Post on 04-Apr-2020
Corporate Scholarship Program
Attachment Program for Physiotherapists in Advancement of Respiratory Rehabilitation and Non-Invasive Ventilation organized by Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
Team Members: Ms. VONG Yonny PTI NDH Mr. CHAN Clement SPT RHTSK Mr. CHAN Geoffrey PTI PYNEH Mr. LAM Patrick PTI PWH Ms. POON Pauline SPT QMH
Hospital Authority Convention 2014 8 May 2014 at the Hong Kong Convention & Exhibition Centre
A. Clinical Visit/ Attachment
1. Guys’ and St. Thomas (GST) Hospital Lane Fox Respiratory Unit (LFRU)
2. Daily Consultant Ward Round, Multidisciplinary Meeting in the LFRU
3. Physiotherapy Service in the LFRU
4. Neuromuscular Service in the LFRU
5. LFRU Outreach (Intermediate care / home visit) Service for Home Mechanical Ventilation
6. Ambulatory Oxygen Assessment Physio-led Clinic
7. Pulmonary Rehabilitation
8. Intensive Care Unit (ICU)
Program Content 5 to 16 Nov 2012
B. Practical and Workshop
9. Continuous Positive Airway Pressure (CPAP) and Non Invasive Ventilation (NIV) -Interface, Setup, Titration, Protocols and Troubleshooting
10. Negative Pressure Ventilation (Cuirass, Iron Lung)
11. Cough Assist
12. Overnight Oximetry , Capnography
13. Sleep Disorders including Obstructive Sleep Apnoea
(OSA) and Obesity Hypoventilation Syndrome (OHS)
14. Respiratory Muscle and Cough Strength Measurement
Program Content 5 to 16 Nov 2012
0.67M
0.16M
0.65M
0.17M
Facts and Figures
Setting / Referral • 14 Critical Care Beds, 2 Out-patient Rooms
Professional Staff Medical (1 shift + oncall)
• 4 Respiratory Consultants (Respiratory, Critical Care & Sleep) • 2 Registrars • 1 Intensivist • Research Fellows and Consultants
Nursing (3 shifts)
• 1 Ward Manager • 48 Nurses (3 shifts) • 1 Outreach Sister & 1 Outreach Senior Nurse
Therapists (1 shift + oncall)
• 2 Senior / Respiratory Physiotherapy Specialist • 1 Physiotherapist • 1 Neuromuscular Transitional Care Co-ordinator (Respiratory Physiotherapy Specialist) • 0.1 Rehabilitation Physiotherapy Specialist • 1 Senior Occupational Therapist
Technical (1 shift + oncall)
• 5 Technicians/Engineers
Medical
Nursing
Therapies
Technical
24/7 coverage
Lane Fox Respiratory Unit (LFRU)
Organization Structure
LFRU
Target Disease & Condition
Chronic Respiratory Failure
Weaning from Invasive Tracheostomy Ventilation
• Airway disease
• Neuromuscular disease
• Chest wall abnormalities
• Obesity
Domiciliary NIV for Chronic Respiratory Failure
Obstructive Sleep Apnoea
Post polio syndrome
CRF Patients
Longterm Respiratory Support
Acute Respiratory Support
Emergency Admission To Lane Fox Unit
Respiratory Assessment Sleep Studies
Regular Reviews
Non-Invasive Ventilation (>150 episodes per year)
Pre-op Assessment Post-op Support
Nutritional Assessment PEG Insertion
Liaise with AICU & PICU
(>70 cases / yr)
Respiratory Physiotherapy Support
Establish & Service HMV
(>150 cases / yr; >1100 cases in total)
Assess for Cough Assist Device
Liaise with Local Hospital
Weaning from Ventilation/ Removal of Tracheostomy
(>70 cases / yr)
ICU Admission Tracheostomy
EOLC
Progressive Neuromuscular Disease
Clinical Support and Remote Weaning
LFRU
Service Partners
General Practitio-
ner
Local Hospitals
Highly Dependent Nursing Home
Clinical Excellence
Educational Excellence
Research Excellence
Respiratory Physiotherapist Roles and Responsibilities
Consultant PT / Physician – led 24/7 Acute NIV Service (covering A&E, Emergency Ward, HDU, LFU)
Respiratory Physiotherapist Roles and Responsibilities
Consultant PT / Physician – lead 24/7 Acute NIV Service (covering A&E, Emergency Ward, HDU, LFU)
46%
26%
11%
4%
13%
Diagnosis
COPD
Pneumonia
LVF
OSA
Others
52%
11%
22%
10%
5%
Referral Source
A&E
Admission Ward
Critical Care
Other Wards
Others
(n=149) (n=149)
Respiratory Physiotherapist Roles and Responsibilities
Assessment
Peak Cough Flow Arterial blood gas sampling and interpretation
Assessment
• Allow continuous monitoring, which has been shown to be useful in the initiation and titration of NIV and ventilator for the treatment of acute and chronic respiratory failure
• The use of the combined PCO2 /SpO2 sensor has been validated against measurements on ABG samples repeatedly drawn from indwelling arterial lines
• Measurements between ABG and TcPCO2
were highly correlated (for PCO2 between 5 to 22kPa) on arrival in the HDU (r=0.99, p<0.001) and 1 hour (r=0.99, p<0.001) and 4 hours (r=0.98, p<0.001) after commencing NIV.
