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

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.
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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
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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
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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.
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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
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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
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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
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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
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