clinical component of the domiciliary oxygen service ... - Brit Thoracic

CHANGES TO THEDOMICILIARY OXYGENSERVICE IN ENGLAND ANDWALESWISIA WEDZICHA 1 and PETERCALVERLEY 2St Bartholomew’s and Royal London MedicalSchool 1University Hospital Aintree, Liverpool 2

WHY DO WE GIVE OXYGEN TOOUR PATIENTS?• To prolong life in the persistentlyhypoxaemic• To improve exercise performance• To reduce breathlessness acutely• To stop us worrying about the lowSaO2!

WHY DO WE GIVE OXYGEN TOOUR PATIENTS - THE EVIDENCE• To prolong life in the persistentlyhypoxaemic – GOOD IN COPD• To improve exercise performance – GOODACUTELY• To reduce breathlessness acutely -VARIABLE• To stop us worrying about the low SaO2 –BENEFIT FOR DOCTOR UNTESTED!

DOMICILIARY OXYGENTHERAPY• Long term Oxygen Therapy• Ambulatory Oxygen Therapy• Short Burst Oxygen Therapy• Temporary/Emergency OxygenTherapy

HISTORY OF OXYGEN SERVICE• Early 1980s - RCTs of LTOT published• 1985 - Oxygen concentrator servicestarted• Lobbying for ambulatory oxygen• 1999 - RCP guidelines for home oxygenpublished• Various consultations/meetings• June 2003 - Ministers announce plans tomodernise home oxygen service• July 2003 - BTS Oxygen group reformed

CURRENT HOME OXYGENSERVICE• Primary Care prescriptions - often onsecondary care recommendation• Cylinder service - delivered/collected viapharmacists• Oxygen concentrator service -installed/maintained by specialistcompanies under contract - national service• Ambulatory oxygen not available onprescription• Different supply and payment routes

PROBLEMS WITH CURRENTSERVICE - RCP GUIDELINES• Secondary care not direct prescribers ofhome oxygen therapy• Patients were not adequately assessed• Ambulatory oxygen provision variable andnot funded - liquid oxygen difficult toorganise• Follow up arrangements patchy

NEW SERVICE FROM OCT 2005• Respiratory specialist hospital assessmentand prescription• GPs will be able to prescribe - mainlypalliative/short burst• Ambulatory oxygen will be available onprescription• Integratedcylinder/concentrator/ambulatory serviceprovided by one contractor• Funding will be devolved to PCTs for theservice.

CLINICAL ASSESSMENT ANDPRESCRIBING – KEY CHANGES• Changes reflect RCP guidelines and updatedclinical standard document• Assessments to be performed in secondarycare – likely to be a team approach with aphysician lead• Oxygen needs assessed for ambulatoryoxygen• Follow up arrangements to be defined• Proposal for separate ‘prescription’/order -discussions with PPA

BRITISH THORACIC SOCIETYWORKING PARTY ONDOMICILIARY OXYGENSERVICESWhat is it doing?

OBJECTIVES - BTS Oxygen Group• Write the clinical standard for assessmentand prescription of domiciliary oxygentherapy• Review the RCP guidelines to take intoaccount proposed changes and provision ofambulatory oxygen therapy• Develop advice for follow up for patients• Produce revised version of DomiciliaryOxygen Record Form/prescription (DORform)• Education of health care professionals

ASSESSMENT for LTOT• Referral to consultant respiratoryphysician• Confident clinical diagnosis• Optimum medical management andclinical stability - 5 weeks• Arterial blood gases - measuredtwice, at least 3 weeks apart

PRESCRIPTION AFTER HOSPITALADMISSION - “TEMPORARYOXYGEN”• LTOT prescription should be avoided onhospital discharge• Patients reviewed 5 weeks later• Temporary oxygen supply if required forhypoxaemia.• This supply should be discontinued whengases improve or LTOT prescribed

AMBULATORY OXYGEN THERAPYPRINCIPLES• Enables the patient to leave the home,improve daily activities and quality of life• Type of device depends on mobility• Many COPD patients spend little timeoutside the home - 50% of LTOT patientsare housebound• Prescribed in patients with LTOT PaO2

AMBULATORY OXYGEN THERAPY-PATIENT GRADING• GRADE 1 OXYGEN REQUIREMENTS -LTOT patients with low activity• GRADE 2 OXYGEN REQUIREMENTS -Mobile LTOT patients• GRADE 3 OXYGEN REQUIREMENTS -patients with exercise desaturation butnot on LTOT