Respiratory Physiotherapist Roles and Responsibilities
Transcutaneous pCO2 (TcPCO2)
Source: Cox et al. Non-invasive monitoring of CO2 levels In patients using NIV for AECOPD. Thorax 2006, 61(4), 364-365 Hazenberg et al. Validation of a Transcutaneous CO2 Monitor in Adult Patients with Chronic Respiratory Failure. Respiration 2011;81:242-246. Carter R. Transcutaneous CO2 and O2 Monitoring in the Adult Patient. The Buyers Guide to Respiratory Care Products 102-109. (http://dev.ersnet.org/uploads/Document/2c/WEB_CHEMIN_2560_1194522858.pdf)
Respiratory Physiotherapist Roles and Responsibilities
Sputum Clearance
Airway Clearance
Recombinant Human Deoxyribonuclease (DNAse)
Respiratory Physiotherapist Roles and Responsibilities
• Intratracheal administration of DNAse 30 mins before chest physiotherapy to facilitate sputum clearance
Source: Malcolm King and Bruce K Rubin. Pharmacological approaches to discovery and development of new mucolytic agents. Advanced Drug
Delivery Reviews 2002, 54(11) 1475–1490. Hill and Webber. Physiotherapy for airway clearance in adults. Eur Respir J 1999;14:1418-1424.
Respiratory Physiotherapist Roles and Responsibilities
Weaning from Mechanical Ventilation to NIV
Respiratory Physiotherapist Roles and Responsibilities
Outreach Program • Home assessment • Home tracheostomy
ventilation • Critical care • Weaning from invasive
Mechanical Ventilation • Intermediate care • Acute care home • Palliative Care
Respiratory Physiotherapist Roles and Responsibilities
Abbreviations: PSG = nocturnal polysomnography; ODI = oxygen desaturation index, CPAP=continuous positive airway pressure.
Assessment Overnight Oximetry (OSA/OHS/CSA/Overlap)
Respiratory Physiotherapist Roles and Responsibilities
Ambulatory Oxygen Physio-led Clinic
Respiratory Physiotherapist Roles and Responsibilities
Pulmonary Rehabilitation
Respiratory Physiotherapist Roles and Responsibilities
Training Support: To safely manage patients requiring acute NIV, PT in the GSTT undergo a
clinical competencies acquisition process. During the training process, PT shall be formally assessed on their clinical competencies
Overseas Corporate Scholarship Program for Allied Health Professionals Attachment Program for Physiotherapists in Advancement of
Respiratory Rehabilitation and Non-Invasive Ventilation
Potential Opportunity of Respiratory Physiotherapy Service in HA
1. Physiotherapy in Acute NIV Service
2. Community Physiotherapy (CPT) in NIV
Service
3. Ambulatory Oxygen Therapy Clinic
Overseas Corporate Scholarship Program for Allied Health Professionals Attachment Program for Physiotherapists in Advancement of
Respiratory Rehabilitation and Non-Invasive Ventilation
Potential Opportunity of Respiratory Physiotherapy Service in HA
1. Physiotherapy in Acute NIV Service
2. Community Physiotherapy in NIV Service
3. Ambulatory Oxygen Therapy Clinic
Physiotherapy in Acute NIV Service
Learning Points from UK
Multidisciplinary team uses standardized evidence-based guidelines and protocols.
Comprehensive care-giver training and competency assessment Continuing support after discharge and emergency support during crisis.
Physiotherapists provide 24/7 service on NIV setup, titration and troubleshooting in Accident and Emergency Department (AED) Clinical competencies acquisition in NIV management for Physiotherapists
through training and assessment to ensure an effective and safe management to patients
Active research allows continuous evaluation and development of the NIV
service
Physiotherapy in Acute NIV Service Physiotherapy Service Improvement
Guidelines Development and Staff Training
• Service guideline on ‘Physiotherapy Management of COPD patients with Non-invasive Ventilation’ was developed and endorsed by PTCOC.
