Respiratory Medicine

Optimise respiratory outpatient services by reducing DNAs, limiting unnecessary follow-up, considering increased virtual consultations, one-stop clinics and moving care closer to home. a) Explore options to reduce DNAs, including through considering increased use of non-face-to-face consultations where clinically appropriate, in line with NHS Long Term Plan ambitions to reduce OP attendances by 30%. Patient preferences need to be considered as part of this. Regular monitoring and evaluation of the effectiveness of virtual clinics is also needed. b) Explore options to increase the proportion of patients discharged at first appointment, including through: ensuring sufficient consultant supervision, decision-making and leadership of outpatient clinics; reviewing the referral letter and using an initial call with the patient to pre-book diagnostic tests in advance of clinic attendance where relevant; considering 'one-stop' clinic models where feasible. c) Liaise closely with system partners to deliver care closer to home through integrated care models.

Improve acute care for respiratory patients by reviewing patient flow and considering measures to increase ward productivity. a) Review protocols and consider adopting a physician of the week model to improve respiratory ward efficiency. b) Consider 'hot' clinic models to enable primary care teams to access specialist input without the need for referral. c) Improve preventative measures in the community for respiratory patients by ensuring i) flu vaccination and pneumococcal vaccination; ii) rescue packs are available together with management plans. d) Consider joint appointments between acute medicine and respiratory medicine to increase respiratory expertise among acute physicians. e) Consider embedding respiratory teams in acute/emergency settings to help facilitate discharge. f) Review patient flows to ensure admitted respiratory patients go to a respiratory ward, with a long-term goal of 65% of respiratory patients to be managed and followed-up by chest specialists. Thereafter with full respiratory ward occupancy, review the respiratory bed base to ensure sufficient respiratory beds exist within the trust with an associated expansion of workforce where required. g) Support trusts to proactively manage predictable winter pressures by establishing systematic solutions in discussion with respiratory teams.

Improve education and relationship building for medical and coding staff within trusts. a) Nominate a respiratory physician as the 'coding lead' for the respiratory department to provide linkages between respiratory and coding departments. b) Ensure that all junior medical staff receive education and a simple guide to clinical coding from the coding department when they join the respiratory department.

Ensure respiratory activity is coded using Treatment Function Code 340 (respiratory medicine). a) Respiratory consultant activity should be mapped to TFC 340 and not general medicine TFC 300, to appropriately reflect the specialty activity.

Explore the reasons for variability in the number of respiratory patients being cared for by respiratory consultants. a) Explore opportunities to ensure that trusts achieve the top quartile proportion of patients with a respiratory diagnosis being looked after by the respiratory team (i.e. appearing under TFC 340).

Ensure physiology outpatient activity is accurately captured and remunerated using Treatment Function Code 341. a) Ensure general physiology activity is set up and recorded as outpatient activity using TFC341. b) Ensure data flows correctly to commissioning for payment.

Increase the use of Cardiopulmonary Exercise Testing (CPET) with interpretation by senior physiologists to manage breathlessness and determine patients' fitness for major or complex surgery. a) Ensure access to CPET for managing complex and unexplained breathlessness. b) Review current levels of CPET activity and agree protocols to ensure preoperative testing is optimised. c) Review international evidence around CPET usage to inform a potential update of guideline NG45: routine perioperative tests for elective surgery.

Improve care for patients in sleep medicine by addressing delays in diagnosis of sleep problems and CPAP initiation, together with resolving gaps in infrastructure. a) Model demand and expand provision of full polysomnography services in line with expanding referral base where appropriate. b) Deliver an optimal and expedited pathway with direct-to-test and, with appropriately trained physiologists in place, direct-to-CPAP-treatment. c) Establish a fast-track service for vigilant critical occupations which ensures a clearly marked referral from primary care leads to treatment initiation within one month. d) Ensure all patients are initiated on treatment within 18 weeks of referral and given the medical associations, ideally sooner. e) Ensure accurate coding and data capture to inform payment under PbR or local negotiations under block contracts to sufficiently fund sleep services and enable investment in improving pathways. f) Ensure technology-enabled CPAP follow-up becomes normal practice.

