COPD RESOURCE PACK SECTION 11. Fife Integrated COPD Care Pathways

Transcription

1 COPD RESOURCE PCK SECTION 11 Fife Integrated COPD Care Pathways In this section: 1. COPD Guidance treatment at each stage of the disease 2. Overview of Respiratory (COPD) Integrated Pathway 3. Chronic Obstructive Pulmonary Disease Spectrum of Care 4. COPD Diagnostic Patient Pathway 5. COPD Non Pharmacological Management Patient Pathway 6. Elective Referrals Primary to Secondary Care 7. cute Exacerbations Fife Respiratory COPD Resource Pack Section 11: Fife Integrated COPD Care Pathways Version 2.1 Last Updated: January 2015

2 1. COPD GUIDNCE TRETMENT T ECH STGE OF THE DISESE COPD Guidance: Treatment at each stage of disease (based on GOLD July 2003 & NICE Feb 2010) 0: t Risk I: Mild II: Moderate III: Severe IV: Very Severe Chronic symptoms Exposure to risk factors Normal spirometry FEV 1 /FVC <70% FEV 1 80% With symptoms FEV 1 /FVC <70% 50% FEV 1 <80% With or without symptoms FEV 1 /FVC <70% 30% FEV 1 50% With or without symptoms FEV 1 /FVC <70% FEV 1 <30% or <50% with presence of chronic respiratory failure or right heart failure voidance of risk factor(s); influenza/pneumococcal vaccination ; ll COPD patients regardless of age should be encouraged to stop and offer help at every opportunity Mucolytics can be used at any stage in patients with troublesome cough and sputum (4 week trial). Do not use routinely to prevent exacerbations. gree and issue Fife COPD ction Plan / CHSS Traffic Lights ction Plan for COPD (with or without home supply of antibiotics/steroids) dd short-acting broncodilator and/or anticholinergic when needed dd regular treatment with one or more bronchodilators (LM/LB) dd pulmonary rehabilitation dd inhaled corticosteroids if repeated exacerbations Consider long term oxygen if chronic respiratory failure. Consider surgical treatments NHS Fife Respiratory MCN Version No: 3 Date: September 2014 Review Date: September 2017 pproved on behalf of NHS Fife by the Fife rea Drugs & Therapeutics Committee Date: December 2014 Page 2 of 9

3 Device options should be patient specific dependant on ability to use/compliance. Use standard MDI first line+/-spacer device. Consider use of dry powder inhaler where appropriate. Stage Drug & Device Options Dosing Options & General Guidance Stage 0: t Risk No inhaled drug therapy nnual influenza immunisation, pneumonia vaccination and smoking cessation Stage I: Mild Bronchodilator as needed or on regular basis to prevent / reduce worsening symptoms Stage II: Moderate dd regular prescription for long acting bronchodilators if patient experiences symptoms or exacerbations Stage III: Severe Regular inhaled corticosteroid if FEV 1 <50% and repeated exacerbations Stage IV: Very Severe Short acting β 2 agonist MDI Salbutamol DPI Easyhaler Salbutamol Short acting anticholinergic Ipratropium bromide Long acting anti-muscarinic (LM) 1 st choice: Tiotropium (Spiriva Handihaler ) 2 nd choice: clidinium (Eklira Genuair ) Long acting β 2 agonist (LB) MDI Salmeterol DPI Easyhaler Formoterol High dose inhaled corticosteroid MDI Fostair (beclometasone + formoterol) DPI 1 st choice: Relvar Ellipta (fluticasone furoate + vilanterol) 2 nd choice: Symbicort Turbohaler (budesonide + formoterol Consider referral for Long Term Oxygen Therapy (LTOT) 1) Use either short acting bronchodilator on a when required basis initially 2) If patient remains symptomatic add a long acting bronchodilator 1) dd LM first line and assess response after 3 months, remembering to stop all short acting anticholinergic therapy 2) If no response stop LM, add LB and reinitiate short acting anticholinergic if benefit was seen 3) If response seen to LM and patient still symptomatic add LB 4) If the initial LM is effective in providing symptom control but is not well tolerated, switching to an alternative LM should be considered Use combination products appropriate to previous treatment remember to stop long acting β 2 agonist if used in previous step. Consider specialist referral nnual oximetry If saturated O 2 <92% at rest refer to Secondary Care NHS Fife Respiratory MCN Version No: 3 Date: September 2014 Review Date: September 2017 pproved on behalf of NHS Fife by the Fife rea Drugs & Therapeutics Committee Date: December 2014 Page 3 of 9

