Analysis

Respiratory disease: how collaboration can make a crucial difference

Experts argue that with appropriate training, non-specialists in all fields of nursing can help improve diagnosis, treatment and access to specialist care for patients with respiratory disease

Experts argue that with appropriate training, non-specialists in all fields of nursing can help improve diagnosis, treatment and access to specialist care for patients with respiratory disease

  • The two most common lung diseases account for 175,000 hospital admissions a year in the UK
  • Failures to identify risk mean many asthma deaths are deemed preventable
  • Efforts are being made to improve care, but patients have complex needs
  • Cuts in CPD budgets are making it more difficult for non-specialist nurses to access training

Asthma, COPD and other respiratory diseases account for 9% of all premature deaths
in England. Picture: Alamy

Respiratory disease is one of the top five causes of premature death in the UK, and official scrutiny in recent years has revealed that care is falling below required standards.

But the RCN and other experts say that, given enough training and resources, non-specialists in all fields of nursing can play a part in helping to improve care.

At St George’s University Hospitals NHS Foundation Trust in London, respiratory nurse consultant Samantha Prigmore says nurses need time to access training to help them pick up on symptoms.

Ms Prigmore says community, ward-based and emergency nurses have many opportunities to make small but significant interventions, and all nurses encountering patients with symptoms such as breathlessness, coughs or frequent chest infections should consider the possibility of COPD, asthma or interstitial lung disease.

1.2 million

people in the UK have a diagnosis of COPD, which covers conditions such as emphysema and bronchitis. An estimated further 2.4 million are undiagnosed

She emphasises the importance of nurses feeling confident about checking patients’ inhaler technique and offering referrals to smoking cessation and oxygen assessments, as well as working with their specialist colleagues.

‘Hospital nurses also need to be aware of the care provided by specialist nurses, as well as an understanding of the high mortality rates behind respiratory conditions and hospital admissions,’ she says.

Ms Prigmore says hospital nurses should ask themselves the following key questions about any patients with respiratory disease symptoms:

  • Are we recognising and supporting this patient, or merely sticking on a plaster and sending them out again?
  • Does this patient need to to be reviewed by a specialist?
  • Has the patient had an appropriate follow-up?

Respiratory disease: the statistics

  • Across the UK, approximately 9.2 million people have a diagnosis of asthma or chronic obstructive pulmonary disease (COPD), the two most common lung diseases
  • They account for 175,000 hospital admissions, 7.8 million consultations in primary care and in the region of £2 billion in direct healthcare costs each year, according to the Royal College of Physicians
  • Combined with other respiratory diseases, such as interstitial lung disease, they also account for 9% of all premature deaths in England

 

A UK confidential inquiry published in 2015, known as the National Review of Asthma Deaths, concluded that two thirds of asthma deaths were preventable and that there was a failure by nurses and doctors to identify and act on risk factors for asthma attacks and deaths.

It said healthcare professionals must be aware of features that increase the risk of asthma attacks and deaths, including concurrent psychological and mental health issues.

Patients with respiratory conditions are often managing complex chronic health issues, so community, emergency, practice and ward-based nurses encounter them regularly.

‘It’s vital that nurses who aren’t specialists in this area have access to training in the needs of respiratory patients’

Janet Davies, RCN chief executive

RCN general secretary Janet Davies says: ‘Patients with conditions such as COPD, asthma and interstitial lung disease have highly complex disease management needs. But non-specialist nurses in all settings also need to be able to recognise whether someone who presents with symptoms such as breathlessness or a cough may actually have a more serious respiratory condition.

    ‘It’s vital that nurses who aren’t specialists in this area have access to training in the needs of respiratory patients. This is not just in order to be able to support patients with respiratory conditions, but also to be able to work out when someone with a respiratory illness needs to be referred to specialist services, such as specialist nurses.’

    But she is concerned that not enough nurses are able to access training, given cuts of up to 60% in continuing professional development (CPD) budgets in the past two years.

    RCN evidence to the Commons health and social care committee showed CPD budgets had been cut from £205 million in 2015-16 to £83.5 million in 2017-18.

    Making use of specialist expertise

    Association of Respiratory Nurse Specialists (ARNS) vice-chair Katy Beckford says nurses working in partnership with their specialist colleagues is crucial for patients.


    Katy Beckford: ‘We are helping 
    patients to avoid a hospital stay’

    Ms Beckford’s service sees around 10,000 cardiac and respiratory patients each year and has a number of specialist heart failure nurses, respiratory nurses and cardiac and pulmonary rehabilitation nurses, as well as other multidisciplinary team members.

