barnet home oxygen assessment review servicecepn.barnetccg.nhs.uk/downloads/hos-ar service.pdf ·...
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Your healthcare closer to home
Services provided by Central London Community Healthcare NHS Trust
www.clch.nhs.uk
Barnet Home Oxygen
Assessment Review Service
Bunmi Adebajo
Clinical & Operational Service Lead
Clinical Specialist Respiratory Physiotherapist
Central London Healthcare NHS Trust
1
NHS England Oxygen provision context
In 2012, the DoH & NHS re-ordered the prescription
of oxygen to only be undertaken by suitably qualified
and trained healthcare professionals.
Currently within the NHS in England & Wales,
specifically designated HOSAR services are
commissioned by local CCGs to provide clinical care
and support to their local oxygen user population.
NHS England Oxygen provision context
• The terms of the 2012 home oxygen supply
(HOS) contract requires that prescribers
select suitable equipment for prescription.
• Restriction of GP and all non designated
HOSAR service personnel to ordering only
temporary or emergency supply (HOOF A)
which does not include ambulatory (HOOF
B) devices applies.
3
HOS-AR Services
Why are Home Oxygen Assessment and Reviews services required?
Long-term oxygen therapy in appropriate individuals can
improve survival rates by around 40%.
At the same time 30% of people on home oxygen therapy
currently derive no clinical benefit from it.
In a recent study, at least 15,000 people were found to have no
recorded oxygen usage in a six-month period, at a cost nationally of
£13m per annum.
The total annual cost of the service in England is approximately
£120m. The introduction of HOSAR services has been shown to reduce
annual spend by up to 20%. If the scale of savings were replicated
across England, it is estimated that they could amount to between £10-
20m of savings a year. 4
Barnet HOS-ARHome oxygen assessment review service
The overarching aim of the Barnet HOS-AR is to ensure that home
oxygen is appropriately prescribed to those people who clinically
need it.
The high-level objectives of the HOS-AR are:
• To provide a systematic and integrated Service
• To provide easy access to assessment and follow up procedures delivered by
appropriately qualified and trained healthcare professionals.
• To reduce/eliminate waste and poor quality care, and strengthen affordability and value,
by targeting the service on those who will benefit from home oxygen
• To ensure a higher standard of clinical treatment and improved outcomes, through more
effective and speedier diagnosis
• To ensure that users of the Service have a positive experience of care
Barnet HOS-AR Service
6
Barnet HOS-AR
Four principal stages underpin the service operational delivery
namely:
• Stage 0 Identification and referral of persons for home
oxygen assessment
• Stage 1 Home Oxygen Assessment undertaken
– (a) Assessment for long-term oxygen therapy
– (b) Assessment for ambulatory oxygen
• Stage 2 Follow up home visits for further assessment &
review
• Stage 3 Withdrawal of oxygen therapy (were indicated)
7
National guidance for home oxygen
The Outcomes Strategy for COPD and Asthma and the subsequent NHS
Companion Document to the Strategy recommend :
Routine pulse oximetry in people with COPD whose FEV1 is lower than
50% predicted to identify those who may need long-term home oxygen
therapy and, for those identified, ensure referral for structured assessment
of need by a home oxygen assessment and review service
The NICE Clinical Guideline for COPD recommends home oxygen
assessment and review assessment for the need for oxygen therapy in :
Patients with very severe airflow obstruction (FEV1 < 30% predicted)
Patients with cyanosis
Patients with polycythaemia
Patients with peripheral oedema
Patients with a raised jugular venous pressure
Patients with oxygen saturations ≤ 92% breathing air.
8
National guidance for home oxygen
The NICE Quality Standard for COPD also highlights the
importance home oxygen assessment and review for:
People with COPD potentially requiring long-term oxygen
therapy are assessed in accordance with NICE guidance by a
specialist oxygen service.
People with COPD receiving long-term oxygen therapy are
reviewed in accordance with NICE guidance, at least annually,
by a specialist oxygen service as part of the integrated clinical
management of their COPD
9
Screening
In considering the need for oxygen therapy, the
first step is pulse oximetry, to determine whether
the individual is hypoxaemic. Pulse oximetry should
be routinely available in general practice
Such a modest investment would enable general
practice to screen patients. People who are shown to
be hypoxaemic i.e. where SpO2 is less than or equal
to 92%, whose condition is stable, should be
referred to the HOS-AR Service to have a full
assessment carried out.
. 10
Screening
Where the person’s diagnosis is unclear or when significant
co-morbidity might contribute to breathlessness or
hypoxaemia, e.g. heart failure, they should be referred to an
appropriate specialist physician
Any person with COPD who is hypoxaemia needs a confirmed
and quality-assured diagnosis
People with potential hypercapnia respiratory failure should be
also reviewed by a physician.