AMBULATORY OXYGEN THERAPY-PATIENT ASSESSMENTASSESSMENT PERFORMED WILL DEPEND ONOXYGEN REQUIREMENTS• GRADE 1 OXYGEN REQUIREMENTS - Sameflow rate as for static source• GRADE 2 OXYGEN REQUIREMENTS - Evaluateoxygen flow rate to keep exercise SaO2 above90% using exercise test eg 6 minute walk• GRADE 3 OXYGEN REQUIREMENTS - Exercisetest required, performed on air and oxygen.Require evidence of exercise desaturation andimprovement with oxygen

SHORT BURST OXYGEN THERAPY• Pre-Oxygenation before exercise ?• Recovery from exercise?• Breathlessness at rest• Palliative care• After exacerbation - temporaryoxygenASSESSMENT - No specificmethodology

SHORT BURST OXYGEN THERAPY -who has it at home?• Hypoxaemic patients - should be on LTOT• Non-hypoxaemic patients - either exercisedesaturators or non-desaturators• Palliative use• Heart failure• Information difficult to obtain onprescription

PATIENT FOLLOW UP• SPECIALISTAT 3 months after prescription and yearlyReassessment if undercorrection or deteriorationin symptoms• AT HOMEVisit within 4 weeks of prescriptionSix monthly visitsCheck on usage of ambulatory oxygen therapy

PATIENT FOLLOW UP - PURPOSE• Record SaO2 on air and oxygen• Check oxygen usage - static and ambulatory• Check correct location of equipment, appropriatenasal cannulae and masks available• Provide contact details for oxygen supplier andrespiratory nurse/physiotherapist/technician• Reinforce non-smoking• Education and support• Complete Domiciliary Oxygen Record

ROLE OF OXYGEN CONTRACTOR• Deliver and maintain integrated servicedirect to patients on a 24 hour 7 days aweek basis - response times set• Decide the best way to supply oxygen tomeet patient’s needs• Apply technical expertise to developtechnologies• Contract requires new technologies to bepassed on to patients• Contractor required to engage in patientinvolvement/audit and information oncomplaints

Patient/Carer perspective - theplus side• Access to wide range of oxygenservices• Patient does not need to return to GPfor oxygen prescription• Single supplier for all oxygen needs• Contractors will have to show patientinvolvement• Assessment and follow up included

CONTRACT AREAS• North West• North East• Yorkshire andHumberside• East Midlands• West Midlands• Wales• Eastern England• SW London,Thames Valley,Hants, IOW• SE London, Kent,Surrey and Sussex• London North• South West

ORGANISATION OF SERVICECONTRACT• Each service contract on regional basis - 3 SHAsper oxygen region• PCT deals with one contractor• PCT will need to obtain cylinder data to pass on tonew contractor• End of contract with pharmacists• Transitional arrangements• Funding transferred to PCT unified budgets• Streamlined payment system - proposed throughPPA as for current service• Monitoring performance and quality of service

TIMETABLE THUS FAR• June 2003 - Ministers announce new plans• July 2003 - BTS Oxygen group reformed• August – October 03 - meetings/paperwork• November 2003 - stakeholder meeting• Dec 03- May 2004 - work on draft contract• May 2004 - invitation for expressions ofinterest in tendering for service advertised• July 2004 - tenders invited• Nov 2004 - tender bids received

TIMETABLE 2005• Jan 2005 - recommendations to ministers• Feb 2005 - ministers announce contractors• Feb 2005 - Sep 2005 – implementation• Oct 2005 - Contract start date for O2service

MANAGING SERVICE CHANGE -TRANSITIONAL PERIOD• EDUCATION/PUBLICITY PROGRAMME!• PCT need to get themselves organised• Contractors need 9 months to prepare for changeat agreed contract date• Information provided by PCT to contractor - easyfor concentrators - problematical for cylinders• Dialogue between PCTs, GPs and Trusts aboutassessment and prescription of O2 –the role ofthe SHA’s• Start assessments for ambulatory oxygen ( MobileLTOT patients first)• Systems for managing and funding service

WHAT SHOULD THE CONSULTANTRESPIRATORY PHYSICIAN DO NOW?• Contact the local PCT and ask for a meeting of allthose interested in home oxygen therapy• Review in house assessment protocols for bothLTOT and ambulatory oxygen• BTS Clinical Standard document available on theWeb.• Work out how follow up will be organised withPCTs. Discuss with local BS-SHA rep any problems• Disseminate knowledge about home oxygentherapy