Service Specification

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1 Service Specification Spirometry in Primary Care Date: February 2011 Document Reference: Service Specification (V4.0)

2 Contents: Section Page 1 Definition of service 3 2 Training 4 3 Reporting / Monitoring 5 4 References 5 2

3 1 Definition of Service 1.1 Aims & Objectives The aim of the service is to assist in the early identification and accurate, quality assured diagnosis of COPD, and / or asthma. For all spirometry to be performed safely and effectively For spirometry to be preformed when the patient is in a stable condition and not in exacerbation For spirometry to be performed on initial assessment and then every months for COPD patients To provide an accurate way of assessing the severity and / or progression of COPD. To identify patients who may be presenting with early onset of symptoms. 1.2 Service Outline Spirometry is a diagnostic test for COPD and is the most effective way of determining the severity of the condition. Making a diagnosis for COPD relies on clinical judgment based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry. All health care professionals managing patients with COPD should have access to spirometry. They should be competent in carrying out the procedure and the interpretation of the results including accuracy of results. For the diagnosis of Asthma the BTS guidelines recommend that spirometry is the preferred initial test to assess the presence and severity of airflow obstruction but should be used in conjunction with other interventions. This is due to cases where spirometry may be normal in asthma depending on symptoms and the time of day when it is recorded. The full assessment should include history taking, trials of therapy monitored by recording symptoms, lung function [spirometry and/or PEFR] and other tests as appropriate. Diagnosis The content of the spirometry procedure should include: An appropriate review of patients health, including checks for potential contra-indications, that the patient is safe to undergo the test and meets the criteria Clear instructions forwarded to patients who will be attending for spirometry testing e.g. inhaler advice, clinically stable, loose clothing, what the tests involves and length of time to carry out the test 3

4 Results of patients diagnosed with COPD are classified and recorded as mild, moderate, severe or very severe Interpretation of the results Prescribed and administered medication Recorded clinical information related to the patient s spirometry test and scanning in hard copies For patients who smoke onward referrals to the smoking cessation service should also be offered at the point of diagnosis. Reversibility Testing In most patients, routine spirometric reversibility testing is not necessary as a part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. However in some cases reversibility testing may need to be undertaken if asthma is suspected. In all cases spirometry should be recorded post bronchodilator [400mg salbutamol via volumatic spacer] and this should be documented. 1.3 Client Group This service should be available to: Patients with symptoms suggestive of COPD in general practice Patients with established COPD Patients with a potential new diagnosis of asthma Spirometry may also form part of the assessment of the following groups of patients: Current or ex smokers, over the age of 35, who have a chronic cough. Patients whose occupations may expose them to respiratory irritants, such as dust, fumes and noxious gases. Patients presenting with undiagnosed respiratory symptoms, cough with or without sputum, shot of breath on exertion, consider other pathologies e.g. cardiac disease. Patients should not undergo spirometry when the test may be harmful due to other medical conditions. 2 Training / Workforce / Staffing Health care professionals who perform spirometry will have completed an approved competency based training course in spirometry and will be expected to keep their skills up to date. Training courses available are as follows: Association for Respiratory Technology and Physiology [ARTP] Two day certificate courses on COPD and Spirometry 4

5 Education for Health A range of one day workshops to identify learning needs and four-six month distance learning diplomas. Respiratory Education UK One day workshops and 2 day diploma courses The PCT is currently sourcing training courses and will contact practices with the details. Practices will be required to respond, indicating their existing skill levels and training requirements. The training requirements will be different for those staff whose role is solely to carry out the test and do not have a role in interpretation or treatment. 3 Reporting / Monitoring The practice will not be required to submit activity or audit reports to the PCT. The PCT will review the QOF performance of individual practices, including the accuracy of disease registers. If this highlights any causes for concern these will be managed with practices individually. 4 References NICE COPD Guidelines British Thoracic Society: Spirometry in Practice. National Strategy for COPD. Derbyshire COPD Guidelines BTS Asthma Guidelines This specification should be read in conjunction with main Basket of Services specification. 5

6 APPENDIX 1: Diagnosing COPD Taken from NICE updated Guidelines 2010 Consider a diagnosis of COPD for people who are: Over 35 and Smokers or ex smokers and Have any of these symptoms - exertional breathlessness - chronic cough - regular sputum production - frequent winter bronchitis - wheeze And do not have clinical features of asthma - chronic unproductive cough - significantly variable breathlessness - night time wakening with breathlessness and/or wheeze - significant diurnal or day to day variability of symptoms Ask about the following factors where COPD is suspected: Weight loss Effort intolerance Waking at nights Ankle swelling Fatigue Occupational hazards Chest pain haemoptysis Perform initial diagnostic evaluation if COPD seems likely: Post bronchodilator spirometry [record absolute and percentage of predicted values] Chest x-ray to exclude other diagnoses [investigate abnormalities using a CT scan] Full blood count to identify anaemia or polycythaemia Body mass index [BMI] calculation Assess severity Consider alternative diagnoses in older people without typical symptoms of COPD and FEV 1 / FVC ratio <0.7, and younger people with symptoms of COPD FEV 1 / FVC ratio >0.7 If no doubt, diagnose COPD and start treatment If still in doubt, make a provisional diagnosis and start empirical treatment Reassess diagnosis in view of response to treatment: Clinically significant COPD is not present if FEV 1 and FEV 1 / FVC ratio return to normal with drug therapy Asthma may be present if: - there is a >400 ml response to bronchodilators - serial peak flow measurements show significant [> 20%] diurnal or day to day variability - there is a > 400 ml response to 30 mg prednisolone daily for 2 weeks Refer for more detailed investigations if needed For all people diagnosed with COPD: Highlight the diagnosis of COPD in the notes and computer database [using read codes] Record the results of spirometric tests at diagnosis absolute and percentage of predicted 6

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