Respiratory Service FrameworkAsthma and COPD Care (Nursing)

Project Learning and Development Strategy

LEARNING AND DEVELOPMENT STRATEGY

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LEARNING AND DEVELOPMENT STRATEGY

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Service frameworksService frameworks are defined as being measurable, are defined as being measurable, evidence–based standards which are the product of a process evidence–based standards which are the product of a process of engagement with HSC staff, service users and the public. of engagement with HSC staff, service users and the public.

Each Framework will follow the individual’s journey, from Each Framework will follow the individual’s journey, from prevention through to end-of-life care, taking account of all prevention through to end-of-life care, taking account of all

aspects of health and social care providing an opportunity to aspects of health and social care providing an opportunity to promote evidence-informed practice with a focus on safe and promote evidence-informed practice with a focus on safe and

effective care. effective care. Template for the Development of Service Frameworks for Template for the Development of Service Frameworks for

Health and Social CareHealth and Social Care Department of Health, Social Services Department of Health, Social Services and Public Safety, 2007. and Public Safety, 2007.

What is a Service Framework? Explicit standards on prevention, treatment and care “Quality requirements” supporting the standards

Specific timeframe - 3-5 years and revision process

Capable of measurement/comparative data

Linked to the HSC quality standards and other policy, documents and guidance

Applicable to both adults and children

Follow a life cycle approach

Developed in collaboration with the HSC and public.

Patient/client Pathway Template

Prevention / PromotionProtection /Lifestyle

Treatment

Ongoing Care / Chronic DiseaseManagement

End of Life Care / Palliative Care

Assessment & Diagnosis

Overarching Standard 6.1.1All people suspected of having COPD should have accurate assessment, diagnosis and management in Primary Care.

RationaleCOPD should be prevented where possible, but, as a minimum, disease progression should be slowed down or avoided by early diagnosis and optimal management in keeping with the most up to date evidence based guidelines.Evidence National Institute for Clinical Excellence (2004) Management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Institute of Clinical Excellence: Londonhttp://thorax.bmj.com/content/vol59/suppl_1/Strategic Framework for Respiratory Conditions (N. Ireland), 2006. http://www.dhsspsni.gov.uk/pcd_-_respiratory_framework.pdf

Responsibility for delivery / implementationHSC TrustsPrimary Care

Quality Dimension 1.All patients older than 35 years, with past/present smoking history, and presenting with exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis or wheeze should have spirometry performed. 2.All patients with a diagnosis of COPD should have an assessment and review according to NICE guidelines 3.All patients suspected of or diagnosed with COPD should have their smoking history recorded and be given appropriate advice about smoking cessation and specialist smoking cessation services.

Performance Indicator Data Source Expected Performance Level

Date to be achieved by

Percentage of patients with COPD who smoke, who have had appropriate smoking advice

DES Data setAudit of GP records

60%80%90%

March 2010March 2011March 2012

Percentage of patients with COPD who are assessed, diagnosed and managed according to NICE Guidelines in primary care.

DES datasetRolling audit of GP records

60%80%90%

March 2010March 2011March 2012

How will they be assessed?

• Service Audits

• Patient Registers

• QOF data sets

• DES data sets

• PAS

• Evidence collected by organisations to support achievement

Current Work

Cardiovascular DiseaseCardiovascular Disease

Respiratory WellbeingRespiratory Wellbeing

CancerCancer

Mental HealthMental Health

Learning DisabilityLearning Disability

April 2008April 2008

May/ JuneMay/ June20082008

July 2008July 2008

The Future of COPD Nursing Care

The RSF Standards

LEARNING AND DEVELOPMENT STRATEGY

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LEARNING AND DEVELOPMENT STRATEGY

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CommunicationCommunication

Patient EducationPatient Education

Location of CareLocation of Care

Health TechnologyHealth Technology

Multidisciplinary WorkingMultidisciplinary Working

Prevention / PromotionProtection /Lifestyle

Modifiable RisksModifiable Risks

Smoking Cessation/ PreventionSmoking Cessation/ Prevention – Specific Targets – Specific Targets

Smoking ReductionSmoking Reduction

Lifestyle assessmentLifestyle assessment

Physical ActivityPhysical Activity

Planned ProgrammesPlanned Programmes

EducationEducation – Medication compliance and efficacy – Medication compliance and efficacy

