Controlled Document Ref: G053 Issue: 1 Folder Section: 15 - Respiratory Approval Date: March 2010 Review Date: March 2012 SOUTHERN DERBYSHIRE Nebuliser Guidelines For patients with chronic respiratory conditions including COPD but excluding asthma Policy Reference: G053 Version: 2 Ratified by: Patient Safety and Quality Name of Originator/Author: Vanessa Vale, Jenny Russell and Jean Sugden Name of responsible committee or Patient Safety and Quality individual: Date Issued: March 2010 Review Date: March 2011 Target Audience: AIR team, District Nurses, Palliative Care
CONTENTS Summary Page 2 Nebuliser Referrals Page 3 Routine referrals Page 3 Urgent referrals Page 5 Palliative care referrals Page 6 Provision of equipment for care homes Page 7 Nebuliser assessments Page 8 Nebuliser assessment process Page 9 Nebuliser Trial forms Trial A Page 10 Trial B Page 11 Referral forms South Derbyshire County and NHS Derby City Page 12 Page 1 of 12
1. Introduction Summary The aim of nebuliser therapy is to deliver a therapeutic dose of a desired drug as an aerosol in the form of respirable particles within a fairly short period of time, 5-10 minutes [British Thoracic Society, Nebuliser Treatment Best Practice Guideline 1997]. It is recommended that before such treatment is prescribed every patient should be assessed fully by a respiratory clinician who has had training in the supervision of nebuliser treatment. Nebulisers are useful when large doses of inhaled drugs are needed, when patients are too ill or otherwise unable to use hand held inhalers and when drugs are not available in hand held inhalers. In patients experiencing an exacerbation of COPD, if the exacerbation is relatively mild treatment with a hand held inhaler should be given using 200-400mg salbutamol. In more acute cases nebulised bronchodilators using 2.5-5mg salbutamol should be given [British Thoracic Society, Nebuliser Treatment Best Practice Guideline, 1997]. There is no significant difference in outcomes between patients treated with regular 2.5mg of salbutamol instead of 5mg [NICE COPD Guidelines 2004]. 2. Purpose The purpose of these guidelines is to provide all staff employed by NHS Derby City PCT, who administer nebulised therapy, with a framework for a standardised approach to the provision of a formal nebuliser assessment and nebulised therapy. 3. Responsibility and Accountability It is the responsibility of all Health Care Professionals who administer nebulised therapy to be aware of and adhere to the NHS Derby City PCT guidelines. 4. Patients Covered These guidelines are applicable to all patients with confirmed chronic respiratory conditions including Chronic Obstructive Pulmonary Disease, excluding asthma, who are treated as inpatients, outpatients and within their own homes. All patients with Asthma should be referred directly to secondary care and patients with palliative care needs should be referred directly to a District Nurse. Page 2 of 12
Nebuliser Referrals Referrals for nebuliser assessments have been separated into three categories: 1. Routine 2. Urgent 3. Palliative Care 1. ROUTINE REFERRALS All routine requests for a nebuliser assessment should be sent to the Adult Integrated Respiratory (AIR) Team [NHS Derby City]. This will ensure that all assessments for nebuliser therapy and ordering of equipment are carried out by an appropriate respiratory clinician. It is necessary for ALL referrers to identify initial indications and carry out an assessment prior to referral to ensure that it is appropriate. Routine Referral Process Identify initial indications Carry out referral assessment Complete referral form and fax it to the appropriate community respiratory team STEP ONE - Initial Indications Patients should be identified from the following indications BEFORE being referred for an assessment: 1. Experiencing persistent symptoms despite adequate bronchodilator therapy 2. Frequent exacerbations 3. Inability to use inhalers STEP TWO - Referral Assessment Carry out the following assessment BEFORE referring patients for a nebuliser assessment: 1. Confirm diagnosis - if diagnosis in doubt refer to the appropriate community respiratory team or secondary care 2. Confirm optimal therapy of bronchodilators via Metered Dose Inhaler [MDI] and spacer and check patients understand the correct use and technique 3. Carry out treatment review 4. Confirm that the patient, or carer, has a good level of understanding and dexterity required to take part in a nebuliser trial. Page 3 of 12
