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Breakout 3.5 ‘Dying for a fag’ The hypoxic patient actively smoking – case study - Sue Smith

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NHS Improvement
NHS Improvement

Breakout 3.5 ‘Dying for a fag’ The hypoxic patient actively smoking – case study - Sue Smith Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

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DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW ‘DYING FOR A FAG’ THE HYPOXIC PATIENT ACTIVELY SMOKING – A CASE STUDY DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Evidence of benefit The two landmark trials (NOTT 1980 & MRC 1981) used for Guidance on prescribing Home Oxygen - no exclusion of smokers.  MRC trial – 43% of subjects current smokers  NOTT – 39% of subjects current smokers More recently – Nice 2004 & BTS 2006 ‘smoking cessation techniques should be continued prior to any home oxygen assessment. Patients should be made aware of the dangers of continuing to smoke” Therefore they set precedents that are now accepted in clinical practice. 1
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW SOUTH DERBYSHIRE 2011 - active Oxygen 2012 800 Patients  750 patients actively using Home Oxygen smokers  110 Active smokers 600  82 successfully stopped smoking successfully 400  28 continued to smoke – stopped smoking Have proven ‘safe’ smoking continued to smoke – switch Oxygen off, move outside at best, into a 200 closed door room at worst. risk assessments  All of these have formal risk assessments 0 undertaken & regular follow up DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW PATIENT IDENTIFIED AS BEING AT RISK FROM SMOKING & USING OXYGEN ENSURE PATIENT AWARE OF RISK, INFORM OXYGEN COMPANY GIVE COPIES OF LEAFLET. PATIENT AWARE OXYGEN COULD BE HOME RISK ASSESSMENT. PATIENT INFORM FIRE SAFETY OFFICER TO SIGN PAPERWORK PATIENT, OXYGEN PRACTITIONER, FIRE SAFETY OFFICER COMPLETE PAPERWORK & FILE IN NOTES REMOVED IF RISK TOO GREAT - 3 WITNESSED EPISODES SMOKING Continue to put themselves Managed ‘safely’ & others at risk 2
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Case study  62yr old, COPD with severe Type 2 Respiratory Failure  Established Home Oxygen user (Since 2007)  ‘cold call’ visit 6 weeks post discharge  Oxygen in situ, but obvious signs of smoking whilst on Oxygen  Declined any risk assessments / fire service etc  Became agitated when removal of Oxygen mentioned  Deteriorating Type 2 Respiratory Failure DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Refused admission Refused input from GP Agitated – Wanting me out his home Became so unwell – neighbour dialled 999 Triggered ‘3 strike rule’ Removal would result in hastened death Agreement sought form local legal / ethical committee Counsel advice 3
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW CLINICAL GOVERNANCE Patient / Public focus Risk Management PATIENT SAFETY Clinical Effectiveness DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Derbyshire Home Oxygen Service / Fire and Rescue Service REDUCING THE RISK OF FIRE IN SMOKERS WHO ARE ASSESSED AS NEEDING OXYGEN THERAPY Information to support the memorandum of understanding between the NHS and DFRS to supply safety advice and practical measures to improve fire safety in the home for home Ref. No: oxygen users Aim: To introduce a policy for reducing the risk of fire in patients who are prescribed oxygen, who are exposed / have the potential to be March 2010 exposed to sources of fire & heat. This is a new policy, which aims to give the prescriber the tools to adequately manage the risks involved, to ensure a level of safety for the patient, relatives, visiting health care 1 Derbyshire Fire and Rescue Service (DFRS) will work in partnership with the NHS, and others as appropriate, to enhance fire safety in the home for home oxygen professionals, fire service and neighbouring properties. The aim is to users. maximise the use of available resources, with close working relationships between the Home Oxygen Service, The fire And Rescue 2 This will include the provision of fire safety advice for the occupant(s) of identified domestic premises and the provision of free smoke detectors if appropriate. Service for Derbyshire and local smoking cessation services. Whilst we aim to reduce the risk as much as possible it must be 3 Any other items deemed desirable, such as fire retardant bedding packs, will acknowledged that due to the nature of the issues involved, the risk normally be provided by the NHS or other partners. cannot fully be eliminated. 4 DFRS will endeavour to support this work as far as is reasonably practicable but this will depend upon the availability of suitably trained DFRS Community Safety Officers (CSOs) and financial support from internal/external budgets. 