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The Primary Care Respiratory Society

Inspiring best practice in respiratory care


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Inspiring best practice in respiratory care

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Conference Abstracts

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PCRS Respiratory Conference 2021 Abstracts

At this year’s virtual conference, delegates will be able to view abstract posters and ask questions to authors in our virtual poster room.


Authors: Marsh V, Hamilton J, Moran J, Adams T, Collier N, Hamilton M, Hale J, Jalota B, Hopkin M.
Institution: NPRANG
Presenter: Viv Marsh
Category: Best Practice / Service Development Abstract
Context: We took the opportunity of the dramatic changes to general practice as a result of covid19 crisis to develop our understanding of remote consultations for routine asthma care. Our aim is to transform our approach to routine asthma care in Dudley.
Analysis of the problem:
Findings from a discussion via videoconference to explore the perceptions that primary care nurses from different practices had in relation to remote consultations for patients with asthma (n= 11): Most remote consultations at that time were being carried out via telephone with limited experience of video consultations. Perceptions and experience varied between nurses’ but included:
Barriers - lack of infrastructure, system functionality, nurse preference for face to face.
Facilitators – flexibility, positive patient experience.
A small project team formed in one general practice identified specific issues on that site where the major barriers were lack of infrastructure and absence of training and support leading to low confidence levels with video consultations.

