Mobile Respiratory Diagnostic Hub Pilot

The City and Hackney Mobile diagnostic hub will deliver quality assured respiratory diagnostic tests such as spirometry and FeNO at multiple sites across the Borough to both adults and children with a suspected chronic respiratory disease.
The phased roll out of the Diagnostic Hub has started, we are currently delivering clinics in two PCNs, with the long-term plan to provide one clinic per Primary Care Network per fortnight depending on site suitability, as well as the running of ad hoc clinics outside of these times as required.

Please start to refer to the service (information on how to do this is below), we are accepting referrals from every PCN, however please bare in mind, there may be a wait for an appointment.

Purpose of the Respiratory Diagnostic Hub
The service is intended to provide quality assured Spirometry and FeNO (as appropriate) to enable the diagnosis of COPD or asthma. The Hubs are for people with a suspected diagnosis of COPD or asthma in the first instance to clear backlogs and then will follow the prioritisation system as outlined below. The Hubs are not for any monitoring of lung function.

Currently, the service is expected to provide testing and interpretation of Spirometry/FeNO results. A discharge summary will be received by referrers following the appointment and GPs will be expected to make a diagnosis in conjunction with the clinical history. GPs will also be expected to refer on any questionable diagnosis/unclear diagnosis for specialist input.

Eligibility

Inclusion

At time of spirometry/FeNO appointment

≥ 6 years old
Breathlessness query cause and/or cough query cause (to confirm or support a differential diagnosis)
Salbutamol MDI with Aerochamber prescription are required to enable diagnostic hub to perform reversibility test.

CXR within the last 6 months or one booked along with this referral

**CXR in the last 6 months is recommended to support a confirmed diagnosis. If a CXR is booked, diagnostic Hub appointment can go ahead prior to CXR (not applicable for paediatric referrals)

Exclusion

At time of spirometry/FeNO appointment:

< 6 years old
A chest infection or exacerbation (within last 6 weeks)
Had a recent eye surgery (12 weeks standard, 6 weeks laser), chest or abdominal surgery (in the last 12 weeks)
Uncontrolled high or low blood pressure
Coughed up blood
Experienced chest pain, had a heart attack or stroke in the last 12 weeks
Condition which may be aggravated by prolonged expiration i.e. history of panic attacks
Recent mouth/dental procedures or infection, which may make placement of the mouthpiece distressing or painful
Symptoms of COVID or tested positive for COVID within the last 10 days

Patients not suitable for Diagnostic Hub and who should be referred elsewhere:

Patients requiring specialist review in the chest clinic
TB or patients with suspected cancer (2 week wait referrals) or any other respiratory “red flags”
Routine follow up spirometry as part of annual review
Patients for whom FeNO readings are needed to assess treatment response
Patients who are housebound
Bed-bound patients or patients who are unable to sit upright
Patients with cognitive impairment or dementia to a degree that they will not be able to follow instructions

How to refer

Who can refer: GP

Clinician doc

Document referral

Send by: e referral — For now, referrals will be made by email. Please send referrals using the attached referral form to the <a href="mailto:huh-tr.acersdiagnostichub@nhs.net" style="color:#0563c1; text-decoration:underline">huh-tr.acersdiagnostichub@nhs.net</a> Appointments: Patients will receive their appointments via the post. If they are unable to attend, they should contact the team on the details below for the appointment to be rescheduled. Patients will also receive a text message or phone call confirming their appointment closer to the date and time of the appointment. If a patient is unable to attend on the day, they should call the service to alert them to this. Referral Prioritisation Due to the significant backlog, a prioritisation stratification in line with the ARTP stratification guidance and agreed by the steering group and Primary Care will focus on patients deemed to the highest priority. This includes: Highest Priority patients <ul> <li class="TableParagraph" style="text-align:justify">Consider spirometry for those patients with a provisional diagnosis but poor response to treatment (although one hopes further investigation would have already been considered). </li> <li class="TableParagraph" style="text-align:justify">patients for whom diagnostic spirometry will potentially impact their treatment pathway or determine their onward care.</li> <li style="text-align:justify">Those who are symptomatic with cough and breathlessness but no clear diagnosis.</li> <li style="text-align:justify">Those who are symptomatic with cough and breathlessness with diagnosis but no spirometry.</li> </ul> Once the service has reduced the backlog of patients waiting for quality assured spirometry from the highest priority group, the service will concentrate on people from lower priority groups, which includes: <ul> <li> <ul> <li class="TableParagraph"><a name="_Hlk140749517">Spirometry to confirm </a>diagnosis is valuable but not an immediate priority. If a patient’s history and clinical picture fits with the provisional diagnosis and they respond well to treatment it is important to confirm diagnosis but not at the expense of patients in whom spirometry might alter the diagnosis or treatment (Medium Priority).</li> <li class="TableParagraph">Reviews of progression of disease but if you still regularly perform spirometry on stable patients (e.g. those with pulmonary fibrosis) these should be at the back of the queue. (Lowest Priority)</li> </ul> </li> </ul> The service will not undertake or accept referrals for: <ul> <li>Annual reviews – this is no longer a requirement for the Quality Outcomes Framework (QOF) and there is little evidence to demonstrate value.</li> <li>Case finding on non-symptomatic people.</li> </ul> Respiratory Diagnostic Hubs Process <ul> <li class="Default">During the appointment the hub will complete FeNo testing first and perform spirometry with or without reversibility as per the standard operating policy and as per National guidance. </li> <li class="Default">The hub will advise the patient the results will be provided to the referring GP and reassure that spirometry is an aid to diagnosis and is not diagnostic on its own.</li> <li class="Default">The hub will send diagnostic summary report to practice and discharge patients to GP for appropriate diagnosis and treatment depending on the outcome of testing.</li> <li class="Default">The hub is not responsible for any initiation of treatment or onward referrals. </li> </ul> To support referral and prioritisation to the Respiratory Diagnostic Hub CEG have outlined possible searches that could be undertaken by each practice if you have not maintained a list of patients awaiting diagnostic spirometry: CEG have created a suite of searches to help practices prioritise patient recall. Practices will be able to identify 3 cohorts to review and prioritise for spirometry with cohort 1 being patients with highest priority followed by cohort 2 as detailed below.: <ul> <li class="xxx">Cohort 1: Patients with a coded exacerbation in the last 12m</li> <li class="xxx">Cohort 2: Patients prescribed Prednisolone in the last 12m</li> <li class="xxx">Cohort 3: Remaining patients with a prescription of LABA/LAMA</li> </ul> Please copy Spirometry Support v1 over to your practice domains. These searches can be found in folder 3. PCN Contracts within the main Practice Support folder. It is important to note that the aim of the CEG searches is to create a list of patients who may need respiratory diagnostic testing but the list will still need scrutiny to determine if priority for spirometry/FENO, and not send all of the patients through to the service at once.

Download referral form