4 2. OVERVIEW OF RESPIRTORY (COPD) INTEGRTED CRE PTHWY PRIMRY HELTH CRE Primary Prevention COMMUNITY SERVICES Primary Prevention Wider health improvement Public Health Promotion Campaigns Occupational Health KEEPWELL KEEP WRM Lifestyle change services Raising awareness of Lung Health Secondary Prevention Weather wareness Expectoration techniques and breathlessness management Drug therapy incl. anticipatory management Vaccination Early Identification Spirometry Pulmonary Rehabilitation Maintenance program Exercise referral scheme Patient resource pack available Targeting health inequalities/communities of interest Lifestyle changes KEEPWELL & Health Improvement Healthy Living centres/ well person shops Screening/Spirometry Secondary prevention Systematic referral pathways Early diagnosis Rehabilitation s Implement SP standards Lifestyle change & self care ccess to relevant diagnostics Referral to cessation service cute Exacerbation Management Utilise action plan Tele-health Surveillance nticipatory care COPD support team Long Term Management Pathways for diagnostics prior to referral to secondary care Enhanced O2 ssessment Pulse Oximetry Hypoxic challenge testing Nebuliser ssessment Referral on to secondary care as required Prevention SECONDRY CRE Patient education (inpatient & outpatient) Referral pathway to primary care service Emergency Management &E MU/Rapid access and ssessment vailability of Consultant by for primary care colleagues Management Specialist assessment, diagnosis, treatment, follow up Imaging Detailed lung function testing Initiation of management plan Early supported Discharge Social s Input Benefits Info as required Initiation of palliative care pathway Nutritional Support INTERMEDITE CRE (Primary & Secondary care) TERTIRY CRE ny outsourced treatments Pulmonary oncology/ radiotherapy Pulmonary hypertension/ SPVU Throacic Surgery Lung Transplantation INTERMEDITE (To Tertiary) Strengthen links between centres Regional planning Direct referral to primary care for rehab Clear referral pathways linking to primary & secondary care Responsive ambulance/transfers and transports Self Care Support groups eg Breatheeasy ccessible information and supported change eg Web Expert patients or buddy system cessation Voluntary sector Nutritional wareness Pulmonary Rehabilitation Community Pulmonary Rehabilitation Maintenance Exercise Program Relaxation and nxiety Management Home exercise diary Holistic Support s Single shared ssessment Domi and Carer assessment and support Nutritional advice/support End of life care Referral/discharge pathways/transitions/triage Supported early discharge nticipatory Care Telehealth ction plan utilisation mbulance Compliance In-reach/outreach services O2 ssessment UNDERPINNING STRUCTURE E-Health/Tele-health/ Workforce planning Page 4 Multidisciplinary/Multiagency of 9 Involvement Standards Patient & Staff education Patient Safety Patient/Carer experience/pfpi Palliative Care, including End of Life Corporate/Financial Governance Clear patient pathways/journey

5 3. CHRONIC OBSTRUCTIVE PULMONRY DISESE SPECTRUM OF CRE CHRONIC OBSTRUCTIVE PULMONRY DISESE End-stage S P E C T R U M O F C R E Palliative Care Spirometry Long-term Oxygen Therapy Pulmonary Rehabilitation Self-management Deterioration dmission voidance Telehealth / nticipatory Care Management SESP Self-Management Support in community Further hospital admissions Further exacerbations Hospitalisation Severe exacerbations Treatment in primary care Diagnosis GP, +/- hospital referral Symptoms P T I E N T P T H W Y Prevention Page 5 of 9

6 4. COPD DIGNOSTIC PTIENT PTHWY COPD Diagnostic Patient Pathway Drug Support Workers Occupational Health Primary Care Management mbulatory Outcome 18 weeks Practice Pharmacist Keep Well Programme Suspected COPD Specialist Respiratory ssessment for Long-term Oxygen Therapy GP Management Spirometry Pulse Oximetry Technical / Educational Spirometry Support Pharmacist Respiratory Laboratory Detailed Lung Function Tests Self-management Plan Rehabilitation s SESP Pulmonary Rehabilitation Imaging GP Direct Referral Page 6 of 9 Electronic Flow of Information Patient/Carer Support Leisure s Lifestyle changes Physical ctivity

7 5. COPD NON PHRMCOLOGICL MNGEMENT PTIENT PTHWY COPD Non Pharmacological Management Patient Pathway PTIENT SERVICES Mild Moderate / Severe Severe / Very severe Primary Care Management Lifestyle Information Self Management Plan Information on Support s vailable; COPD Nutritional dvice Exercise Specialist Respiratory Rehabilitation s Community Pulmonary Rehabilitation Relaxation & nxiety Management Holistic Support s Single Shared ssessment Maintenance Exercise Programme Home Exercise Diary Domiciliary Support Carer ssessment & Support Patient Support for Self Management Nutritional dvice End of Life Care Page 7 of 9

8 6. ELECTIVE REFERRLS PRIMRY TO SECONDRY CRE Elective Referrals Primary to Secondary Reason for Referral ction in Primary Care Outcome Oxygen Therapy Pulse Oximetry Screening (at rest & on exertion) 92% at rest Enhanced oxygen assessment? Fit to Fly Pulse Oximetry Screening 95% at rest Hypoxic challenge testing? Nebuliser Therapy Conventional inhaled therapy maximised Therapy Concordance Nebuliser ssessment? Something Else Too Breathless Occupational COPD dvice Up to date chest radiograph Pulse Oximetry Blood Tests (Hb,PV,T4,Ca) Up to date chest radiograph Up to date Spirometry Specialist Respiratory More/Different Treatment Page 8 of 9

9 7. CUTE EXCERBTIONS cute Exacerbations Prevention Early Intervention Hospital Referral Drug Therapy, including long-acting bronchodilators ction Plan Referral Guidelines Pulmonary Rehab Patient/Carer education & support, including smoking cessation and self-management plan Expectoration techniques & breathlessness management Tele-Health Surveillance Specialist Respiratory : Rapid ssessment; Immediate Supported Discharge; Early Supported Discharge (admission avoidance) Vaccination COPD Support COPD Support Team Weather wareness Expectoration techniques & breathlessness management Page 9 of 9