    ‘We can make a significant impact on a patient’s health by being specialist,’ says Ms Beckford, who is also lead for the integrated Community Cardiac and Respiratory Specialist Service (CARSS) at Berkshire Healthcare NHS Foundation Trust.

    ‘We keep ourselves up to date and focus on only one disease area. 

    ‘Some of the things we do are small, but can be missed by a generalist – we keep up with the relevant guidelines and changes to COPD, such as in medication. We make sure diagnoses are correct, that the patient is on the correct care pathway.

    ‘Also, we have the time. Although we are busy, we don’t just have a 10-minute clinic appointment, and a lot of the work we do is educating the patient so they understand their disease.

    ‘Some of the things we do are small, but can be missed by a generalist’

    Katy Beckford, Association of Respiratory Nurse Specialists vice-chair

    ‘Patients are changing – there are more multiple long-term conditions, and they are getting sicker and older, but we are keeping them out of hospital.’

    Evaluating care

    In March, the Royal College of Physicians announced it is adding adult and paediatric asthma to the existing National COPD Audit Programme (NACAP) to support improvements in care for patients in the UK.

    NACAP senior clinical lead Mike Roberts says the plan is to allow asthma and COPD patients and carers to ‘set out the vision for a service that puts their needs first’.

    5

    The five leading causes of premature death in England are respiratory disease, cancer, heart disease, stroke and liver disease

    The audit programme has been commissioned by the Healthcare Quality Improvement Partnership (HQIP) for the next three to five years.

    In 2014, an earlier NACAP found unacceptable care and variation in the organisation and delivery of COPD services, as well as rising hospital admissions and significant vacancies in specialist respiratory nursing.

      s Prigmore is carrying out research to identify and evaluate the impact of respiratory nurse specialists on patient health outcomes, and co-authored a study published in BMJ Open Respiratory Research.

      According to this research, nurses in the UK have significantly expanded and advanced their scope of practice in the management of respiratory diseases, particularly outside hospital settings.

      The researchers wrote that respiratory nurse specialists provide ‘vital support’ to COPD patients to help them manage their condition and have consistently demonstrated positive contributions in delivering hospital-at-home and early discharge schemes.

      It is difficult to get an accurate picture of the number of respiratory nurse specialists in the UK. ARNS has 1,500 members, but Ms Beckford believes there are more.

      One thing is clear: not all of the UK’s respiratory disease patients have access to a specialist nurse, not least because the workforce is an ageing one. Nearly half of the nurses surveyed for Ms Prigmore’s study either planned to retire or would be eligible to do so within ten years.

      ‘Proving our value’

      One respondent reported working for a ‘very overworked respiratory nursing team with one frozen position and one unadvertised position’.

      30,000

      The number of people who die due to COPD in the UK each year

      This reflects findings from the NACAP in 2014, which showed there were 551 unfilled whole-time equivalent vacancies across respiratory specialist nursing.

      Ms Beckford argues that for commissioning groups and services, having a specialist team ‘will save money, as we can make a significant impact on patients’ outcomes’.

      ‘We are always having to prove our value. It is difficult when you are looking at a particular endpoint – as a service, we have to prevent hospital admissions.

      ‘But we know the demographic is going to increase. We have more patients who are getting older and sicker, so the admissions are going to increase because patient volume is going to increase. We have to prevent the avoidable ones.'

      COPD and asthma reviews: a checklist for practice nurses

      • Check symptoms using a validated tool, such as the COPD assessment tool or asthma control test
      • Check inhaler technique at every review
      • Offer smoking cessation advice at every review, and refer on if needed
      • Refer to pulmonary rehabilitation services
      • Refer for oxygen assessment if 02 sats <92%
      • Review self-management plan
      • Refer for assessment in secondary care where there are: frequent exacerbations; questions over correct diagnosis; symptoms out of proportion to lung function; sudden decline in symptoms and/or lung function, as more invasive treatment options such as lung volume reduction surgery may be appropriate
      • Consider co-morbid conditions, in particular anxiety, depression and malnutrition, and treat or refer on
      • If symptom management is poor, contact local respiratory team and, if needed, palliative care
      • Think about the impact on family and carers – provide support

      COPD and asthma reviews: a checklist for community, ward and ED nurses

      • Consider COPD, asthma and interstitial lung disease in patients with respiratory symptoms such as breathlessness, cough and frequent chest infections. Diagnosis usually involves spirometry, which needs to be performed by a competent practitioner
      • Always check inhaler technique
      • Refer for smoking cessation at every opportunity
      • Check nutritional status – is the patient overweight or underweight?
      • Review self-management plan
      • If symptom management is poor, contact local respiratory team and, if needed, palliative care
      • Think about the impact on family and carers – provide support

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