Strategy for change:
The project team, practice nurses (n=2), HCA, visiting specialist nurse and the practice manager worked together to implement a strategy offering a digital first approach to routine asthma care (see Figure 1). We also changed the system to target patients with indicators of risk e.g. overuse of SABA. Safety nets for digitally excluded/non-responders have been put in place.
Measurement of improvement:
Organisation of routine asthma care in this practice has been transformed:
• patients are prioritised for review based on risk factors
• all reviews are offered digitally first
• patients who are digitally excluded or in clinical need are invited for face to face review
• 1 patient referred to the Difficult Asthma Service
• Increased staff/patient engagement/satisfaction
Next steps:
Test and refine the strategy throughout August, share the learning and strategy with other practices in Dudley, embed the changes into ongoing routine asthma care.
Authors: Dosanjh, A.
Institution: Pediatric Respiratory
Presenter: Amrita Dosanjh M.D.
Category: Scientific Research Abstract
Aim: This study was conducted to systematically review the literature to identify pediatric studies with measurable levels of IL-6 from infants with Respiratory Syncytial Viral Bronchiolitis or pneumonia.
IL-6 has been identified as a biomarker in COVID 19 pneumonia and a comparison will be made between these two diseases.
Method: The search terms used were RSV, Bronchiolitis, IL-6 and infant using PubMed.
The articles were included if they contained specific data documenting IL-6 levels of infants with LRTI. Studies were excluded if the data was not included in either table,graph or narrative format. Studies of older children were not included.
Results: The results indicated that there were approximately 43 articles identified, including non English publications. There were 13 studies to date, with IL-6 measurements selected which met the inclusion criteria for further analysis. Studies were excluded if levels were not reported. IL-6 levels were typically reported as pg/ml, mean and SD.
The samples included serum, plasma and nasal aspirates.IL-6 levels ranged widely from 0->2000pg/ml, depending on the location of sampling and the severity of the patient. Patients with more severe disease demonstrated higher levels than milder or control subjects ( p<0.05).
Conclusions: IL-6 may be a useful marker for further consideration in COVID 19 patients and has been shown to be detectable in upper airway and blood sampling. The use of IL-6 has previously differentiated patients with mild from severe lower respiratory tract viral illness, and thus should be further studied in the setting of COVID 19.
Authors: Gardiner L, Shannon H, Osman L
Institution: University of Birmingham
Presenter: Lucy Gardiner
Category: Best Practice / Service Development Abstract
Background: Pulmonary rehabilitation (PR) is well recognised for improving exercise tolerance and health related quality of life (HRQoL) in people with chronic obstructive pulmonary disease (COPD). However, attendance and completion rates for PR remain suboptimal. Dance is an effective alternative approach to exercise in other chronic disease populations. Latin-based dance may also serve to improve engagement in pulmonary rehabilitation.
Aim: To determine whether Latin dance-based exercise results in greater improvements in exercise tolerance and HRQoL when compared to conventional forms of aerobic exercise used as part of PR. Further, to determine any differences in completion rates between the dance-based and conventional programmes.
Methods: This retrospective service evaluation compared people with COPD who were enrolled into the Barts PR service conventional and dance-based PR programmes, between February and May 2019. The programmes were identical, other than the style of aerobic exercise style. Within- and between- group differences following PR in exercise tolerance and HRQoL were compared. Completion rates were also compared.
Results: The number of patients recruited to the dance and conventional groups was 5 and 11, respectively. Median change in exercise tolerance following PR was 47.5m in the dance group (incremental shuttle walk test) and 35.0m in the conventional group (six-minute walk test). Median change in the CAT was -2 in the dance group and 1 in the conventional group. Completion rate was 34.5% higher in the dance group, although the groups were of unequal numbers. There were no statistically significant differences reported.
Conclusion: The results of this service evaluation were inconclusive. Completion rate was higher in the dance-based PR programme compared with the conventional programme. However, caution should be exercised in interpreting this finding due to the recognised limitations of this retrospective, single centre study. Further data are required in the form of a larger, adequately powered observational study.
Authors: Langley S, Marsden C & Bancroft J
Institution: Central London Community Healthcare
Presenter: Sue Langley
Category: Best Practice / Service Development Abstract
Background.
The benefits of traditional pulmonary rehabilitation exercises are extensively documented. Alternative methods of exercise have begun to be used in other patient groups including those with Dementia and Parkinsons Disease. The project was undertaken to discern whether alternative exercises would demonstrate similar benefits for individuals with a chronic respiratory condition. The initial designed was for a maintenance program post completion of traditional pulmonary rehabilitation using dance and tai chi.
Assessment Methods & Tools:
The following tools were chosen for assessment purposes; GAD-7, PHQ9 & CAT. An Incremental Shuttle Walk Test (ISWT) was also used. Data was collected using all of these methods at the start of the program and again at 3 and 8 months. These were chosen as they allowed for comparisons to be made from the traditional program.
Initial Findings:
Preliminary interpretation would suggest that continued improvements in physical and psychological wellbeing are shown up until month 3. Between 3 & 8 months the improvements noted plateau. The very essence of a maintenance program is to ensure that fitness levels are maintained and the results would suggest that this is indeed true. The team discussed these results and it was felt that generally the results were promising and indeed would support our initial thoughts that a maintenance program would provide continued benefits to the population.
Recommendations:
The program unfortunately had to be cut short before a second phase of assessments could take place due to increased demand and a loss of staff. This was a pilot study and initial results would suggest that there is benefit to be gained from non traditional exercise which has led the service to adapt its previous program to provide a Tai Chi pathway as an alternative to traditional Pulmonary Rehabilitation. A secondary study to review this randomised group is underway.
Authors: Anderson K, Davis C, Hardstaff R
Institution: Southern Health NHS Trust
Presenter: Kay Anderson
Category: Best Practice / Service Development Abstract
Background
Inhaled respiratory medication for patients with asthma and COPD is beneficial as it targets lungs, reducing risks of systemic side effects from oral therapy. Used correctly, inhalers can control respiratory symptoms, minimising risks of hospital admission from exacerbations.
Evidence suggests inhaler technique is inefficient. Limited understanding by hcp on correct use of inhaler devices can contribute to inadequate inhaler technique assessments; whilst the plethora of new devices adds confusion.
Aims
To identify the need for inhaler technique assessment training for registered non- respiratory specialist hcps across Southern Health NHS Foundation Trust.
Methods
A questionnaire was launched via Snap survey across physical health, mental health and learning disabilities to 1979 Registered Nurses, 191 Physiotherapists, 194 Occupational therapists and 28 Pharmacists in inpatient and community settings. Hcp on maternity leave or long term sickness were excluded.
Three Pharmacists independently highlighted that Pharmacy technicians complete inhaler technique assessments, so 20 additional Pharmacy technicians were included.
The survey was available for 3 weeks with weekly emailed reminders. A survey link was attached in the Trust’s weekly communication bulletin.
Results
The questionnaire was completed by 18.7% (439) of hcp and considered representative of population with 1/5 of work force responding. Pharmacy technicians were highest respondents with 74% (14) returns, fewest returns were from Registered nurses 17% (332).
Results show that non-respiratory specialist hcp do complete inhaler technique assessments and 36% (161) of them had received inhaler technique assessment training. Of that 36% (161), 86% (139) had received inhaler technique assessment training over a year ago.
Results show non-respiratory specialist hcp considered themselves more competent than confident completing inhaler technique assessments and 40% (171) of them did not understand the difference between Dry Powder and Metered Dose Inhalers.
97% agreed inhaler technique assessment improves patient care and 88% agreed if they received training on inhaler technique assessments it would improve patient care.
Conclusions
Non-respiratory specialist hcp do assess inhaler technique. This service evaluation has identified a need for inhaler technique training for non-respiratory specialist hcp.
Further work is needed to assess where training is prioritised across Southern Health NHS Foundation Trust.
Authors: Anderson K, Field S, Hardstaff R
Institution: Southern Health NHS Trust
Presenter: Kay Anderson
Category: Best Practice / Service Development Abstract
Background
Patients with a COPD exacerbation are reviewed at home by respiratory specialist hcp within 24 hours of discharge from hospital or following referral from GP.
Patients are assessed and in the community and advised on their inhaler technique to ensure optimal use. They are supported to help reduce the impact of COPD on their wellbeing and daily life through training and education on self management and are assessed using the COPD Assessment Test (CAT) questionnaire.
Aims
To identify whether patients’ with COPD demonstrate improvements in inhaler technique and a reduction in CAT scores after assessment and training by respiratory specialist hcps in Southern Health NHS Foundation Trust.
Methods
Following a COPD exacerbation, patients had their inhaler technique assessed in the community using (UKIG) 7 steps scoring guidance.
Patients were supported to complete a COPD Assessment Test (CAT) questionnaire.
Education and training on inhaler technique and self management was given by respiratory specialist hcp.
Both assessments were completed on day 1 and reassessed at day 28, on discharge from SD / AA.
Results
Between January and December 2019, results show when patients inhaler technique was assessed on both day 1 and day 28 of SD / AA, 61% (62) showed an increase in their 7 steps score, 39% (40) of these patients were optimised. Results show 33% (34) patients showed no change and on day 28, 64% (66) of all patients scored 7 out of the 7.
Results show CAT score decreased in 62% (70) patients by day 28 of SD / AA pathway indicating a reduction on the impact of COPD on wellbeing and daily life. .
Conclusions
Supported Discharge and Admission Avoidance service improves CAT scores and inhaler technique for patients with COPD
Further work is needed to identify if improved inhaler technique and reduced CAT scores reduces COPD exacerbations for patients in Southern Health NHS Foundation Trust.
Authors: Dr Ranjbar H,
Dr Dorai S,
Institution: Royal Sussex county hospital
Presenter: Hoda Ranjbar
Category: Best Practice / Service Development Abstract
Oxygen is one of the most commonly used, yet poorly prescribed drugs. The British Thoracic Society (BTS) 2015 National Emergency Oxygen Audit highlighted national shortcomings in oxygen prescribing and administration. A 2017 local audit at RSCH continued to demonstrate poor compliance with the BTS Oxygen Prescribing Guidelines in all areas audited. We carried out yearly re-audits in November 2018 and 2019 to objectively measure the impact of implementing trust-wide and local interventions (July 2018 and August 2019).