People whose oxygen saturation levels are satisfactory
(above 95%) do not need to be seen by a HOS-AR service 11
• Known clinical diagnosis
• Optimisation of other therapeutic measures
• Known Chronic Hypoxaemia > 92%
• SpO2 at rest or exercise de-saturation of
> 4%, tested through pulse oximetry
Referral Criteria considerations
Referral sources
• The Barnet HOSAR service can receive referrals from a
broad range of sources that have made an initial
assessment. Such referrers include :
• Primary Care
• Community services
• Secondary Care
• Tertiary Care
• Others (for example: Occupational health, private health,
self referral by patients)
13
Clinical indications for referral & disease types
• Known Chronic
Hypoxaemia < 92%
SaO2 at rest
• COPD – approx. 70% of
patients
• Severe chronic asthma
• Cystic fibrosis
• Interstitial lung disease
• Bronchiectasis
• Pulmonary vascular
disease
• Primary pulmonary
hypertension
• Pulmonary malignancy
• Chronic heart failure
• Nocturnal hypoventilation as
adjunct to ventilatory support
techniques (NIV or CPAP)
•Neuromuscular/spinal/chest
wall disease.
14
15
Hypoxic/Complex
Include complex cases with co-morbidities; or
Other diagnoses e.g. sleep apnoea
May require further specialist input prior to
oxygen therapy
Confirmed hypoxaemia < 92%
SpO2 + requires oxygen
Borderline cases SpO2
92-93%
Borderline
No hypoxaemia transfer back to
referrer
No O2 needed
Pulse Oximetry Result
Adult Home Oxygen Service assessment & review Standard Referral
pathway
16
Exclusion
• Non Barnet GP registered Adult
• Patient residence no more than 0.5miles across Barnet
Borough boundary
• Persons who cannot clinically benefit from home oxygen.
• Children (as they are under paediatric services and usually
have their own community services).
• People who have not had a clinical assessment and quality
assured diagnosis (except specific instances of palliative
patients who are not assessed or reviewed through the
normal service.
• Palliative patients should have evidence of hypoxaemia. Some
assessment of equipment may be needed and thus prescribers for
palliative patients may need discussion with the HOS-AR service. 17
LTOT ( Long term Oxygen therapy)
• Completion of a Home Oxygen
Consent form (HOCF) for all patients
when first assessed.
• Completion of a Home Oxygen
Risk assessment form (IHORM) for all
patients when first assessed
• Measured arterial blood gas tensions
– PaO2 at or below 7.3 kPa breathing
air, when clinically stable
• Assessment of impact on PaO2
following supplemental oxygen being
administered for at least 30 min – aim
for at least 8kPa
• Assessment for hypercapnia
• Assessment and training using
equipment that patient will use within the
home, ensuring safe use.
• Completion of HOOF A form
• Safety check
• Feedback to referrer/GP on outcome
of assessment and oxygen orders
• Home visit within 4 weeks of
commencement of treatment, carer to
be present if appropriate
• Review equipment risks and issues
• Assessment of further education needs
of both patient and carer
• Review of clinical status and indication
for continuing oxygen requirements
18
AMBOT ( Ambulatory Oxygen therapy)
• Assessment for use of oxygen
therapy during exercise and
activities of daily living
• Exercise oxygen desaturation of fall
in SpO2 of 4% to a value of <90%
• Short term response to use of
oxygen when undertaking exercise
tests such as 6 minute walk test or
shuttle walk test
• Determine oxygen flow rate required
to correct exercise desaturation
(SpO2 above 90%)
• Gap of 30 min rest between walk
tests is recommended
• Assessment of walking distance and
measurement of resting/end exercise
dyspnoea using a visual analogue
score/ Borg score
• Assessment of likely compliance
• Patient and carer training
• Safety check
• Completion of a HOOF B
SBOT
• Cluster headache is the only indication for oxygen therapy in the absence
of hypoxia.
• High flow oxygen is very effective in some patients in relieving
symptoms of an acute cluster headache (CH) quickly and safely.
• The evidence base is clear, and the use widely accepted in the medical
and CH patient communities (www.ouchuk.org).
• In the majority of these patients, the headaches occur in clusters
(bouts).
• Cluster headache bouts alternate with remission periods, when patients
are pain free. During the remission phase oxygen may be unused but
carried just in case patients have sudden recurrence of symptoms.
• Patients are often started on a supply by a neurologist via a GP and
thereafter self-manage their supplies; this can lead to problems with
under supply, misuse and frustration. The range of oxygen equipment
which can be prescribed by a non-specialist is limited and
specialist assessment is needed to get this right. 20
Palliative care
• A full assessment not always appropriate, however there must be
clinical evidence of hypoxaemia
•The RCP guidelines oxygen therapy in palliative care recommends use for
were hypoxaemia is present.
Oxygen is not a treatment for breathlessness• A recent systematic review concluded that oxygen is not beneficial to
non-hypoxaemic patients with cancer (Uronis, 2008) and in 2010 a
randomised controlled trial (Jenkins et al) found that patients with
nonhypoxaemic breathlessness gained no benefit from oxygen
therapy.
• Home Oxygen Therapy (Long Term Oxygen Therapy LTOT and
ambulatory oxygen if appropriate) is provided to patients with cancer
and coexistent chronic hypoxaemia.
