Table 1 Service model for the Breathlessness Intervention Service (BIS) at Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust (March 2008)
Disease group course: | Non-malignant (nm) course | Malignant (m) course |
|---|---|---|
Examples: | e.g. COPD, heart failure, neurological disorders | e.g. all cancers, UIP |
Referral: | Post, fax, electronic | Post, fax, electronic |
Assessment lead: | Clinical Specialist Physiotherapist or Clinical Specialist Occupational Therapist | Medical Consultant (i.e. sees a doctor earlier in the intervention than non-malignant patients) |
BIS team: | Clinical Specialist Occupational Therapist Clinical Specialist Physiotherapist Medical Consultant | Medical Consultant Clinical Specialist Occupational Therapist Clinical Specialist Physiotherapist |
Medical assessment: | May be required | Always required (review of pharmacological management at 1st visit) |
First appointment: | Maximum wait of 3 weeks for first appointment | Maximum wait of 1 week for first appointment |
Range of face-to-face visits: | 2-3 | 1 (with primary care professional) |
Average no. of telephone contacts (with patient/primary care staff): | 3 | 2 |
Ratio of face-to-face to telephone: | 1:1 | 2:1 |
Average length of service contact: | 4 weeks + 16 week follow up (from 1st assessment) post any pulmonary rehab/other referral | 2 weeks + 6 week follow up (from 1st assessment) post any pulmonary rehab/other referral |
Service outcome measures collected at first assessment: | • modified BORG at rest, self-reported, on exertion and on completion of exercise test • anxiety due to breathlessness at rest, self reported, on exertion and on completion of exercise test • physiological measures e.g. oxygen saturation, heart rate | • modified BORG at rest, self-reported, on exertion and on completion of exercise test • anxiety due to breathlessness at rest, self reported, on exertion and on completion of exercise test (if acceptable) • physiological measures e.g. oxygen saturation, heart rate |
Non-pharmacological interventions: | 1st stage of intervention | More likely to be concurrent with pharmacological interventions |
Pharmacological interventions: | 2nd stage of intervention | More likely to be concurrent with non-pharmacological interventions |
1st stage interventions (selection & application as clinically indicated): | The majority of these interventions are used with this group, & taught over a longer period of time: → explanation & reassurance → anxiety management → psychological support → hand-held fan → information fact sheets → emergency plan → positioning to reduce work of breathing (rest, recovery & activity) → breathing control → education to patient, carer & health care generalists → pacing & lifestyle adjustment → individualised exercise plan → relaxation & visualisation → airway clearance techniques → advice regarding nutrition & hydration → support to family & patient to utilise education & self-support programmes → sleep hygiene → smoking cessation prompt → brief cognitive therapy → pharmacological review → well-being intervention → hypnosis → mindfulness CD → referral to specialist services (see below) | More selective use & application of these interventions, & taught over a shorter period of time: → explanation & reassurance → anxiety management → psychological support → hand-held fan → information fact sheets → emergency plan → positioning to reduce work of breathing (rest, recovery & activity) → breathing control → education to patient, carer & health care generalists → pacing & lifestyle adjustment → individualised exercise plan → relaxation & visualisation → airway clearance techniques → advice regarding nutrition & hydration → support to family & patient to utilise education & self-support programmes → sleep hygiene → brief cognitive therapy → pharmacological review → well-being intervention → hypnosis → mindfulness CD → referral to specialist services (see below) |
2nd stage interventions: | Choice of 2nd stage interventions dependent on outcome of first stage interventions: → further pharmacological review e.g. low dose opioids, anti-depressants, anxiolytics → referral to specialist services (see below) → referral for LTOT or SBOT assessment | 2nd stage interventions likely to be applied concurrently with 1st stage interventions: →further pharmacological review e.g. low dose opioids, anti-depressants, anxiolytics →referral to specialist services (see below) →referral for LTOT or SBOT assessment |
Other symptom management: | May be required | Frequently required |
Documentation: | → individualised patient plan → summary to patient of outpatient consultation with medical consultant → discharge summary to referrer with copies to GP, specialist services the patient was already in contact with (e.g. respiratory physicians), other involved health care professionals (e.g. district nurses, nursing home care staff) | → individualised patient plan → summary to patient of outpatient consultation with medical consultant →discharge summary to referrer with copies to GP, specialist services the patient was already in contact with (e.g. respiratory physicians), other involved health care professionals (e.g. district nurses, nursing home care staff) → supplementary medical letters more common |
Referrals: | → Pulmonary rehabilitation → Specialist dietetic → Specialist psychological services → Hospice day services → other specialist assessment → Cardiac rehabilitation → other rehab services (n.b. these services usually have a wait time) | → Palliative care specialist service (n.b. rapid access available) → Specialist psychological services → Hospice day services → other specialist assessment |