Intervention 1
- Introduction of the 'NEWS 2' scale
- Re-designing drug charts with 'tick-boxes' for target oxygen saturations
Intervention 2
- Mandatory junior doctor teaching on safe oxygen prescribing
- ‘Oxygen Safety’ posters on audited wards
- Reminders at handover for staff to measure and document oxygen saturations

Following Intervention 1, all patients with valid oxygen prescriptions had a specified target saturations range. Intervention 2 ensured all patients had ‘actual’ saturations within their prescribed target range, and 99% had oxygen saturations documented with sufficient frequency for their NEWS score. These were huge improvements from previous audits, during which a significant porportion of patients were at risk of hypercapnia, and those over or under-oxygenated were left unrecognised for hours. Despite improvements, 14% of patients continued to use oxygen without valid prescriptions in 2019, and drug charts were inconsistently signed for during drug rounds.

Although the implemented changes enabled drastic improvements for patient safety and quality in oxygen use, future work should ensure oxygen is always treated as a drug with suitable prescription and documentation.
Authors: Dickens AP, Martins S, Salibe-Filho W, Sousa LVA, Albuquerque Neto AA, Adab P, Enocson A, Sitch A, Stelmach R, Jordan R on behalf of the Breathe Well Group
Institution: Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, UK
Presenter: Andy Dickens
Category: Scientific Research Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: Dickens AP, Martins S, Salibe-Filho W, Sousa LVA, Albuquerque Neto AA, Adab P, Enocson A, Sitch A, Stelmach R, Jordan R on behalf of the Breathe Well Group
Institution: Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, UK
Presenter: Andy Dickens
Category: Scientific Research Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: Dickens AP, Pan Z, Chi C, Kong X, Enocson A, Adab P, Cheng KK, Sitch A, Jowett S, Jordan RE on behalf of the Breathe Well Group
Institution: Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, UK
Presenter: Andy Dickens
Category: Scientific Research Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: Dickens AP, Pan Z, Chi C, Kong X, Enocson A, Adab P, Cheng KK, Sitch A, Jowett S, Jordan RE on behalf of the Breathe Well Group
Institution: Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, UK
Presenter: Andy Dickens
Category: Scientific Research Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: Jordan RE, Stanoevski G, Adab P, Enocson A, Stavrikj K, Ristovska R, Gjorgjievski D, Stamenova A, Krstevska E, Adams R, Dickens AP, Sitch A, Rai K, Farley A on behalf of the Breathe Well Group
Institution: University of Birmingham
Presenter: Rachel Jordan
Category: Scientific Research Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: Attar-Zadeh D, Heading CE, Shah U, Bancroft S
Institution: Royal Pharmaceutical Society in North West London
Presenter: Darush Attar-Zadeh
Category: Best Practice / Service Development Abstract
Context and analysis:
Patients and health care professionals under-utilise tools that could bring benefit to asthma patients. Our study aimed to determine whether a Data Driven Care approach in community pharmacies could remedy this.

Strategy:
Patients were invited to community pharmacy consultations (across 19 pharmacies) where, with patient consent, data were collected, and support provided. Methodology used previously was expanded and refined, and a follow-up (FU) consultation 2-4 months later was arranged. Initially n=98; and at FU n=71.
To facilitate tailored support, data were collected from: structured patient conversations; measurements in the pharmacy (Asthma Control Test (ACT), CO, Peak Flow (PF)); Patient Medication Records (PMR) and the Asthma Right Care (ARC) SABA slide-rule. Demographic and qualitative data were also collected.
Support included: education on how to improve lung function; help with inhaler technique; referrals (e.g. GP surgery or smoking cessation service, to websites of Asthma UK, RightBreathe, Meteorological office, PF meter issued; support preparing a Personalised Asthma Action Plan (PAAP).
Examples of how the collected data assisted support:
• PMR assisted identifying patients who would benefit from an invitation for a consultation
• ACT and PF values supported discussions on current management and guided self-management
• ARC slide-rule together with the PMR information supported discussion of potential SABA over-reliance and preventer under use.

Improvement:
Follow-up findings included:
• Consultations increased patient confidence (67/68) in managing their asthma, and in using their inhalers in the right way on the right occasions (67/68)
• Patients reported home PF meters were useful for monitoring lung function (55/61); most patients kept some record of readings (47/68).
• Initial awareness of PAAPs was low (22/97) rising to at least (57/71) at FU. Nevertheless, at FU only (37/71) reported having a completed PAAP.
Messages:
Collecting and sharing data with patients facilitates tailored support in pharmacy settings and enhances patient engagement and care.
Authors: Hartman D, Phillips K, Robinson R
Institution: Hywel dda University Health Board
Presenter: Debbie Hartman
Category: Best Practice / Service Development Abstract
This evaluation is of a novel, locally adaptable role piloted in the Tywi/Taf (2Ts) cluster area, funded by Primary Care Cluster Funding It was undertaken in direct response to the National Review of Asthma Deaths (NRAD) report (2014) as a quality improvement project. The 2Ts cluster prioritised asthma care as an area of clinical need, and a Secondary care specialist Asthma Consultant supported the role.