5 The joint DFRS/NHS Home Fire Safety Checks (HFSCs) to support this partnership will be conducted by DFRS Community Safety Officers and nominated NHS staff. Purpose and Scope: This will allow joint activity to reduce the potential for unwanted fires in the property Oxygen therapy has been the mainstay of therapy & treatment within acute hospitals for as far as possible. years. As a result of improved accessibility and local service developments, there is an 6 There will normally be 2 ways by which a joint visit will be facilitated. Firstly, DFRS increasing cohort of patients in the community using home oxygen therapy services. staff may come into contact with a Home Oxygen User (HOU) during a routine The Home Oxygen service provides 90,000 patients in England and Wales with different HFSC. If this is the case, the HFSC will be completed and detectors fitted (if models of home oxygen therapy and a tailored, patient -centred service. The new home required). A referral form provided by the NHS will then be faxed to an agreed oxygen supply service commenced on the 1 st February 2006, with Air Products being the contact number giving details of the circumstances found in the premises. If a further contracted supplier of all oxygen modalities in the East Midlands. More recent Local joint visit is deemed necessary, this will ensue in due course. Consideration within developments include the formation of the Home Oxygen Assessment Service for DFRS needs to be given as to how a referral is made to the NHS if a Firefighter or Derbyshire County & Derby City in May 2009. Handyperson comes across a HOU and concerns are raised. It may be best that The objective is for Derbyshire County PCT to develop and improve clinical assessment through awareness training or internal communication we set up a mechanism for and follow up services to provide improved patient care and wellbeing. The registered them to inform their Area Office Manager/HFSC coordinator who will then inform an Area CSO who will refer to the NHS. population for the PCT is 747,500 with approximately 1343 in Derbyshire, and 900 patients in Derby City patients currently (July 2008) being provided with home oxygen 7 Secondly, NHS staff may enter the household of a HOU and have concerns about therapy by Air Products. Most prescribing of Home Oxygen Therapy is currently initiated fire safety and will make a faxed referral to the relevant DFRS Area Office for the in Primary Care by GPs, though this is now being supplanted by the Derbyshire Home individual concerned and a joint visit with a CSO will also ensue. Oxygen Service. There are many risks associated with Home Oxygen Therapy, mainly concerned with the 8 The NHS has offered to supply suitable transport for joint visits between DFRS and patients’ health and inadequate prescription of home oxygen. There are also risks the NHS in circumstances where this is either necessary or desirable. This will be in associated with the incorrect use of oxygen therapy equipment and fire risks associated the NHS representatives own vehicle which will be suitably insured for this purpose with exposure to flame or heat, oxygen enrichment of surrounding area, use of materials and roadworthy. This will also allow 1 CSO to attend a household with the NHS representative so lone working does not occur. not compatible with Oxygen therapy. This Policy predominantly covers Home Oxygen therapy users who continue to smoke, but also incorporates basic safety aspects and risk reduction tools for all Home Oxygen patients. 4
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Patient Letter / Consent Safety Leaflet Risk Assessment Documentation DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW CLINICAL GOVERNANCE Patient / Public focus Risk Management PATIENT SAFETY Clinical Effectiveness 5
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW  PART A HOOF – » HOSPITAL DISCHARGE » GP EMERGENCY OUT OF HOURS » PALLIATIVE CARE ORDERS Can we withhold Oxygen on suspicion alone? DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW CLINICAL GOVERNANCE Patient / Public focus Risk Management PATIENT SAFETY Clinical Effectiveness 6
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW RIGHT TO LIFE (and quality of life)  PATIENT AND PUBLIC AWARENESS OF OXYGEN INDICATIONS AND SAFETY  LOCAL TRAINING  National Programme? DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Clinicians & Health care Professionals Carer / neighbour Capacity input Assessment Patient safe Oxygen Service discharge Social Services Home Access Home Fire & Rescue visit Multi Disciplinary Team Meeting 7
DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Questions of current guidance  Can supplemental Oxygen be of clinical benefit Patients who continue to smoke?  Do we make a ruling not to prescribe Oxygen for smokers irrespective of their Hypoxia? DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW  QUESTIONS ? Sue Smith. Oxygen Practitioner. Derbyshire Home Oxygen Service Assessment & Review Royal Derby Hospital 01332 787825 sue.smith31@nhs.net 8