Improve experience and outcomes for patients with pulmonary embolism by reducing unnecessary tests and ensuring respiratory or joint clinician-led follow-up where possible. a) Establish a pulmonary embolism pathway to include seven-day access to the performing and reporting of CT pulmonary angiography and outpatient management. b) Assess the clinical probability of all patients with suspected pulmonary embolism by using an appropriate likelihood score system in conjunction with D-Dimers, where indicated, prior to requesting a CT pulmonary angiogram. Carry out a systematic review if variation is identified. c) Ensure robust processes are in place for following up patients post pulmonary embolism (including review by a respiratory physician where possible).

Reduce acute admissions and length of stay, and deliver a high quality pleural service which achieves the Best Practice Tariff by addressing workforce and infrastructure requirements. a) Allocate sessions in the consultant's job plan who leads the pleural service. The number of sessions will relate to activity but should be a minimum of three per week to ensure activity before and after the weekend is picked up. b) Secure nurses and additional infrastructure to support the pleural service and provide care for drains in the wards. c) Secure administrative support to drive efficiencies in booking patients into the service. d) Secure an appropriate venue for performing day case procedures where these can be coded to respiratory medicine (not as emergencies or ward walk-ins), with standardised documentation in line with both NatSSIPs and LocSSIPs. e) Ensure appropriate equipment i.e. pleural packs are available, together with a selection of drains and an appropriate specification ultrasound machine. f) Ensure data capture is correct to enable achievement of Best Practice Tariff or other incentive schemes. g) Consider early referral to thoracic surgery for unresolved pneumothoraces and parapneumonic effusion / empyema.

Review referral systems and patient pathways in collaboration with community, primary and acute services to improve care for patients with asthma. a) Ensure only appropriate patients are referred and admitted to hospital through establishing more effective links with community services across Integrated Care Systems. b) Where referral criteria defined by NICE (NG80) are not being followed consistently, initiate local discussions to understand barriers. c) Monitor frequent attendances to emergency departments and explore reasons for this in collaboration with ED colleagues so that appropriate interventions can be made in line with NRAD recommendations. d) Review trust-wide data around readmission rates for asthma to understand opportunities for intervention. e) Review pathways to ensure patients admitted to hospital with asthma are managed by respiratory physicians, with onward referral to specialised centres where appropriate. f) Ensure patients are provided with sufficient education and support to enable correct inhaler use. g) Ensure patients are provided with plans for follow-up post attendance or at discharge.

Review departmental resourcing to improve outcomes, reduce length of stay and reduce the likelihood of readmissions for patients with asthma. a) Ensure at least one consultant in the department has overall responsibility for asthma which is reflected in their job plan. b) Staff respiratory departments with the appropriate level and makeup of respiratory team members to facilitate effective triage and deliver NACAP care bundles, with a minimum target of 1 asthma nurse per 300 admissions (excluding nurse time spent delivering specialised services for more complex patients). c) Ensure departments have access to data collection / data entry resource to contribute fully to NACAP. d) Review and discuss data on asthma activity to explore opportunities to improve services.

Optimise care for pneumonia patients by ensuring the correct diagnosis (and that it is coded correctly), as well as reviewing patient pathways and infrastructure to enable care bundle delivery, reduce length of stay, readmissions, morbidity and mortality. a) Ensure a named respiratory consultant is appointed as a clinical lead for pneumonia, with this leadership responsibility reflected in their job plan. b) Review pathways to ensure prompt diagnosis and point of care testing for viral pathogens. c) Review infrastructure to support pneumonia care and enhance the role of specialist teams to improve outcomes, with a minimum target of one nurse per 400 admissions, pro rata; which could be increased if average readmission rate is over 20%. d) Use the British Thoracic Society (BTS) care bundle for community-acquired pneumonia to support safe and prompt discharge by a respiratory team. e) Ensure chest x-rays are formally reported for patients not managed by respiratory physicians to prevent underlying diagnoses being missed and reduce the likelihood of readmission. f) Ensure all patients are discharged with clear supporting information to explain persistent symptoms and reduce the likelihood of readmission. g) Agree clear processes for follow-up chest x-rays post-discharge with results being shared across primary, secondary and community care as appropriate. h) Audit inpatient pneumonia mortality, particularly in patients aged 18-40. Ensure a structured judgement review is carried out for all patients under 40 who have died from pneumonia, with further discussion at regular Morbidity and Mortality (M&M) meetings.

