A Seamless Service.
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Recognition that COPD and asthma a
significant problem for our health economy
Data: 1800 admissions in 1996
1995: COPD and asthma GL
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Across economy, DPH’s involved
Revised 1998 after first BTS GL
1996-8 COPD education project
1998 – pathway working
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1997: open access spirometry with report
2000: Hosted BTS early discharge course
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2001 SED: 1200 reviewed, 300 at home
Activity across hospital, LOS 9 to 3 days
2006-8: SAM. Economy sign off
4 then 2 PCTs, now 2 CCGs
Different speeds of development
2008 – community services
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UHNS, commissioners, provider units
Clinics, PR, nebuliser……
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SED still functions to identify patients for
community service integration
SED reviews patients for oxygen prior to
discharge
Education & Self Management as an inpatient.
Tier 4 oxygen clinics
T4 COPD clinics
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NIV since early 1990’s
Takes place on a bespoke 12 bedded
respiratory HDU
Nurse led initiation and setting change
24/7 consultant support
Go beyond boundaries (pH of 7)
10% mortality
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Quality assured spirometry
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PR a success with low drop outs
T3 oxygen service
Specific community nursing team
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Supported in practices by community physiologist
UHNS outreach
COPD focused, do SED follow ups / step-up
x6 consultant community clinics per week
x1 consultant MDT per week
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1200 places offered across North Staffordshire
per year
8 venues across the locality – 2 sessions per
week for 8 weeks
High level of satisfaction from questionnaires
Multi-disciplinary team input and signposting
to wider community services
Patient admitted
to AMU
Assessed by
team
Daily review
by team.
Education,
self
management
plans, rescue
meds given &
inhaler
technique
checked
Transferred to
ward
Medically fit
for discharge
Loan
nebuliser
issued (if
needed )
Referral to
Community
respiratory
team faxed
Referral from :
•Single point of
Care
• ‘Potteries Way’
• GP / Practice
Nurse
Home visit
Triage by
Nurse
Specialist
Referral from
Acute or
Community
Hospitals
•Step down post
exacerbation
• follow up
Oxygen review
Clinic
Appointmen
t
Discussion
with or
review by
Consultant
Discharge to
GP & / or Lead
Health
Professional
with Action
Plan
Follow up at
Acute Hospital
for further
investigation
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Dr Martin Allen: Martin.Allen@uhns.nhs.uk
Tel Number 01782 675753 (Alison Jessop
Secretary).
Karen Leech: karen.leech@uhns.nhs.uk Tel
Number 01782 674069
Vicky Campbell:
Victoria.Campbell@ssotp.nhs.uk Tel Number
0300 1230995 ext 4538