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Breakout 3.5 ‘Dying for a fag’ The hypoxic patient actively smoking – case study - Sue Smith

  • 1. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW ‘DYING FOR A FAG’ THE HYPOXIC PATIENT ACTIVELY SMOKING – A CASE STUDY DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Evidence of benefit The two landmark trials (NOTT 1980 & MRC 1981) used for Guidance on prescribing Home Oxygen - no exclusion of smokers.  MRC trial – 43% of subjects current smokers  NOTT – 39% of subjects current smokers More recently – Nice 2004 & BTS 2006 ‘smoking cessation techniques should be continued prior to any home oxygen assessment. Patients should be made aware of the dangers of continuing to smoke” Therefore they set precedents that are now accepted in clinical practice. 1
  • 2. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW SOUTH DERBYSHIRE 2011 - active Oxygen 2012 800 Patients  750 patients actively using Home Oxygen smokers  110 Active smokers 600  82 successfully stopped smoking successfully 400  28 continued to smoke – stopped smoking Have proven ‘safe’ smoking continued to smoke – switch Oxygen off, move outside at best, into a 200 closed door room at worst. risk assessments  All of these have formal risk assessments 0 undertaken & regular follow up DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW PATIENT IDENTIFIED AS BEING AT RISK FROM SMOKING & USING OXYGEN ENSURE PATIENT AWARE OF RISK, INFORM OXYGEN COMPANY GIVE COPIES OF LEAFLET. PATIENT AWARE OXYGEN COULD BE HOME RISK ASSESSMENT. PATIENT INFORM FIRE SAFETY OFFICER TO SIGN PAPERWORK PATIENT, OXYGEN PRACTITIONER, FIRE SAFETY OFFICER COMPLETE PAPERWORK & FILE IN NOTES REMOVED IF RISK TOO GREAT - 3 WITNESSED EPISODES SMOKING Continue to put themselves Managed ‘safely’ & others at risk 2
  • 3. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Case study  62yr old, COPD with severe Type 2 Respiratory Failure  Established Home Oxygen user (Since 2007)  ‘cold call’ visit 6 weeks post discharge  Oxygen in situ, but obvious signs of smoking whilst on Oxygen  Declined any risk assessments / fire service etc  Became agitated when removal of Oxygen mentioned  Deteriorating Type 2 Respiratory Failure DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Refused admission Refused input from GP Agitated – Wanting me out his home Became so unwell – neighbour dialled 999 Triggered ‘3 strike rule’ Removal would result in hastened death Agreement sought form local legal / ethical committee Counsel advice 3
  • 4. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW CLINICAL GOVERNANCE Patient / Public focus Risk Management PATIENT SAFETY Clinical Effectiveness DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Derbyshire Home Oxygen Service / Fire and Rescue Service REDUCING THE RISK OF FIRE IN SMOKERS WHO ARE ASSESSED AS NEEDING OXYGEN THERAPY Information to support the memorandum of understanding between the NHS and DFRS to supply safety advice and practical measures to improve fire safety in the home for home Ref. No: oxygen users Aim: To introduce a policy for reducing the risk of fire in patients who are prescribed oxygen, who are exposed / have the potential to be March 2010 exposed to sources of fire & heat. This is a new policy, which aims to give the prescriber the tools to adequately manage the risks involved, to ensure a level of safety for the patient, relatives, visiting health care 1 Derbyshire Fire and Rescue Service (DFRS) will work in partnership with the NHS, and others as appropriate, to enhance fire safety in the home for home oxygen professionals, fire service and neighbouring properties. The aim is to users. maximise the use of available resources, with close working relationships between the Home Oxygen Service, The fire And Rescue 2 This will include the provision of fire safety advice for the occupant(s) of identified domestic premises and the provision of free smoke detectors if appropriate. Service for Derbyshire and local smoking cessation services. Whilst we aim to reduce the risk as much as possible it must be 3 Any other items deemed desirable, such as fire retardant bedding packs, will acknowledged that due to the nature of the issues involved, the risk normally be provided by the NHS or other partners. cannot fully be eliminated. 4 DFRS will endeavour to support this work as far as is reasonably practicable but this will depend upon the availability of suitably trained DFRS Community Safety Officers (CSOs) and financial support from internal/external budgets. 