Optimise care for patients with chronic obstructive pulmonary disease (COPD) to reduce length of stay, readmission rates, and overall mortality by using discharge bundles. Where demand exists, consider implementing seven-day services. a) Ensure a named respiratory consultant is appointed as a clinical lead for COPD, with this leadership responsibility reflected in their job plan. b) Consider implementing seven-day services and extending working days (e.g. to 8am-8pm) where possible/indicated to increase the potential for patients to receive facilitated discharge, reducing the likelihood of readmission. c) Appoint sufficient dedicated competency-based teams to consistently deliver discharge bundles designed to reduce likelihood of readmission –working toward a target of 1 nurse for every 300 COPD admissions. d) Model the number of patient discharges to track whether implementing the actions above has sufficiently reduced COPD LoS, readmission rates and overall mortality. e) Review the number of patients sent home under a supportive early discharge scheme against readmission rates to establish whether there is scope to increase zero LoS patients working toward a target of 20% zero LoS without increasing readmission rates beyond 15%.

Ensure a dedicated non-invasive ventilation (NIV) service is in place, with the recommended infrastructure to improve outcomes and reduce mortality. a) Review consultant and nursing infrastructure against BTS standards to deliver NIV services in line with existing NCEPOD 2017 and BTS recommendations. b) Ensure infrastructure is sufficient to enable timely initiation of NIV, using BTS quality statement and NACAP timeline for guidance. c) Enable close liaison between respiratory and critical care units to ensure that escalation plans are in place for all patients on NIV, and that these plans are implementable. d) Ensure processes are in place to enable early follow-up post-acute NIV for consideration of home ventilation as per HOT-HMV. e) Consider development of an acute NIV CQUIN or other incentive that will facilitate data collection.

Review aspects of respiratory care integration and supporting infrastructure at system level to reduce variation in service provision, enable better care delivery and facilitate information flow between providers. a) Review service provision across the STP to ensure services are uniform and equitable for respiratory patients, regardless of where they live. b) Consider how respiratory departments interface with diagnostic hubs and community services to deliver truly integrated care. c) Ensure there are sufficient staff with the appropriate skill mix to deliver integrated care. This should include respiratory consultant sessions in the community. d) Integrate electronic systems to allow for data access and sharing across providers and commissioners. This data should be used to review and evaluate progress in improving outcomes at system level.

Improve access to smoking cessation therapies and reduce tobacco dependence in patient populations through a comprehensive suite of interventions. a) Use ward-based non-medical prescribers to prescribe nicotine replacement therapy (NRT) within 12 hours of admission. b) Identify a clinical lead for tobacco dependency treatment services with adequate protected time. c) Ensure an electronic method of recording smoking status is in place. d) Use free online training on treating tobacco dependency for staff through the 'e-learning for health' platform available for all NHS staff. e) Monitor the success using the BTS online audit platform and applying QI practice to improve results until they reach the standards set out by NICE and the NHS Long Term Plan.

Review service infrastructure to ensure delivery against national specialised service specifications, reducing the likelihood of delays in treatment or discharge. a) Review infrastructure against national specifications and identify areas where additional support or resource is needed to ensure optimum service delivery. b) Consider how to support trusts in addressing gaps or inequities in service provision which arise as a result of services not meeting all requirements of national specifications.

Consider hub and spoke models to amalgamate low volume specialised services. a) Review specialised activity levels across regions and consider consolidating services or moving to hub and spoke models where possible to improve shared decision-making and reduce the likelihood of low volume services.