Palliative care
• Home Oxygen should not be routinely provided for lung cancer
patients at diagnosis and should not be provided solely for the relief
of breathlessness in cancer. Other pharmacological and non-
pharmacological therapies are more appropriate
• Severe intractable breathlessness in advanced non-malignant respiratory
disease such as COPD may require palliation in the absence of terminal or end-
of-life disease . In such patients oxygen is not effective in relieving
breathlessness unless there is proven hypoxaemia
• In patients with advanced non-malignant respiratory disease in whom death is
imminent oxygen may be used where hypoxaemia cannot be proven without
undue discomfort to the patient
• There may be some patients that may develop intermittent hypoxaemia and for
those an intermittent source of home oxygen probably in the form of oxygen
cylinders may be appropriate
22
Intermittent oxygen therapy (SBOT)
It is now recognised that short burst therapy is not beneficial for relief of
breathlessness in the absence of hypoxaemia and thus should not be
used.
Intermittent oxygen therapy may be considered where patients develop
transient hypoxaemia e.g. in exacerbations of COPD, heart failure and also
in cancer patients. Such patients may develop intermittent hypoxaemia
when they develop a chest infection or heart failure in the presence of
underlying pulmonary malignancy.
Intermittent oxygen therapy will need specialist
assessment.
23
Cigarettes and E-cigarettes - The Risks
The dangers of using an electronic cigarette or
similar device whilst using oxygen therapy are
exactly the same as in smoking ordinary
cigarettes.
Electronic devices also carry a risk of
explosion or ignition and can cause a
fire whilst recharging.
24
Travel
• Oxygen prescription does not automatically exclude air
travel
• Established oxygen therapy users should speak to their
doctor in advance about air travel as a fitness to fly
assessment should be considered in all patients receiving
LTOT
• Travel includes all modes and not restricted to aircraft,
trains, cruise, ships, ferries
– Patient responsibility to check with airlines in advance to establish
what their policies and capabilities before making arrangements
– Arrangements for oxygen therapy is not only for in-flight provision
but also for transit and transfers within the airport. This must be
done at least one month before the trip
25
Review considerations
• 6 monthly review assessment for established
stable users. (CH may be annually.
• ABG or CBG may be required .
• Annual ABG to assess oxygenation and
hypercapnia; more frequent if clinical indications
• Safety checks, IHORM updates
• Renewal or adjustment of HOOF B Order if
requirements have changed
• Consideration of removal if no longer required
26
Risk considerations
• Appropriate clinical presentation
• Does the patient smoke?
• Does any one else smoke at the patient’s property?
• Does the patient use e-cigarettes
• Is there a history of drug or alcohol dependency?
• Does the home have a working smoke detector?
• Has there been a previous fire in the house?
• Has the patient had a fall in the previous three months?
• Does the patient have any identified cognition, understanding,
behaviour issues?
• Do they live in a property joined to another?
• Is property a multiple occupancy property?
• Can they independently vacant the premises?
• Are there vulnerable dependents at the residence?27
IHORM Form
28
HOCF form
29
Air liquide Portal
30
Interdependencies with other services
• The Barnet HOS-AR is interdependent with all other respiratory services
(including lung function), cardiac services, neurology, care for the elderly, social
care, smoking cessation services, pharmacists and palliative care. The service
will liaise as appropriate with these services.
• Local fire service . When required the Barnet HOS-AR will notify the local fire
service when oxygen equipment is provided and, in the case of persistent
smokers, a risk assessment of the premises requested of the fire service.
• Ambulance service . Whilst ambulance services now employ universal
precautions (28% oxygen) with respect to the risk of high concentration oxygen
in acutely unwell people with COPD, and others at risk from oxygen induced
hypercapnia, people known to be at risk should be advised and oxygen alert
cards provided. In some cases, a specific protocol (PSP) may be appropriate
depending on local ambulance service arrangements
31
Barnet Home Oxygen Referral Form
Patient Population by modality
Referral sources
34
Top five Barnet Oxygen users clinical code
35
COPD45%
Primary Pulmonary Hyper tension
26%
Cluster headache13%
ILD11%
Other conditions5%
Top five Barnet Clinical Codes for Oxygen
Summary
• Oxygen is a treatment for hypoxia not breathlessness.
• Oxygen therapy should always be planned, prescribed and reviewed by
staff trained in oxygen prescription and use.
• Long term oxygen treatment (15-24 hours per day) should only be
prescribed after specialist review and risk assessment.
• Patients who may benefit from ambulatory oxygen require specialist
assessment.
• Patients who smoke need very careful consideration for long term
oxygen therapy. Hypoxic patients who smoke should be offered clear
communication of the reasons oxygen therapy cannot safely be offered
to them whilst they smoke, individualised information about the benefits
of smoking cessation for them, treatment for tobacco dependence and
planned follow up.
36
Summary
• Patients on long term oxygen therapy at risk of harm from excessive oxygen
should be identified and their care plan shared with their GP and local hospitals
as well as ambulance and out of hours services.
• Home Oxygen Service Assessment and Review (HOSAR) services integrated
with local respiratory services are effective and vital to ensure evidence based
patient centred care and optimal value for money.
37
Questions
38