5 The joint DFRS/NHS Home Fire Safety Checks (HFSCs) to support this partnership will be conducted by DFRS Community Safety Officers and nominated NHS staff. Purpose and Scope: This will allow joint activity to reduce the potential for unwanted fires in the property Oxygen therapy has been the mainstay of therapy & treatment within acute hospitals for as far as possible. years. As a result of improved accessibility and local service developments, there is an 6 There will normally be 2 ways by which a joint visit will be facilitated. Firstly, DFRS increasing cohort of patients in the community using home oxygen therapy services. staff may come into contact with a Home Oxygen User (HOU) during a routine The Home Oxygen service provides 90,000 patients in England and Wales with different HFSC. If this is the case, the HFSC will be completed and detectors fitted (if models of home oxygen therapy and a tailored, patient -centred service. The new home required). A referral form provided by the NHS will then be faxed to an agreed oxygen supply service commenced on the 1 st February 2006, with Air Products being the contact number giving details of the circumstances found in the premises. If a further contracted supplier of all oxygen modalities in the East Midlands. More recent Local joint visit is deemed necessary, this will ensue in due course. Consideration within developments include the formation of the Home Oxygen Assessment Service for DFRS needs to be given as to how a referral is made to the NHS if a Firefighter or Derbyshire County & Derby City in May 2009. Handyperson comes across a HOU and concerns are raised. It may be best that The objective is for Derbyshire County PCT to develop and improve clinical assessment through awareness training or internal communication we set up a mechanism for and follow up services to provide improved patient care and wellbeing. The registered them to inform their Area Office Manager/HFSC coordinator who will then inform an Area CSO who will refer to the NHS. population for the PCT is 747,500 with approximately 1343 in Derbyshire, and 900 patients in Derby City patients currently (July 2008) being provided with home oxygen 7 Secondly, NHS staff may enter the household of a HOU and have concerns about therapy by Air Products. Most prescribing of Home Oxygen Therapy is currently initiated fire safety and will make a faxed referral to the relevant DFRS Area Office for the in Primary Care by GPs, though this is now being supplanted by the Derbyshire Home individual concerned and a joint visit with a CSO will also ensue. Oxygen Service. There are many risks associated with Home Oxygen Therapy, mainly concerned with the 8 The NHS has offered to supply suitable transport for joint visits between DFRS and patients’ health and inadequate prescription of home oxygen. There are also risks the NHS in circumstances where this is either necessary or desirable. This will be in associated with the incorrect use of oxygen therapy equipment and fire risks associated the NHS representatives own vehicle which will be suitably insured for this purpose with exposure to flame or heat, oxygen enrichment of surrounding area, use of materials and roadworthy. This will also allow 1 CSO to attend a household with the NHS representative so lone working does not occur. not compatible with Oxygen therapy. This Policy predominantly covers Home Oxygen therapy users who continue to smoke, but also incorporates basic safety aspects and risk reduction tools for all Home Oxygen patients. 4
  • 5. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Patient Letter / Consent Safety Leaflet Risk Assessment Documentation DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW CLINICAL GOVERNANCE Patient / Public focus Risk Management PATIENT SAFETY Clinical Effectiveness 5
  • 6. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW  PART A HOOF – » HOSPITAL DISCHARGE » GP EMERGENCY OUT OF HOURS » PALLIATIVE CARE ORDERS Can we withhold Oxygen on suspicion alone? DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW CLINICAL GOVERNANCE Patient / Public focus Risk Management PATIENT SAFETY Clinical Effectiveness 6
  • 7. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW RIGHT TO LIFE (and quality of life)  PATIENT AND PUBLIC AWARENESS OF OXYGEN INDICATIONS AND SAFETY  LOCAL TRAINING  National Programme? DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Clinicians & Health care Professionals Carer / neighbour Capacity input Assessment Patient safe Oxygen Service discharge Social Services Home Access Home Fire & Rescue visit Multi Disciplinary Team Meeting 7
  • 8. DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW Questions of current guidance  Can supplemental Oxygen be of clinical benefit Patients who continue to smoke?  Do we make a ruling not to prescribe Oxygen for smokers irrespective of their Hypoxia? DERBYSHIRE HOME OXYGEN SERVICE ASSESSMENT & REVIEW  QUESTIONS ? Sue Smith. Oxygen Practitioner. Derbyshire Home Oxygen Service Assessment & Review Royal Derby Hospital 01332 787825 sue.smith31@nhs.net 8