• In-service trainings were conducted among PWH, QMH, PYNEH, TWEH and NDH with more than 150 attendance.
• Multidisciplinary Journal Club Sharing in Medicine and Rehabilitation Team of TWEH: 5PT, 3 OT, 5 nurse, 1 Consultant, 3 Associate Consultant and 1 Physician.
• Physiotherapy Commissioned Training Program 2013/2014 : ‘Advances in NIV and Home Mechanical Ventilation (HMV) for Physiotherapist’, held from 17 to 20 Jan 2014 with more than 200 participants
Ensure Service Quality and Safety Enhance Clinical Risk Management
Improve Clinical Practice
Physiotherapy in Acute NIV Service New HA Service Development:
NIV Program Development and Evaluation
• To improve service quality and safety, a
multidisciplinary COPD NIV Program involving physician, physiotherapist and nurse has been implemented in 5 pilot hospitals (PWH, PMH, POH, QMH and UCH) since mid to late 2013.
• A physiotherapist baseline database is constructing for evaluation and further planning.
Ensure Service Quality and Safety Enhance Clinical Risk Management
Improve Clinical Practice
Physiotherapy in Acute NIV Service New Physiotherapy Service Development:
5 Pilot Hospitals Experience:
• Early mobilization with NIV therapy
• Bronchial hygiene therapy enhanced with cough assist machine and manual assisted coughing technique
• Titration of parameters during exercise and bronchial hygiene therapy to optimize outcome if necessary
Ensure Service Quality and Safety Enhance Clinical Risk Management
Improve Clinical Practice
Physiotherapy in Acute NIV Service New Physiotherapy Service Development:
5 Pilot Hospitals Experience (cont’d)
• Proactive discussion with Respiratory physician and nurse to facilitate better NIV management including fitting, weaning and parameters adjustment.
• Supporting weaning process of long-term tracheostomy
>> cuff-down + NIV therapy
Ensure Service Quality and Safety Enhance Clinical Risk Management
Improve Clinical Practice
Overseas Corporate Scholarship Program for Allied Health Professionals Attachment Program for Physiotherapists in Advancement of
Respiratory Rehabilitation and Non-Invasive Ventilation
Potential Opportunity of Respiratory Physiotherapy Service in HA
1. Physiotherapy in Acute NIV Service
2. Community Physiotherapy (CPT)
in NIV Service
3. Ambulatory Oxygen Therapy Clinic
Community Physiotherapy and NIV Service
Learning Points from UK Multidisciplinary team backup with standardized evidence-based guidelines
and protocols. Well-established Outreach program including proactive case management with crisis intervention planning to prevent avoidable hospital readmission
CPT provide regular community visits to patients on NIV or home
tracheostomy, those residing at acute care home as well as NMD patients in chronic respiratory failure. Comprehensive care-giver training and competency assessment.
PT conducted objective measurement (transcutaneous PCO2 and ABG) on the PCO2 level of hypercapnic or NIV patients
PT titrate the NIV setting of patients in the community, according to the protocol and guidelines, to facilitate timely intervention
Community Physiotherapy in NIV Service Potential Opportunity in HA
1. Standardization of documentation of NIV assessment and intervention.
2. With reference to the Community PT experience for NIV users in NDH, PMH and QEH. It is recommended to:
• explore the possibility of implementing similar service in other clusters to facilitate early discharge and prevent unplanned hospital re-admission of respiratory failure patients with NIV.
• explore the feasibility of assessing PaCO2 level in the community by PT to facilitate early, safe and effective intervention for patient residing in the community
Better Manage Growing Service Demand Increase Efficiency, Reduce Demand
Community Physiotherapy in NIV Service New Physiotherapy Service Development North District Hospital (NDH) Experience:
Proactive case management and collaboration
SaO2 80%
24/ 11/ 2014 Telemonitoring data: Mean SaO2 80%, <88% 10 hr 28 min (79.1%) on 3.5 LO2/min NC
Case Mr. Mak
CPT trigger Crisis Management
suggesting NIV initiation
Respiratory Consultation
Clinical Admission with NIV initiated
& decrease O2 support
SaO2 90%
21/12/2014 Telemonitoring data: Mean SaO2 92%, <88% 19min
(Nocturnal BIPAP, ST mode, RR 12, IPAP 20, EPAP 12 RT: 1; Insp time: 1.0, 1 LO2)
Community Physiotherapy in NIV Service Physiotherapy Service Improvement NDH Experience: Transcutaneous PCO2 measurement
Overseas Corporate Scholarship Program for Allied Health Professionals Attachment Program for Physiotherapists in Advancement of
Respiratory Rehabilitation and Non-Invasive Ventilation
Potential Opportunity of Respiratory Physiotherapy Service in HA
1. Physiotherapy in Acute NIV Service
2. Community Physiotherapy (CPT) in NIV
Service
3. Ambulatory Oxygen Therapy Clinic
Ambulatory Oxygen Therapy (AOT) Clinic
Learning Points from UK
• PT led AOT clinic provides thorough assessment
to ensure best understanding of
respiratory condition and equipment
selection for optimization of patient daily life
activity.