STEP THREE - Referral to AIR Team 1. Complete an AIR team referral form, including as much information as possible 2. Fax to: NHS Derby City Fax 01332 861182 Tel: 01332 861189 Amber Valley, Erewash, Derbyshire Dales and South Derbyshire and Derby City 3. The appropriate community respiratory team will arrange to see the patient within four weeks Referrals for nebuliser assessments are accepted from: 1. Primary Care GP s and Practice Nurses or any other appropriate Health Care Professional. 2. Secondary Care For patients within secondary care it is the responsibility of the secondary care respiratory clinician to carry out a formal assessment and issue a nebuliser accordingly. If a patient is admitted to hospital and given nebulised therapy, the treatment should be changed to a hand held inhaler and patients should be observed for 24-48 hours before discharge from hospital. [British Thoracic Society, Nebuliser Treatment Best Practice Guideline, 1997]. Patients on the early discharge scheme from hospital will have their nebulisers managed by the respiratory team in the community. All COPD patients discharged with a nebuliser, should be reviewed within one month post discharge by the AIR Team. 3. Community Hospitals Patients on nebulised therapy should be weaned off nebulised therapy and onto inhaled therapy prior to discharge. If this is unsuccessful then a referral should be made to the AIR Team using the correct referral form at least two weeks prior to discharge. The patients will then be seen within four weeks of Discharge. Page 4 of 12
2. URGENT REFERRALS All urgent requests should be dealt with by the appropriate clinician at the time they are presented. For patients presenting with an exacerbation, it should be sufficient to increase their current reliever medication via a hand held inhaler and spacer device. If a patient is already on maximal bronchodilator therapy with stable oxygen saturation it may be appropriate to issue the patient with a nebuliser. This should then be followed up by an urgent referral to the appropriate AIR Team who will arrange to see the patient within two working days. Urgent Referrals Process Patient presents with exacerbation GP to increase current reliever medication e.g. 400mcg Salbutamol QDS, via hand held inhaler and spacer device OR If already on maximal bronchodilator therapy with stable oxygen saturation Consider hospital admission OR Send urgent referral to appropriate AIR Team Page 5 of 12
3. PALLIATIVE CARE REFERRALS All palliative care requests should be dealt with by the appropriate clinician as required. For patients with palliative care needs, nebulisers should be issued by the community clinician involved in the patients care. Ordering of equipment can be authorised by the nominated network leads at NHS Derby City. Prior to authorisation the following should be checked by the network lead: Does the patient have a confirmed diagnosis of COPD or asthma? What is to be administered? Who made the request for the nebuliser? After authorisation to order the equipment and the patient being issued with a nebuliser, it is the responsibility of the community clinician to provide a follow up and on-going care of patients. Palliative Care Referral Process Nebuliser required for palliative care Obtain authorisation to place order by nominated network lead Order and issue nebuliser On-going care provided by issuer of nebuliser Page 6 of 12
Provision of Equipment for Care Homes Provision of equipment to Care Homes should be based on an assessment of need with the assessor utilising recognised accredited tools, scales and clinical guidance / agreed local protocols [Provision of Community Equipment for Care Homes in Derbyshire and Derby City PCT Guidelines 2007]. Assessment should be undertaken by a relevant professional and all staff assessing for equipment must be competent and confident, having received appropriate training. CARE HOME REFERRALS Care homes without qualified nursing staff All patients in care [residential] homes without qualified nursing staff should be referred for a formal assessment via the Community Specialist Respiratory Team using the appropriate referral form. Once a formal assessment has been undertaken the respiratory clinician will determine the best treatment and follow up the patient within an agreed timescale. When equipment is provided to the care home and it is no longer required by the person being cared for, it is the responsibility of the care home to notify the supplier immediately so that arrangements can be made to return the equipment. Care homes with qualified nursing staff All patients who meet the referral criteria for a nebuliser should be referred for assessment to the appropriate community respiratory team. If a nebuliser is required it is the responsibility of the care home to purchase and service the equipment. Page 7 of 12
Nebuliser Assessments Nebuliser therapy is a specialist therapy. It is recommended that formal assessments for nebuliser therapy should be carried out for all patients. This will ensure that objective evidence is provided stating that using a nebuliser will benefit the patient along with identifying any patients that have been prescribed a nebuliser inappropriately due to the lack of a formal assessment. The NICE COPD Guidelines [2004] state that nebuliser therapy should not be prescribed or continue to be prescribed without assessing and confirming that one or more of the following occurs: - A reduction in symptoms - An increase in the ability to undertake activities of daily living and exercise capacity - An improvement in lung function It also states that if therapy is prescribed, the patient should be provided with equipment, servicing, advice and support. Page 8 of 12