NRAD(2014) identified overuse of Ventolin as a risk factor for asthma death. It was recognised that Ventolin overuse was an issue within the cluster.
Asthma UK surveys consistently demonstrated a low number of patients with asthma plans in Wales which was also applicable to the cluster. There was consensus that there was an ineffective primary/secondary care interface.

A Respiratory CNS was employed for 4 days a week in primary care and for the 5th in the Specialist Asthma Clinic in Secondary care.
• Primary care asthma clinics were established to facilitate mentoring of practice nurses.
• Data searches on ‘EMIS’/Vision were used to highlight patients in need of priority
• New severe/complex asthma patients were identified and referred to the Specialist Asthma Clinic

The primary objectives were
1. To identify patients at high risk of asthma death by looking for patients using more than 12 salbutamol inhalers in 12 months
2. To standardise the delivery of Practice asthma Care.
3. To increase the number of patients with asthma plans
4. To redesign the management of complex asthma patients

All primary objectives were achieved including a significant decrease in Ventolin usage and improved asthma care in all practices, with clear benefits to patients and Cluster practices.
Improved primary/secondary care interface can result in improved patient and service outcomes. Collaborative working has led to the timely availability of complex asthma treatments with benefits for patients, staff and the service.

Authors: Gaduzo S, Newey A, Gregory M, Shaw A, Drummond J, Oldham L
Institution: Stockport NSFT
Presenter: Stephen Gaduzo
Category: Best Practice / Service Development Abstract
Context
QOF changes for COPD saw referrals to pulmonary rehabilitation (PR) increase from 500 in 2018/19 to nearly 800 in 2019/20. With no corresponding increase in already below national average PR resources, our waiting list grew alarmingly. Suspension of PR services due to Covid-19 left little hope of reducing this in the short term.
Analysis of problem
Health Innovation Manchester had already made available licenses for myCOPD app from myMhealth. We saw an opportunity to use this in a targeted way to enable patients on the waiting list to access the limited and generic activity advice the app includes, as well as the wider self-help it provides.
Strategy & method
All patients with COPD on PR waiting list were sent an introductory letter. We liaised with "Healthy Stockport" to set up a helpline, with materials and training from myMhealth. This was followed by a telephone call explaining the App's potential benefits and IT requirements. If interested they were recruited by means of email with registration link generated from myMhealth website. These patients were followed up with a further call 2-3 weeks later offering support, giving helpline number and encouraging them to engage with the PR section.
Results to date
In the first month of this ongoing process, 348 patients on the waiting list were contacted. 148 were recruited, 191 declined. Of those sent email link 102 (69%) registered. Of these, 26 (25%) had started PR section, a further 7 (7%) had accessed PR section but not yet started exercises. The commonest reasons given for declining were IT issues (56%), patient choice (21%) and the team being unable to make contact (16%). All those declining were sent British Lung Foundation home exercise booklet.
Lessons learned
Recruitment methods and patient uptake of myCOPD App elsewhere has been mixed. By targeting patients already on PR waiting list and shielding during Covid-19 lockdown, we have shown an initial high registration and engagement rate. We plan further follow up calls to monitor progress, hoping to sustain this to completion of the program. Plans continue to develop for future PR offering, whether face to face or virtual.
Conclusion
While in no way replacing PR, myCOPD can offer something during a time when face to face groups are not possible. Online solutions can discriminate against patients without IT access.
Authors: Porteous O, Bartram S, Razak Y, Kemp E, Elkin SL
Institution: Imperial College Healthcare NHS Trust
Presenter: Oliver Porteous
Category: Best Practice / Service Development Abstract
COVID-19 has required primary care to undertake reviews remotely. We have introduced a new asthma review process using improvement methodology. Previously, this process invited patients to visit an HCA or nurse to record data relevant to their asthma and determine need for an appointment with a doctor. This process lacked structure, efficiency, and oversight.

