Nebuliser Guide
• Details of nebuliser Suppliers
• Care of your nebuliser booklet
• Price list for rental or purchase agreements (£70 - £100 & £5 - £6)
Nebuliser Trial:
• Check inhaler technique
• Consider use of spacer device
• Assess the individual and / or carer’s ability to use and clean etc
• Only continue treatment if there is an improvement during trial
• Offer choice of mask or mouthpiece
• Consider which drugs require mouth piece only
• Always provide education / written instructions / technical
support details
Nebulised medications in COPD
• Salbutamol 2.5mg / 5mg up to QDS
Patients admitted with acute exacerbations of COPD requiring nebulised therapy should be considered for 2.5mg nebulised Salbutamol in place of 5mg (Ref)
• Ipratropium Bromide 250mcg/1ml or 500mcg/2ml up to QDS
• Saline solution - Sodium Chloride 0.9% w/v up to QDS
• Colomycin antibiotic therapy 1 or 2 Million International Units (MIU) mixed with 4ml sterile water BD
Ref: Nair S. A randomised controlled trial to assess the optimal dose and effect of nebulised Albuterol in acute exacerbations of COPD. Chest 2005; 128; 48 - 54
Pulmonary Rehabilitation
• Programme of exercise and education
• Individually designed
• Benefits – improve muscle strength, cope better with
breathlessness, improve fitness, improve mental health
• 6 sessions a week – 3 centres
• Commitment – 2 sessions week for 6 weeks
• May need to be assessed for ambulatory oxygen
Pulmonary Rehabilitation pathway
Initial assessment
(History taking from patient, medical and drug history, Quality of Life
Questionnaire, Incremental shuttle walk test)
Included in Pulmonary Rehabilitation
(Cardiovascular Training + Strength training+ Education)
Final assessment
(Quality of Life Questionnaire,
Incremental shuttle walk test – improvement of 47.5m )
Patient discharged form the service
PR Venue and timings
• Crawley – Physiotherapy gym, Crawley Hospital
Time - Wed: 2.45pm
Fri: 2.00pm
• Mid Sussex – Dolphins Leisure centre, Haywards Heath
Time – Tue: 1.30pm
Thu: 1.30pm
• Horsham – Physiotherapy gym, Horsham Hospital
Time – Mon: 10.00am
Wed: 11.45am
Time for a challenge
Sit to Stand test
Aim to stand up and sit down for 1minute.
Part A HOOF training
•Jo Hobbs
•Service Lead/ Clinical Manager
•Dolby Vivisol
Dolby Vivisol Supporting Patients and Health Care Professionals
24/7 365 days a year
• Major Home Healthcare provider in the UK
• 20,000 active Patients across the UK
• 250 Employees in the UK (all CRB checked & “Patient Ready”)
• Long term contracts with the NHS – Home Oxygen –Scotland, South East Coast & South Central
• Partner with all main manufacturers…
Guides
• British Thoracic Society
• National Home Oxygen Safety Group
• NHS Improvement
Clinical assessment
• Clinical assessment for correct home
oxygen requirement with appropriate
equipment
Forms!
• Initial Home Oxygen Risk Mitigation (IHORM) form completed (National form)
• Home Oxygen Consent Form (HOCF) completed
• Home Oxygen Order Form (HOOF) completed
IHORM
• National form from 1st August 2017
• “It is the responsibility of the registered health care professional who is gaining consent to complete and add the IHORM with the HOOF and HOCF to the patient’s notes. If all documents are not confirmed as being completed in full the Home Oxygen Order cannot be fulfilled”
• “If a High Risk is identified (shaded box), It is highly recommended that oxygen is not requested without referral to Home Oxygen Assessment and Review Service (HOS-AR) or support services e.g. falls team, stop smoking service”
IHORM IG approved 298
Initial Home Oxygen Risk Mitigation Form (IHORM) and Home Oxygen Consent
Form (HOCF) for new patients only . BOTH FORMS MUST BE COMPLETED AND SIGNED BEFORE OXYGEN CAN BE INSTALLED.
DO NOT SEND FORMS TO SUPPLIER FORMS WILL BE PLACED IN PATIENT NOTES
THERE ARE CONFIRMATION BOXES ON THE HOME OXYGEN ORDER FORMS.
Oxygen can pose a risk of harm to the user and others in the event of fires, falls and inability to use complex equipment. The initial identification and onward communication of these risks is the responsibility of the health care professional ordering the oxygen and remains so until that prescription ceases or is superseded. The table below reflects risk factors that are based on evidence of real life serious and untoward incidents, 90% of which are smoking and e-cigarette/charger related.
The Initial Home Oxygen Risk Mitigation (IHORM) is to be completed in conjunction with the Home Oxygen Consent Form (HOCF) prior to oxygen being ordered from the oxygen supplier via the Home Oxygen Order Form (HOOF). It is the responsibility of the registered health care professional who is gaining consent to complete and add the IHORM with the HOOF and HOCF to the patient’s notes. If all documents are not confirmed as being completed in full the Home Oxygen Order cannot be fulfilled.
