Newcastle Oxygen Service

1
Newcastle Oxygen Service

• Chris Irving MBA BSc
• Clinical lead

2
Background

• 450 patients on oxygen (population of 216,000
  Census 2001)
• 512 individual accounts in Newcastle
• An annual estimated expenditure in excess of
  500,000
• Significant number of patients on inappropriate
  form of therapy or who no longer require this
  service

3
Cost of Oxygen

• 54 Tariffs
• Daily rates
• Cost depends on device, flow rate and hours/day
• Avoid 7 patients from inappropriately being given
  lightweight ambulatory oxygen
• Full time band 6 nursing staff

4
Team Formed February 2007

• Commissioned service current investment of
  approximately 72,000 per annum
• 2 Band 6 Senior nurses to join the COPD supported
  discharge service
• Employed by Newcastle PCT, based in secondary
  care
• Access to support from secondary care respiratory
  consultants
• Access to all secondary care notes and computer
  systems
• Joint working initiatives with the RVI Chest
  Clinic

5
Training

• Estimated 1 WTE per 200 patients for inner city
  area based on estimated number of visits
• Specialist training in spirometry (ARTP
  certified), ABG sampling (ARTP certified), Open
  Exeter, smoking cessation, excel, COPD, Air
  Liquide equipment and cognitive behavioural
  therapy (CBT) supervision by CBT specialist

6
Aim of the Team

• Provide a quality driven, patient focused, city
  wide oxygen review and assessment service for
  patients currently on and who potentially require
  oxygen therapy across primary and secondary care.

7
Objectives

• Review all patients receiving O2 at home annually
• Provide initial O2 screening for patients
  referred by GPs non respiratory consultants
  either in hospital or in their own home
• Provide 6 week follow up for all new oxygen
  patients
• Provide continuing support for all oxygen patients

8
Objectives

• To build ongoing relationships with Air Liquide.
• To work collaboratively with secondary care
  respiratory service to develop joint services
• To demonstrate significant potential cost savings
  sufficient to justify the retention of the
  service.

9
Review Service

• Assessment Process
• Patient selected from database provide by Air
  Liquide (Air Liquide data cleaned)
• GP details checked
• Paediatrics excluded
• Hospital base medical/mermaid system notes
  reviewed
• History prepared
• Patients contacted by phone

10
Home assessment

• Oxygen prescription checked against Air Liquide
  data, litres per minute, hrs per day, filter
  check and general safety
• Clinical assessment including SaO2, Spirometry,
  BMI, HAD score, medication check and inhaler
  technique
• Ambulatory assessment within the home
• General social assessment
• Offer smoking cessation and pulmonary rehab if
  appropriate
• Patients given contact numbers for on going
  support

11
Home assessment

• Benefits for the patients
• Patients using correct amount and hrs usage of
  oxygen
• Referral to respiratory consultant for assessment
• Referral to district nurse
• Referral to GP/medication review
• Provision of loan equipment/wheelchairs
• Prescription of or change of inhalers
• Referral for intermediate care
• Referral to physiotherapy and occupational
  therapy
• Referral for social services care
• Referral to welfare rights
• Nutritional supplements
• Cognitive Behavioural Therapy

12
Assessments May Nov 2007

• 425 patients selected for assessment
• 76 patients deceased
• 65 not Newcastle PCT
• 255 patients (May-Nov 2007)
• 91 of these (35.6) had resting oxygen
  saturations above the range in which long term
  oxygen is indicated (SaO2 94)

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02 Resting Saturations
14
02 Resting Saturations gt94
15
Readmissions following oxygen removal
16
Cost Savings
17
Monthly Expenditure
18
Cost Comparison
19
Cost Savings Realised

• Reduction of oxygen accounts from 512 to 411 May
  Dec 2007
• Monthly oxygen budget reduced from 55,082 to
  44,554 May Dec 2007 annual saving of 126,336
• PCT refunded 63,627 from changes made by Oxygen
  Team July Dec 2007
• Total savings of 189,963

20
Case Study One

• Elderly gentleman prescribed lightweight portable
  oxygen with conserving device (no formal
  assessment)
• Patients SaO2 70 on exertion
• Not triggering conserving device
• Without conserver O2 lasts lt4hrs
• Patient changed to two standard ambulatory
  cylinders with trolley
• Cost saving 13.71 - 4.47 9.42 x 365
  3372.60

21
Case Study One

• Patient received correct modality of oxygen to
  suit his needs
• Patient able to mobilise outdoors without
  excessive desaturation
• Substantial cost saving incurred

22
Case Study Two

• Female prescribed oxygen from GP
• Resting O2 sats 93
• Prescribed LTOT, given one concentrator for the
  living room and one for the bedroom
• 2 x 594.95 1189.90

23
Case Study Two

• Air Liquide technical support contacted
• Joint visit carried out
• Oxygen piped into both rooms from one
  concentrator
• Cost saving of 594.95 per annum

24
ASSESSMENT SERVICE

• As per BTS guidelines 2004 for LTOT and
  Ambulatory oxygen
• Quint (2006) 53 of referrals were prescribed
  following assessment (current UK guidelines)
• Dilworth (1989) 67,Baudouin (1990) 57, Walsaw
  (1988) 71, Waterhouse (1994) 38

25
Ambulatory Assessments

• April 2006 Dec 2007 54 assessments
• 39 negative (72)
• 15 positive (27)
• Estimated savings at mid point ambulatory 4.38 x
  39 x 365 62349

26
Future Plans

• Carry out all hospital ambulatory assessments in
  Newcastle
• Reassess all patients with Sao2 92-94 with ABGs
• Complete 6 month audit of patients who have had
  oxygen withdrawn with follow up visits and oxygen
  saturations
• Re-evaluate all high users of ambulatory oxygen,
  plan to re issue HOOF based on weekly usage not
  daily usage
• Aim to have oxygen budget lt35K by the end of 2008

27
Patient experience

• For the three months I have been off my oxygen
  I feel a lot better within myself. I still get a
  bit frightened sometimes when I get a chest
  infection. I have a bit more freedom than before,
  it is hard to explain because when I was on the
  machine I thought this is it. This is my life
  now, it was for 5 years it made me very depressed
  and angry, that was all due to smoking. But now
  it is a lot different, I play with my
  granddaughter a bit more where I could not before
  and go out a lot more.

28
Summary

• Increased quality of care for patients
• Holistic service
• More evidence based oxygen prescribing
• Reduction of inappropriate patients on oxygen
• Significant cost savings

29
Questions
30
References

• Baudoin, S V et al (1990) Long term domiciliary
  oxygen treatment for chronic respiratory failure
  reviewed, Thorax, 45pp 195-198.
• Dilworth, JP et al (1989) Prescription of oxygen
  concentrators adherence to published guidelines,
  Thorax, 44 pp576-578.
• Quint, J K et al (2006) Impact of new home oxygen
  service on respiratory units doi10.1136/thx.2006.
  065565
• Walsaw, M J et al (1988) Prescription of oxygen
  concentrators for long term oxygen treatment
  reassessment in one district, British Medical
  Journal, Vol 297, pp1030-1032.
• Waterhouse, J C et al (1994) Survey on
  domiciliary oxygen by concentrator in England and
  Wales, European Respiratory Journal, 7
  pp2021-2025.