Pulmonary Rehabilitation

Pulmonary rehabiliation

Referral to and timely availability of pulmonary rehabilitation has now been shown to, reduce the three month readmission rate in COPD from 33% to 7%. To date this is the only intervention that has been shown to alter the very high 3 month readmission rate seen in COPD (Seymour et al Thorax 2010;65:423-435)

The the National COPD Audit 2008 confirms that

The majority of PCOs state that they provide Community Pulmonary Rehabilitation (70%), Early Discharge (73%) and Admission Avoidance Schemes (75%) of which 83% are funded by PCO, 4% by hospital, 11% jointly and 2% is not funded.

Fifty percent of PCOs have a written plan to develop COPD, 39% say it is in development, and 11% do not have plan. If yes or in development, 97% include pulmonary rehabilitation therefore it is an important area to get right.

Resources from IMPRESS include

Principles, Definitions & Standards for Pulmonary Rehabilitation supported by IMPRESS in consultation with British Association of Occupational Therapists (BAOT), Association of Respiratory Nurse Specialists (ARNS) and Association of Chartered Physiotherapsits in Respiratory Care (ACPRC)

This document includes 4 standards with markers of good practice:

Standard 1 A rehabilitation programme must contain individually prescribed, physical exercise training together with lifestyle and self-management advice.
Marker of good practice Written prescriptions of endurance and strength exercise training at the highest tolerated intensity and evidence of increments with progress.

Standard 2 The programme should be delivered by a multi-disciplinary team and include two supervised sessions per week for at least four weeks. Further home training should be encouraged.
Marker of good practice Diversity of team membership, staffing ratios and existence of training diaries

Standard 3 Individual progress should be assessed by the use of appropriate assessment and outcome measures (usually health status and functional exercise capacity)
Marker of good practice Records of individual patient progress in all cases

Standard 4 There should be evidence of programme quality control and improvement.
Markers of good practice There should be records of patient attendance and drop out, patient satisfaction questionnaires and audit of effectiveness. The presence of appropriate safety measures, including staff resuscitation training and availability of oxygen.

Webcast from Dr Rupert Jones at the inaugural IMPRESS conference: Care closer to home. The models of pulmonary rehabilitation Dr Jones estimates that if you assume a 2% prevalence of diagnosed COPD and 30% of those will benefit from PR, then in a population of 250,000, 1500 will need pulmonary rehabilitation, and a GP with 2000 patients may have 40 patients with COPD of whom 12 will need referral to PR. It is therefore important to create models of provision that match this need. He gives examples.

Webcast from Dr Louise Restrick at the inaugural IMPRESS conference showing how her team increased completion rates from the national average of 50% to 92%. An outreach model of integration, the Whittington model

This model from NHS Islington is also available as a NICE example of shared learning Introduction of pulmonary rehabilitation programme in primary care in accordance with COPD guidance

From Primary Care Respiratory Society (PRS UK) (ex GPIAG)

Best practice

Opinion sheet