Review how trusts achieve and maintain specialised status; updating service specifications. Where service demands have changed over time, specifications and subsequent resources need to be aligned to deliver appropriate care. a) Update national specification for complex home ventilation to: i) formalise guidance around developing weaning centres; ii) review tariffs to ensure appropriate remuneration, notably for services delivering significant volumes of tracheostomies and >14h NIV together with home visits; iii) consider additional remuneration for transitional services.

Establish formal registries to capture patient-level information which can support monitoring and inform commissioning decisions. a) Determine key metrics to be collected that include outcome and process measures that reflect costs and benefits of delivering specialised services. Consider how such registries can be used to sensibly support payment.

Improve patient outcomes by reviewing infrastructure to support appropriate medicines use. a) Improve uptake of staff flu vaccination using NICE QS190. b) Ensure patients are offered flu and pneumococcal vaccination. c) Appoint an antibiotic steward at department level. d) Improve adherence to inhaler therapy, especially for inhaled steroids to reduce the reliance on reliever therapy. This will improve outcomes and reduce the carbon footprint of inhalers. e) Develop guidance at ICS level to standardise formularies. This should include patient education on inhaler therapy, ensuring patients use their inhaler correctly and shared decision-making in choice of inhaler.

Address variations in service delivery and meet the needs of the local population by staffing respiratory departments with the appropriate numbers and skill mix of doctors, specialist nurses, physiologists and allied health professionals. a) Review the trainee numbers for respiratory medicine to ensure the specialty evolves in line with ambitions set out for respiratory care in the NHS Long Term Plan. b) Consider optimising skill mix by appointing specialist/enhanced roles for Physician Associates, nurses and Allied Health Professionals within the respiratory team. c) Consider how to address recruitment and retention challenges in the respiratory workforce. d) Consider appointing more band 2 physiologists to conduct spirometry and support sleep diagnostics, with view to these staff developing into band 4 roles with experience. Where advanced diagnostics are required, ensure there is sufficient numbers / skill mix to deliver results in a timely way to achieve the 6-week RTT target. e) Appoint enough administrative staff to address clerical workload and reduce clinical time spent on administrative tasks in line with NHS People Plan ambitions. f) Carry out detailed workforce planning including scoping extended practice for nurses, AHPs and pharmacists.

Reduce litigation costs by application of the GIRFT five-point plan. Share learning by ensuring claims, inquests and complaints are reviewed in regular M&M meetings. a) Assess benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT 'Litigation data pack'. b) Discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk – notably any claims which should have been classified to thoracic surgery. c) Once claims have been verified, further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d) Triangulate claims with learning themes from complaints, inquests and serious incidents (SI) / Patient Safety Incidents (PSI) and where a claim has not already been reviewed as SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including Multidisciplinary Team meetings, Morbidity and Mortality meetings where appropriate. Sustainable and effective interventions that measurably reduce risks to patients should be implemented and where these are successful, should be shared through multiple routes, including discussion at meetings. e) Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional teams to follow-up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit. f) Review categorisation of medical negligence claims to separate thoracic surgery claims from respiratory medicine / cardiac surgery.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a) Use sources of procurement data, such as SCS and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b) Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c) Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Ensure respiratory services are able to provide optimal care for patients with COVID-19 and post-COVID-19 syndrome by establishing respiratory support units, enabling remote treatment monitoring and optimising multidisciplinary expertise. a) Establish staffed respiratory support units in line with national recommendations, including a multi-professional outreach service. Aim for a minimum nurse to patient ratio of 1:4, with nurses trained in administering CPAP and HFNO. b) Review job plans to allow introduction of twice daily respiratory consultant-led ward rounds for COVID-19 patients, by reducing respiratory consultant commitments to the acute take where feasible. c) Procure CPAP devices with capability for remote monitoring where possible through co-ordinated discussions between respiratory and IT departments. d) Review tariff arrangements to support providers in offering CPAP treatments with remote monitoring to reduce departmental footfall. e) Prioritise restoration of bronchoscopy and Endobronchial Ultrasound, recognising the pressures on GI endoscopy. f) Develop COVID-19 follow-up services in line with national recommendations. g) Ensure adequate multidisciplinary resourcing is in place to review patients with post-COVID-19 syndrome through MDTs.