If the risks identified on the IHORM indicate significant levels of risk the patient should be discussed directly with the local Home Oxygen Service or Clinical Oxygen Lead for a full risk assessment prior to oxygen being ordered as recommended in the British Thoracic Home Oxygen Guidelines June 2015. Regardless of risk or diagnosis all adult patients should be referred the Home Oxygen Assessment and Review Service (HOS-AR) for the team to determine next steps if deemed relevant.
If any responses below fall within a shaded box, please refer to the Required Action column and supporting notes.
All actions should be explained to the patient and why they are being taken in line with service contracts. Ensure that both verbal and written information has been given to the patient or their representative
Patient Name DOB
Address Oxygen
requested?
Yes - Sending HOOF
No - Risk is too high
Recorded at Please indicate:- Hospital / Clinic / Home / other location NHS No
Risk Level Risks No Yes Required Action
HIGH
Does the patient smoke cigarettes / e-cigarettes?
If a High Risk is identified (shaded box), It is highly recommended that oxygen is not requested without referral to Home Oxygen Assessment and Review Service (HOS-AR) or Respiratory Specialist or support services e.g. falls team, stop smoking service,
Have they smoked in the last 6 months? Quit date.
Does anyone else smoke at the patients premises?
A recent history of drug or alcohol dependency?
Patient reported they have had a fall in the last 3 months?
Have they had previous burns or fires in the home?
Does the person have identified mental capacity issues?
MODERATE
Can the patient leave their property un-aided? If 3 or more risks are identified (shaded box), It is highly recommended that oxygen is not requested without referral to HOS-AR or Respiratory Specialist or support services e.g. stop smoking service,
Is the patient or any dependents/ in the property
vulnerable? E.G. disabilities/ children
Do they live in a home that is joined to another?
Patient reports they have working smoke alarms at
home? (if unknown please state no)
Do they live in a multiple occupancy premises (Bedsit/flat)
Mitigation actions taken e.g. contacted falls team Referred to Fire and Rescue
Declaration I confirm that I am the healthcare professional responsible for the care of this patient. I have discussed the risks listed on this form with the patient/carer/ guardian (delete as necessary) and from the responses given Oxygen can/cannot (delete as necessary) be requested at this time.
Clinicians Signature Profession
Print Name HOS team Yes / No
Contact No. Date
Lead Consultant is (Hospital Discharge only)
Home Oxygen Consent Form
• Consent to sharing of information with:
• The home oxygen supplier (us) and to allow us access to deliver, service, refill and remove the equipment.
• Local Fire and Rescue Service
• Electricity supplier (if electrical equipment ordered)
Home Oxygen Order FormPart A HOOF Part B HOOF- Specialist teams
HomeOxygen Order Form (HOOF) Part B (After Specialist / Paediatric Oxygen Assessment)
All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed
1. Patient Details
1.1 NHS Number* 1.7 Permanent address* 1.9 Tel no.
1.2 Title
1.10 Mobile no.
1.3 Surname* 2. Carer Details (if applicable)
1.4 First name* 2.1 Name
1.5 DoB* 2.2 Tel no.
1.6 Gender Male Female 1.8 Postcode* 2.3 Mobile no.
3. Clinical Details 4. Patient’s Registered GP Information
3.1 Clinical Code* 4.1 Main Practice name:*
3.2 Patient on NIV/CPAP Yes No 4.2 Practice address: 4.3 Postcode* 4.4 Telephone no. 3.3 Paediatric Order Yes No
5. Assessment Service (Hospital or Clinical Service) 6. Ward Details (if applicable)
5.1 Hospital or Clinic Name: 6.1 Name:
5.2 Address 6.2 Tel no.:
5.3 Postcode: 5.4 Tel no: 6.3 Discharge date: / /
7. Order* 8. Equipment*
For more than 2 hours/day it is advisable to select a static concentrator
9. Consumables* (select one for each equipment type)
Litres/Min Hours/Day Type Quantity Conserving Device Nasal Cannula Mask % and Type
8.1 Static Concentrator Back up static cylinder(s) will be supplied as appropriate
8.2 Static Cylinder(s) A single cylinder will last for approximately 8hrs at 4l/min
8.3 Self Fill Concentrator Same as static concentrator and can fill ambulatory cylinder(s) (8.5/8.6)
8.4 Transportable Concentrator (trolley based) Can be used in place of a static concentrator and / or for ambulatory use
8.5 Standard Ambulatory Cylinder(s) Cylinders for use outside of a home setting
8.6 Lightweight Ambulatory Cylinder(s) Lighter than the standard ambulatory cylinder
8.7 Portable Concentrator (carry over shoulder) Lighter weight than transportable concentrator and limited to pulse dose
8.8 Liquid Oxygen (LOX) Dewar Please select number of flasks required below
8.9 Liquid Oxygen (LOX) Flask To be used in conjunction with the LOX Dewar
10. Additional Equipment
10.1 Humidification (not usually indicated for less than 4l/min) Yes No 10.2 Tracheostomy (mask only) Yes No
11. Delivery Details*
11.1 Standard (3 Business Days) 11.2 Next (Calendar) Day 11.3 Urgent (4 Hours)
12. Temporary Secondary Supply (e.g. Holiday Order with different modality) 13. Contact Details (if applicable)
12.1 Address: 13.1 Name:
Postcode: 13.2 Tel no.
