HEART LUNGCANCER DIAGNOSTICS

NHSNHS Improvement

STROKE

Improving oxygen servicesSnapshotDudley PCT introduced a new servicepathway in 2008 to regulate a previouslydisjointed oxygen service managedthrough a single point of contact,resulting in improved identification andtreatment of oxygen patients as well assignificant cost savings.

BackgroundThe process of oxygen assessment andprescribing within the Dudley PCT wasconducted using 'Home Oxygen OrderForms' (HOOFs). Patients with COPDwould be assessed by their GP whowould then decide whether they requiredhome oxygen, how much and for howlong. This information would be recordedon the HOOF and Airproducts wouldthen supply the oxygen to the patient.The whole service was very ad-hoc, therewas no use of pulse oximeters andoxygen prescribing was either seen asbeing a last resort treatment option orutilised too quickly. The quality of theinformation on the HOOFs was alsovaried.

In 2008 the Respiratory localImplementation Team (LIT) commenced areview of the Home Oxygen AssessmentService as it was felt that the use ofHOOFs were adversely affecting thequality, consistency and appropriatenessof oxygen prescribing.

At the time the review was beingconducted:

• 700 patients were on home oxygen(the majority of these were onconcentrators)

• 222 patients were being prescribedShort Burst Oxygen Therapy (SBOT)

• 170 Long Term Oxygen Therapy (LTOT)• 115 were on a combination of LTOT

and ambulatory oxygen• 115 of these patients were 'high

users'.

An audit of the home oxygen service wasconducted by the Lead Nurse for COPDin January 2008. The audit highlighted aservice that was disjointed in places withseveral areas which offered room forimprovement:

• HOOFs were being completed withminimal information

• Patient usage did not correlate withwhat was prescribed on the HOOF

• The service was not cost effective dueto expensive prescribing

• There was a lack of ownership with noreal coordination of the service

• Questions were raised relating topatient safety through inappropriateprescribing and potentiallyinappropriate management of apatients’ condition

• There was no (or lack of) patienteducation especially in areas wherethere was no clinical assessment andfollow up service

• HOOFs were being used to prescribeoxygen with there being any agreedoxygen guidelines in placeNo monitoring was in place andtherefore compliance and techniquewere not being assessed

• There was non-compliance withdirectives and guidelines

• Oxygen was being provided 'ad-hoc'and often wasn't required

• HOOFs were not easy to complete• The service was not cost effective.

Changes implementedOnce the audit was presented to theRespiratory LIT, it was agreed that Dudleypatients and clinicians would benefitfrom an oxygen service redesign and thatthe new service would need to bemanaged by a provider with specialistknowledge of oxygen assessment. TheDudley Respiratory Assessment Service(DRAS) based at the acute generalhospital was identified as being bestplaced to provide the service.

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Dudley PCT

Lung

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Case STUDYLung Improvement

JULY 2012

NHSNHS Improvement

Lung

The service redesign considered thefindings of the audit alongside therequirements of the local population. The‘Oxygen Assessment Service’ (OAS) waslaunched in October 2008.

As part of this, new guidelines wereintroduced to regulate monitoring andreferring patients for home oxygen.

A total of 60 GP practices were suppliedwith pulse oximeters (at a cost of £155each) so that patients can be screened inPrimary Care and those with oxygensaturation of less than 92% can beidentified. These are then referred to aformal assessment (British ThoracicSociety guidelines) for LTOT using asimple ‘Open Access’ referral form.During the assessment patient’s ArterialBlood Gases (ABGs) are measured, andonly those who have PaO2 less than7.3kPa proceed to the LTOT pathway,those with a PaO2 between 7.3 and 8.0will have further assessment (e.g., nightoximetry).

Patients who commence LTOT are thenreviewed at four weeks aftercommencement of treatment via acommunity/Primary care assessment,three months at the OAS (ABGsmeasured), six months and then annually.

All patients who are on home oxygentherapy are added to a register and willbe reviewed at the OAS. Those withSaO2 greater than 92% on air arereviewed as to whether they need to beon oxygen.

All results are reviewed by LeadRespiratory Consultant, who reportsupon and responds to the GP involved,with recommendations.

Overall impact and benefits(including measurement andevidence)By formal assessment and review theteam can ensure that the correctmodality and/or flow rate is achieved.As a result of the new pathway, a singlepoint of contact dealing with everythingto do with oxygen now exists which isaccessible to all who need, or may need,access to the OAS.

A greater clarity now exists with HOOFforms (excluding palliative andpaediatrics) only being completed by the‘Oxygen Team’.

In the first year, 238 people were sent tothe assessment service and only 68needed oxygen. Previously all would havebeen prescribed oxygen by primary care.One hundred and seventy peopletherefore have avoided being placed onoxygen with consequential cost savingsto the Dudley PCT.

The oxygen service ensures patientsafety by:

• Avoiding inappropriate prescribing• Avoiding inappropriate management

of condition• Ensuring adequate patient education.

By monitoring patients the team canidentify issues with poor compliance andconcordance.

Current position of goodpractice/future plansThere was very much a team approach tothe redesign of the service and theservice continues to be monitored via theRespiratory LIT. There is to be a furtherreview of the whole of the Respiratoryassessment service to ascertain anyfurther opportunities for improving theoxygen pathway.

QIPP return – productivity andqualityThe service ensures cost efficiency byensuring oxygen is only prescribed inappropriate cases. As demonstratedspend savings have been made with 170patients avoiding being placed on oxygenat an average cost of £770.00 eachtotalling £130,900 per annum saved net,minus the cost of the assessments£14,518.

This gives a total saving of £116,382for the PCT.

An integrated service tailored to meetthe individual patient needs has resultedin an improved, easy to access servicewith clear guidelines for referral throughboth primary and secondary care. Wherethe majority will be seen and assessedwithin two weeks.Patient satisfactionPatients receive more regular reviews andare counselled appropriately in the eventof oxygen therapy being removed.Communication regarding patientoxygen prescribing has improvedmaterially between primary andsecondary care.

Patients/carers have a single point ofcontact with their oxygen concerns.

The local voluntary sector groupBreatheasy were also consulted onchanges to the clinical pathway and theircomments have been positive as they feeltheir needs are being prioritised withinthe commissioning process.

NHS Improvement added valueThe OAS has demonstrated how thehealth economy can work collaborativelyto deliver an improved quality service forpatients. The savings generated wereachieved well above the anticipatedbusiness case developed prior toimplementation.

ContactMark Hopkin,Email: mark.hopkin@dudley.nhs.ukTel: 01384 873 311

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Case STUDYLung Improvement

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