Patient PartnershipPatient Partnership

Negotiating a Negotiating a plan of care plan of care and lifestyle and lifestyle adjustmentsadjustments

Assessment & Diagnosis

History Taking History Taking

Airflow Limitation Airflow Limitation – SPIROMETRY – SPIROMETRY

Accurate, interpreted Accurate, interpreted

ScreeningScreening – Symptomatic smokers – Symptomatic smokers

Registers Registers

Treatment

Self Management Self Management – Face-to-face care planning– Face-to-face care planning

Written copyWritten copy

One core written planOne core written plan

Acute ExacerbationAcute Exacerbation – Early Supported Discharge – Early Supported Discharge

Resp. PhysicianResp. Physician

Emergency Oxygen Emergency Oxygen – Alert cards– Alert cards

BTS GuidelinesBTS Guidelines

NIV NIV – Management of NIV– Management of NIV

Case ManagementCase Management – Expertise in Co-morbidities – Expertise in Co-morbidities

Ongoing Care / Chronic DiseaseManagement

TelemonitoringTelemonitoring – 50k patients in next 3 years – 50k patients in next 3 years

Pulmonary RehabilitationPulmonary Rehabilitation – MRC 3+ offered referral – MRC 3+ offered referral

Monitoring uptakeMonitoring uptake

Programme Development and accessProgramme Development and access

Nebuliser Therapy Nebuliser Therapy – Assessment for– Assessment for

Equipment – Compressor/ O2Equipment – Compressor/ O2

LTOT LTOT – Adherence to Assessment Criteria– Adherence to Assessment Criteria

Ongoing MonitoringOngoing Monitoring – Annual Review/ ½ yearly – Annual Review/ ½ yearly

Case ManagementCase Management

End of Life Care / Palliative Care

Key Worker Key Worker – Core Palliative Care Competencies– Core Palliative Care Competencies

Early Needs AssessmentEarly Needs Assessment – MRC 5 – MRC 5

Trigger QuestionsTrigger Questions

Patient ChoicePatient Choice

Supportive and Palliative Care RegisterSupportive and Palliative Care Register

Breaking Bad News Breaking Bad News - Communication- Communication

The Future of Asthma Nursing Care

The RSF Standards

LEARNING AND DEVELOPMENT STRATEGY

S

LEARNING AND DEVELOPMENT STRATEGY

S

CommunicationCommunication

Patient EducationPatient Education

Location of CareLocation of Care

Health TechnologyHealth Technology

Multidisciplinary WorkingMultidisciplinary Working

Modifiable RisksModifiable Risks

Smoking Cessation/ PreventionSmoking Cessation/ Prevention – Specific Targets – Specific Targets

Maternal Health/ Parental Health Maternal Health/ Parental Health

Lifestyle assessmentLifestyle assessment – Allergy Triggers – Allergy Triggers

Physical ActivityPhysical Activity

EducationEducation - Medication compliance and efficacy - Medication compliance and efficacy Patient PartnershipPatient Partnership

Health Inequalities Health Inequalities – Immigrant Populations– Immigrant Populations

Electoral WardsElectoral Wards

Prevention / PromotionProtection /Lifestyle

Assessment & Diagnosis

History Taking History Taking - One airway (allergic Rhinitis) - One airway (allergic Rhinitis) allergy testingallergy testing Diagnostic Therapy Trial Diagnostic Therapy Trial

Airflow Limitation Airflow Limitation – SPIROMETRY – SPIROMETRY Accurate, interpretedAccurate, interpreted

Treatment

Self managementSelf management – Face-to-face care planning– Face-to-face care planning Written copyWritten copy One core written planOne core written planAnaphylaxis ManagementAnaphylaxis Management – Register – Register Allergy expertiseAllergy expertiseAcute Exacerbation Acute Exacerbation – Treatment as per Guidelines– Treatment as per Guidelines

Review and Follow-upReview and Follow-up – Admission – Admission

A&EA&E

Non-admissionNon-admission

Ongoing Care / Chronic DiseaseManagement

ReviewReview – – Frequent admissionsFrequent admissions

Early Follow upEarly Follow up

Appropriate ReferralAppropriate Referral – Difficult to Control Asthma – Difficult to Control Asthma

Alert CardsAlert Cards – Education – Education

Inhaler TechniqueInhaler Technique

Allergy HistoryAllergy History - Testing - Testing