Methods
The updated review process sends patients an online survey to record their data(1), which includes video guidance on inhaler technique. Prescribing clinicians review responses alongside medical history and return personalised management plans via text, or book remote appointments for asthmatics with poor control (ACT score<19, low PEFR, or >1 exacerbation since last review). HCAs check for gaps in the review.

The review process was created using process mapping with four Plan-Do-Study-Act cycles. Each cycle comprised 9-12 randomly selected asthmatics, totalling 43 patients. Feedback was collected by structured telephone interview. Experience-based-co-design and safety reviews informed changes to the process, summarised in Table.1.

Results
Eliminating HCA and nurse visits has led to fewer appointments. Workload has been reallocated to patients in the online survey, and to doctors who now complete every review.
90% of patients, and all 8 staff surveyed, were happy with the process. Process time has reduced from an average 56.5mins to 44mins per patient with poor asthma control, and 40.5mins to 34mins for well-managed asthmatics. 33% of patients over 65-years-old were negative of the process’ digital provisions. This was mitigated by ringing patients to offer guidance.

Conclusion
We have developed an almost entirely remote process which delivers a higher quality and more comprehensive review, but increasing workload of doctors.
Moving forward, we envisage offering group consultations for asthma education, and upskilling clinicians to meet the training needs of this process.

1. MedLink Solutions. Asthma review. Available from: bit.ly/Golborne1Asthma [Accessed 30/07/2020].

Table.1 PDSA cycle changes.
Authors: Marsh V, Steed EA, Barat A, Hammersley V, Jackson T, Morgan N, McClatchey K, Sherringham J, Delaney B, Taylor S, Pinnock H, for the IMP2ART group
Institution: NPRANG
Presenter: Viv Marsh
Category: Scientific Research Abstract
Aim. Within the IMP²ART programme, to develop theoretically-informed, patient-centred resources to increase motivation for attending an asthma review and enhance expectations of engaging with supported self-management.

Methods. In May 2020 a scoping search was performed to understand the main reasons and factors influencing patients not attending asthma reviews. Nine studies were retrieved from the period 1989-2018; the majority of these were UK studies (n=7). The search was then extended to explore what should be done to improve asthma review attendance rates. Data from a corresponding workstream about the use of remote consultations in asthma was also included.
The findings informed a topic guide used to aid discussion and consultation with patient colleagues (n-5) who are members of the AUKCAR PPI group. Finally, we drew together themes and perspectives, and applied both behaviour change and educational theory, to compile an list of new resources to be developed for the IMP²ART implementation strategy.

Results. The following themes and problems within them were identified to target for new patient resources

Patient perceptions: Only attend if unwell/Asthma not serious/Don’t want to waste HCP time/Acceptance of symptoms/poor control/Appointment benefits practice not patient

Self-management skills: Poor understanding of what self-management means/It means different things to different people/Not using/valuing their asthma action plan

How to prepare for review: Needs to be patient centred

Newly diagnosed with asthma: Opportunity to educate patients often missed/Need to promote self-management from day 1

Health literacy: Hard to reach patients – socially/digitally excluded/Disability/Low literacy levels/Language

Choice: Inflexible review routines and structures

Conclusion. Using the final list, a new set of patient resources will be produced to add to the IMP²ART implementation strategy. New resources will be patient centred and patients will be involved in their design and development.
Authors: Enocson A, Maglakelidze N, Jolly K, Maglakelidze M, Maglakelidze T, Chkhaidze I, Dickens A, Kurua I, Gogvadze K, Rai K, Adams R, Jordan RE, Sitch A, Turner A, Adab P on behalf of the Breathe Well Group
Institution: University of Birmingham
Presenter: Alexandra Enocson
Category: Scientific Research Abstract
This poster is only available to Conference Delegates in the virtual platform.