Breath of fresh air

A physio-led Respiratory Team in Edinburgh offers a unique service in Scotland. Jennifer Trueland meets the team, which picked up a CSP Excellence award last year

Five members of the Edinburgh Community Respiratory Team (CRT) have taken maternity leave since it was set up in 2008.

Each time, the mother-to-be left with her colleagues’ best wishes ringing in her ears – and carrying presents of baby clothes that were hand-knitted by patients.

These lovingly-crafted gifts demonstrate the intimacy of the relationships that evolve between the patients, whose chronic obstructive pulmonary disease (COPD) can be so severe that they are virtually housebound, and the physiotherapists who visit them.

The CRT won the Care Closer to Home category at last year’s CSP Service Excellence Awards. Meeting the team, and finding out about the service, it’s not hard to see why.

Made up of band 7 physiotherapists, a part-time physio assistant, part-time occupational therapist and administrative support, the team offers a rapid access service targeting COPD patients in Scotland’s capital.

And rapid means just that – if the referral is urgent, a physiotherapist can be on the patient’s doorstep within two hours.

The seven-days-a week service provides supported discharge from hospital, acute exacerbation management, supplementary prescribing, home-based pulmonary rehabilitation and self-management. In almost every case, hospital admission is prevented.

In the year ending in March 2011, hospital admissions were avoided in 97 per cent of the cases in which the referrer thought a patient might need hospital care.

So how did it all start? Initial steps were taken in January 2008 and the first patients were seen in the April.

Genevieve Harborow was in from the beginning – even brandishing an article from Frontline as ammunition to help persuade managers to fund it.

COPD patients tend to befrequent flyers – they’re in and out of hospital a lot. Managers were looking for ways to address this, and I read an article in Frontline about a similar service in Medway (in Kent), which I drew to their attention.

‘They saw that they could save money by cutting hospital admissions.’

After a modest start the service soon expanded, and is still the only physio-led, community-based COPD service of its kind in Scotland.

The service, which sees people with severe and very severe COPD – as measured by the international guidelines (GOLD 2001) - aims to improve patients’ quality of life.

 If someone is particularly unwell, he or she can be visited twice daily, although when stable, the frequency is likely to be once a month.

As well as teaching pulmonary rehabilitation techniques, the physios help to educate patients about the condition, and how to manage it themselves. Some of the work is very hands-on and ranges from sputum clearance to prescribing home exercise.

‘We’re looking at it as non-medical professionals and the models we use are very different to nursing models,’ says team leader Ann Thomson. ‘We work very closely with our nursing colleagues but the skill set is different.’

Preventing admissions is key

Much of the team’s work revolves around preventing admission to hospital.

To this end, in their capacity as supplementary prescribers, they can alter patients’ medication when required, without the need for the patient to see the GP or be admitted to hospital.

Referrals can be made by any healthcare professional although, in practice, most come from GPs, district nurses or from respiratory nurses in hospital.

Getting the referrers on board was an important part of setting the service up – as is continuing to push awareness.

Persistence is required, particularly with some GPs, and diplomatic skills are needed so that other parts of the health system see them as a boon, rather than a threat.

Around a fifth of referrals are made with the explicit aim of preventing hospital admission.

In the year ending in March 2011, the service received 570 referrals and a total of 1,335 referrals were received in its first three years.

The patients come from a wide spectrum in terms of age and background, although many of their clients live in some of Edinburgh’s more deprived areas.

They also see company directors, however, and fondly cite one ‘very glamorous’ older woman, who had been a representative for a cigarette company and had, therefore, been obliged to smoke.

‘Near instantaneous’ results

To Ms Thomson, one of the best things about her work is making a visible difference.

There is ‘visual satisfaction’ in seeing a lung re-inflate, or in sputum clearance. Having said that, it wasn’t an area that evoked  even minimal interest as a student – she recalls having what she diplomatically terms ‘not a good placement’.

Recognising that she needed to remedy this, however, she applied to a hospital with a cardiothoracic unit and didn’t look back.

Ms Harborow also enjoys the ‘near instantaneous’ results that the job brings at times. Coming from a critical care background, she took on her current role because she was interested in the chance to develop a new service – and has no regrets.

The pair relish the autonomy their roles bring – and reckon that the team has amassed some 100 years of ‘physio experience’ between the members.

Frustrations occur, however, when patients will not engage, says Ms Thomson, but this only happens rarely.

One of the benefits of caring for people in their own homes is the close and ongoing relationships that build up – as the hand-knitted baby clothes testify. fl

ABOUT Chronic Obstructive Pulmonary Disease (COPD)

  • COPD remains a major public health problem. In 2020, COPD will rank as the fifth highest burden of disease’, according to a study published by the World Bank and World Health Organization.
  • Although COPD has received increasing attention from the medical community in recent years, it is still relatively unknown or ignored by the public as well as public health and government officials.

Source: www.goldcopd.org

Telecare initiative

  • The CRT is taking part in Telescot, a randomised control trial to establish the clinical, social and service impact of introducing telemetry–aided, supervised self-monitoring for managing COPD in the community.
  • The first group of patients was given advice and treatment from the CRT, which they could contact by telephone as needed.
  • The second group received the same advice and treatment, but also used telemonitoring, in the form of a small computer that records symptoms and oxygen saturations.
  • These data, sent via broadband telephone lines, were monitored by CRT members, who contacted a patient if symptoms or data readings flagged up a potential problem.
  • Recruitment to the trial ended in March 2011 and the results are due to be published in the summer.

For more information, visit: www.telescot.org
Resource: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the Diagnosis, Management and Prevention of COPD was updated last year. To obtain copies, visit: www.goldcopd.org

Author
Jennifer Trueland

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