Candidate Advanced Nurse Practitioner Respiratory South Tipperary General Hospital Clonmel 2018

The 4 Pillars of Advanced Practice Clinical Evidence, Research and Development Facilitation of Learning Leadership

Respiratory Medicine: The branch of medicine that deals with the causes, diagnosis, prevention and treatment of diseases affecting the lungs. It deals with many diseases and conditions, including: ARDS (acute respiratory distress syndrome), Asthma, COPD (chronic obstructive pulmonary disease), cystic fibrosis, ILD (interstitial lung disease), lung cancer, lung transplants, occupational lung disease, pulmonary hypertension, pulmonary tuberculosis, sarcoidosis of the lungs, and SARS (severe acute respiratory syndrome). Respiratory medicine is also sometimes called pulmonology which is the science concerned with the anatomy, physiology, and pathology of the lungs.

AN ACUTE CHANGE FOR A CHRONIC PROBLEM: IMPROVING COPD IN STGH Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease caused by exposure to inhaled noxious substances including cigarette smoke. It is characterised by persistent dyspnea, chronic cough and sputum production. The natural progression of the disease includes exacerbations – events described as acute worsening of respiratory symptoms which typically last for several days. It is estimated that approx. 500.000 people in Ireland suffer from COPD and possibly another 500.000 remain undiagnosed. At least 25% of these will suffer one or more exacerbations annually. COPD is the commonest disease-specific cause of emergency hospital admissions in Ireland (389 admissions per 100,000 population) (1).

Age-sex standardised hospitalisation rates for COPD per 100,000 population for selected OECD countries, 2013 (or nearest year)

AN ACUTE CHANGE FOR A CHRONIC PROBLEM: IMPROVING COPD IN STGH Tipperary county has one of the highest admission rates in Ireland (1). In 2017 STGH dealt with 644 presentations of COPD, with an average LOS of 4 days. It is recognised that not all admissions for COPD are appropriate and some can be avoided. Approx 15,000 hospitalisation per year with a primary diagnosis of COPD. Approx 32,000 discharges with primary or secondary diagnosis of COPD.

STGH Respiratory Presentations for 2017

AN ACUTE CHANGE FOR A CHRONIC PROBLEM: IMPROVING COPD IN STGH 20% of patients with a severe AECOPD will readmit within 30 days of discharge, with a third readmitting within 90 days. One Irish study found that 41% of patients admitted with COPD readmitted into the same unit within 90days. 644 presentation of COPD in 2017 to STGH. In Sept of 2017 38 presentations, average LOS 4 days, 3 LOS of 21 days plus. In Oct of 2017 63 presentations, average LOS 4 days with 6 patients LOS being 21 days plus, one patient stayed 41 days.

COPD Readmission 2017 Here are two patients admissions and discharges between Sept/Oct 2017. Patient A: Admitted on 8/9/17 – 13/9/17 5 days Readmitted on 22/9/17 – 22/9/17 1 day Readmitted on 14/10/17 – 27/10/17 13 days Patient B: Admitted on 5/9/17 – 14/9/17 9 days Readmitted on 23/9/17 – 27/9/17 4 days Readmitted on 11/10/17 - 20/10/17 9 days Readmitted on 21/10/17 – 27/10/17 6 days

In April 2018, a pilot initiative was undertaken in STGH with the aim to improve care of COPD exacerbations via;

COPD Pathway Prior to Pilot Patient A: Date 3/4/18 BIBA: 12.45 ED Ref to Medics: 15.49 CAT 2 S/B Medics: 21.15 ABG: 13.44 BNP: 13.53 Nebs: 15.35 Antibiotics: 15.35 Transfer to ward 22.00 on 3/4/18 Referral sent to Respiratory Team on 4/4/18 @ 13.30 Patient B: Date 26/3/18 BIBA: 22.28 Triage: 23.28 S/B Medics at 4.30 am 27/3/18 Transferred to ward on 1/4/18 Bloods taken on 27/3/18 time not noted No ABG taken Nebs 6am on 27/3/18 Antibiotic 6am on 27/3/18 Physio Respiratory Assessment on 4/4/18 24.45 Hours for Respiratory Team Review with recommendation for discharge. No referral to Respiratory Team.

Pilot Pathway Patient A: Date 12/4/18 OPD Referral 12.00 ED arrival 12.10 Triage 12.31 Resp CANP referral 13.15 Resp CANP review 14.00 Resp Cons review 16.21 Discharged 16.43 (4.5 hours) ABG 13.10 Bloods 13.10 CXR 13.30 No nebs given Patient B: Date 12/4/18 Self Referral ED arrival 9.36 Triage 9.51 Resp CANP referral 11.30 Resp CANP review 12.10 Resp Cons review 15.30 Discharged 16.10 (6.5 hours) Bloods 10.30 ABG 10.30 CXR 10.13 Nebs 11.30 Home on oral antibiotics with follow up phone call in 48hrs Home on oral antibiotics and steroids with follow up phone call in 48hrs

To date XXX patients have been managed through the pathway To date XXX patients have been managed through the pathway. Improvements in time to time points from triage are displayed below;

This rate of admission avoidance is in keeping with data from BTS studies analysing various forms of hospital at home approaches to COPD care in the UK (2). In 2017 the estimated total number of bed days for AECOPD in STGH amounted to 2,576. This pathway has the potential to reduce the number of bed days consumed by AECOPD by approx. 1700 per annum. Longer term data may show effect on LOS on those ultimately admitted, and on overall re-admission rates. It is acknowledged that investment into the initiative is necessary to maximise its potential. By assessing the feasibility of this pilot program in STGH, we can aim to expand its reach, expecting an equally positive, albeit larger impact, on patient care, satisfaction and health outcomes, while targeting admission avoidance and cost aversion.

Referral Pathway to ANP Respiratory There will be three points of referral: BIBA and referral to ANP in A&E GP referral to ANP Direct contact with ANP via telephone

NEW ROLE Time change from CNM to CANP New level of responsibility, working solo Establishing service, challenges, new work colleagues, new work schedule, IT systems, How to set up a service that will make a difference and showcase the need and role of ANP’s Understanding role difference Educational Requirements CPD Family Life