NEBULISER ASSESSMENT PROCESS Fax referral form received Appointment made 1 st Visit Assessment Confirm diagnosis Assess exercise tolerance and breathlessness scores. Check patient compliant with treatment and has written information to support the process Increase short acting reliever treatment for 2 weeks Salbutamol 100mcg, 4 puffs, QDS via spacer 2 nd Visit End of 2 week Trial Re-assess exercise tolerance and breathlessness scores Nebuliser NOT required 1 st nebulised treatment given to patient for 2 weeks If on Tiotropium follow nebuliser trial A [page 9] if not using Tiotropium follow nebuliser trial B [page 10] 3 rd Visit End of 2 week Trial Re-assess exercise tolerance and breathlessness scores Agree on method of most effective treatment with patient Continue nebulised therapy Stop nebulised therapy Give patient management plan, advice and nurse contact details Give patient management plan, advice and nurse contact details Refer back to GP and discharge episode of care Refer back to GP and discharge episode of care Page 9 of 12
Nebuliser Trial A Tiotropium Prescribed Patient Name: Date of Birth: / / NHS No: Date: YOUR TRIAL WILL LAST FOUR WEEKS STEP ONE week 1 and 2 Medicine Dose Salbutamol 100mcg INHALER 4 PUFFS 4 times a day with SPACER DEVICE ANSWER THE FOLLOWING QUESTIONS AT THE END OF WEEK 2 QUESTION Y or N COMMENTS Has the treatment made a difference? Is your breathing easier in any way? Can you do some things that you couldn t do before? Can you do the same things but faster? Are you less breathless when you do things that you did before? Has your sleep improved? [Fill in MRC and Oxygen Cost Diagram] STEP TWO week 2 and 3 Medicine Dose Salbutamol 2.5mg NEBULISER SOLUTION 1 Nebule 4 times a day in NEBULISER ANSWER THE FOLLOWING QUESTIONS AT THE END OF WEEK 4 QUESTION Y or N COMMENTS Has the treatment made a difference? Is your breathing easier in any way? Can you do some things that you couldn t do before? Can you do the same things but faster? Are you less breathless when you do things that you did before? Has your sleep improved? [Fill in MRC and Oxygen Cost Diagram] Page 10 of 12
Nebuliser Trial B Tiotropium Not Prescribed Patient Name: Date of Birth: / / NHS No: Date: YOUR TRIAL WILL LAST FOUR WEEKS Medicine Salbutamol 100mcg INHALER Ipratropium 20mcg STEP ONE week 1 and 2 Dose 4 PUFFS 4 times a day with SPACER DEVICE 4 PUFFS 4 times a day with Spacer Device ANSWER THE FOLLOWING QUESTIONS AT THE END OF WEEK 2 QUESTION Y / N COMMENTS Has the treatment made a difference? Is your breathing easier in any way? Can you do some things that you couldn t do before? Can you do the same things but faster? Are you less breathless when you do things that you did before? Has your sleep improved? [Fill in MRC and Oxygen Cost Diagram] STEP TWO week 2 and 3 Medicine Dose Salbutamol 2.5mg [Nebuliser Solution] 1 NEBULE 4 times a day in NEBULISER Ipratropium 500mg [Nebuliser Solution] 1 NEBULE 4 times a day in NEBULISER FILL THE FOLLOWING QUESTIONS AT THE END OF WEEK 4 QUESTION Y / N COMMENTS Has the treatment made a difference? Is your breathing easier in any way? Can you do some things that you couldn t do before? Can you do the same things but faster? Are you less breathless when you do things that you did before? Has your sleep improved? [Fill in MRC and Oxygen Cost Diagram] Page 11 of 12
Name: Address: DOB: Tel: NHS No: GP: Practice: Postcode: Alternative Contact: Name: Relationship: Tel: Mobile: GP tel no: Does patient require a home visit? Y / N Does the patient need an interpreter? Y / N Any known risks for staff visiting alone? Y / N If Yes, please state language: Does the patient live alone? Y / N Diagnosis and date of onset (include any relevant medical history and a current medication list) Is the patient aware of their diagnosis? Y / N Spirometry Date performed: FEV 1: %predicted: FVC: FEV 1/FVC: Reason for referral: Active follow-up of patients recently discharged from hospital Date of discharge: Management of respiratory condition Nebuliser assessment / follow-up Unconfirmed diagnosis of COPD for spirometry Inspire COPD education group Priority: Urgent Priority 1 patient contacted within 2 working days Priority 3 within 2 weeks Priority 2 patient contacted within 5 working days Routine usually within 4 weeks Problems identified: Recurrent infection / exacerbations Repeated hospital admissions for chest Sputum clearance problems Disordered breathing pattern Increased breathlessness Panic / anxiety Decreased exercise tolerance Limited knowledge of condition Other services involved: Referred by: Designation: Contact address: Contact number: Date of referral: Please return to: AIR Team Coleman Health Centre Coleman Street Alvaston Derby DE24 8NH Tel: 01332 861189 Fax: 01332 861182 Page 12 of 12