14. Additional Patient Information 15. Clinical Contact (if applicable)
15.1 Name:
15.2 Tel no. 15.3 Mobile no.
16. Declaration*
I declare that I am the registered healthcare professional responsible for the information provided, the information given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false information, I may be liable to prosecution or civil proceedings
*I’ve completed/ or confirm there is a previously signed copy of the Home Oxygen consent form HOCF AND an Initial Home Oxygen
Risk Mitigation Form IHORM
Name: Profession:
Signature: Date:
Fax back no. or NHS email address for confirmation / corrections:
Home Oxygen Order Form (HOOF)
Part A (Before Oxygen Assessment – Non-Specialist or Temporary Order)
All fields marked with a ‘*’ are mandatory and the HOOF will be rejected if not completed
1. Patient Details
1.1 NHS Number* 1.7 Permanent address* 1.9 Tel no.
1.2 Title 1.10 Mobile no.
1.3 Surname* 2. Carer Details (if applicable)
1.4 First name* 2.1 Name
1.5 DoB* 2.2 Tel no.
1.6 Gender Male Female 1.8 Postcode* 2.3 Mobile no.
3. Clinical Details 4. Patient’s Registered GP Information
3.1 Clinical Code* 4.1 Main Practice name:*
3.2 Patient on NIV/CPAP Yes No 4.2 Practice address: 4.3 Postcode* 4.4 Telephone no 3.3 Paediatric Order Yes No
5. Assessment Service (Hospital or Clinical Service) 6. Ward Details (if applicable)
5.1 Hospital or Clinic Name: 6.1 Name:
5.2 Address 6.2 Tel no.:
6.3 Discharge date: / /
5.3 Postcode: 5.4 Tel no:
7. Order* 8. Equipment* For more than 2 hours/day it is advisable to select a static concentrator
9. Consumables* (select one for each equipment type)
Litres / Min Hours / Day Type Quantity Nasal Canulae Mask % and Type
8.1 Static Concentrator Back up static cylinder(s) will be supplied as appropriate
8.2 Static Cylinder(s) A single cylinder will last for approximately 8hrs at 4l/min
10. Delivery Details*
10.1 Standard (3 Business Days) 10.2 Next (Calendar) Day 10.3 Urgent (4 Hours)
11. Additional Patient Information 12. Clinical Contact (if applicable)
12.1 Name:
12.2 Tel no. 12.3 Mobile no.
13. Declaration*
I declare that I am the registered healthcare professional responsible for the information provided; the information given on this form for NHS treatment is correct and complete. I understand that if I knowingly provide false information, I may be liable to prosecution or civil proceedings.
* I have completed/or confirm there is a previously signed copy of the Home Oxygen Consent Form HOCF AND
the Initial Home Oxygen Risk Mitigation Form IHORM Follow the link for more help https://www.pcc-cic.org.uk/article/home-oxygen-order-form
Name: Profession:
Signature: Date: Referred for assessment: Yes No
Fax back no. or NHS email address for confirmation / corrections:
14. Primary Clinical Code
CODE Condition CODE Condition
1 Chronic obstructive pulmonary disease (COPD) 11 Neuromuscular disease
2 Pulmonary vascular disease 12 Neurodisability
3 Severe chronic asthma 13 Obstructive sleep apnoea syndrome
4 Interstitial lung disease 14 Chronic heart failure
5 Cystic fibrosis 15 Paediatric interstitial lung disease
6 Bronchiectasis (not cystic fibrosis) 16 Chronic neonatal lung disease
7 Pulmonary malignancy 17 Paediatric cardiac disease
8 Palliative care 18 Cluster headache
9 Non-pulmonary palliative care 19 Other primary respiratory disorder
10 Chest wall disease 20 Other If no other category applicable
Static Concentrator
• Most cost effective for LTOT use
• Standard 1 to 5 litres/min
• Back up cylinder provided for up to
8 hours usage, in case of power
failure or equipment fault
• High flow up to 9 litres/min
• Low flow 0.1 to 2 litres/min
• Low low flow 0. 1 to 0. 8 litres/min
Static Cylinder
• Commonly used for paediatrics
LTOT- low flow regulators can be
attached to reduce flow rate and
enable weaning off oxygen. (Can
be secured to the wall if
requested).
• Usually for orders of less than 2
hours per day in adults, i.e.
Cluster headaches.
Safety
• A field based risk assessment is carried out
by the technician to ensure it is safe to
install oxygen
Thank you
Good HOOF guide
COPD Team – 01403 620459