• Detailed and up-dated assessment
report for Physician to facilitate further
investigation and management.
Ambulatory Oxygen Therapy (AOT) Clinic Potential Opportunity in HA
• To consult relevant stakeholders to explore the feasibility of
establishing AOT clinic in out-patient or
extended care setting.
• NDH has incorporated portable oxygen concentrator
therapy for NIV users to enhance their physical activities
and oxygen compliance.
• To improve patients’ symptoms, exercise
tolerance and physical independence.
Ensure Service Quality and Safety Improve Clinical Practice
Ambulatory Oxygen Therapy (AOT) Clinic Physiotherapy Service Improvement
NDH Experience- O2 empowerment pilot study
(O2 cylinder and Portable Oxygen Concentrator)
Increase oxygen compliance
Facilitate Pulmonary Rehabilitation Program
Safe pursuit of outdoor activities
Increase Physical endurance
Empower Physical activities
Overseas Corporate Scholarship Program for Allied Health Professionals Attachment Program for
Physiotherapists in Advancement of Respiratory Rehabilitation and Non-Invasive Ventilation
Conclusion
• This attachment program has inspired the advancement of physiotherapists’ role in NIV service and pulmonary rehabilitation. Further training of more PT is recommended.
• Apart from the current service in HA, PT service for respiratory patients and NIV users could be enhanced for better care and reduction in unplanned readmission, via multidisciplinary collaboration and continuing professional training
• With management’s support, effective resource allocation and continuing professional training in HA,
we believe a higher level of care for chronic respiratory patients can be attained.
Reference
1. Carter R. Transcutaneous CO2 and O2 Monitoring in the Adult Patient. The Buyers Guide to Respiratory Care Products 2012, 102-109. (http://dev.ersnet.org/uploads/Document/2c/WEB_CHEMIN_2560_1194522858.pdf)
2. Cox et al. Non-invasive monitoring of CO2 levels In patients using NIV for AECOPD. Thorax 2006, 61(4), 364-365
3. Department of Health (2012). Health Facts of Hong Kong. (http://www.dh.gov.hk/english/statistics/statistics_hs/files/Health_Statistics_pamphlet_E.pdf)
4. Dixon Anna and Robinson Ray (2002). “The United Kingdom” Healthcare systems in eight countries; trends and challenges. European Observatory on Health Systems. Health Trends Review, HM Treasury.
5. Food and Health Bureau of the Hong Kong Special Administration Region Government (2008). Synopsis of Healthcare Financing Studies - Healthcare System and Financing: Overseas Experience.
Reference 6. Fried Bruce and Gaydos Laura (2002). “The United Kingdom” World
Health System: Challenges and Perspectives: Eds. Bruce Fried and Laura Gaydos. Chicago: Health Administration Press.
7. Ham Chris (1997). “The United Kingdom.” Healthcare Reform: Learning from International Experience. Ed. C. Ham OUP.
8. Harker Rachael (2011). NHS Funding and Expenditure (http://www.nhshistory.net/parlymoney.pdf)
9. Hazenberg et al. Validation of a Transcutaneous CO2 Monitor in Adult Patients with Chronic Respiratory Failure. Respiration 2011;81:242-246.
10. Hill and Webber. Physiotherapy for airway clearance in adults. Eur Respir J 1999;14:1418-1424.
11. Kaiser (2009). An online health policy resource for faculty and students. http://www.kaiseredu.org/topics_im_ihs.asp?imID=1&parentID=61
12. Malcolm King and Bruce K Rubin. Pharmacological approaches to discovery and development of new mucolytic agents. Advanced Drug Delivery Reviews 2002, 54(11) 1475–1490.
Acknowledgement LFRU, Guy’s and St. Thomas’ NHS Foundation Trust,
London, United Kingdom Respiratory Team and Physiotherapy Department of
NDH, PMH, POH, PWH, PYNEH, QMH, RHTSK, TWEH and UCH
Thank you
Q&A