Both the NHS Long Term Plan1 and local data highlight a need to improve the quality of spirometry testing in primary care. Spirometry is essential for the diagnosis and follow up of certain respiratory diseases notably chronic obstructive pulmonary disease (COPD) and asthma which are key projects of the AHSNs Patient Safety Collaborative.
Current practice for spirometry training is via ARTP (Association for Respiratory Technology and Physiology) accreditation which has three levels: Performance only (HCAs/technicians); Performance and Interpretation (Nurses/Physiologists) and Interpretation only (GPs/NPs). If the delegate is successful, they are entered onto the ARTP register for three years and then there are revalidation requirements which are a reduced portfolio of evidence, but no practical assessment. The ARTP certificate is therefore assessing skill of performing and a physiological interpretation of the results. The ARTP do not assess nor support with application of the spirometry results into a clinical context.
It is advised currently that only ARTP standard trained staff should undertake spirometry testing and interpretation, this advice will become mandatory from April 2021.
In recent years, if a local CCG commissioned an ARTP Spirometry two-day course, there was no individual support provided within the model and a pass rate of only 10% was achieved.
This novel training model learnt from the previous training and combined the traditional ARTP accredited two-day spirometry training with three half days of specialist mentorship and clinical support in the practice. The cost was £1,500 per delegate. Adding the mentorship model into training ensured there was time for discussion and clinical context to assess each spirometry trace, allowing the team time to understand important issues relating to diagnosis and management while also increasing confidence and competence.
The aim of this project was to develop and test a model to support the successful delivery of ARTP accredited spirometry training. This model provided individual clinical support and mentorship to ensure the translation of theory into practice for every delegate, increasing their confidence so they could be sure they were performing accurate spirometry readings, interpreting the results accurately and applying those results on an individual patient basis. The model focuses on continuous improvement and promotes a culture of safety where patients can be accurately assessed and diagnosed. It also ensures the workforce delivering spirometry are competent in applying the results into a clinical context for both the diagnosis and the ongoing management. For example, with current practice an ATRP trained professional could view a spirometry report and code the patient as having COPD due to evidence of airflow obstruction, however an ATRP trained professional who had also received mentorship and was able to interpret within the specific context of the individual patient might recognise that while there is evidence of mild obstruction, the result was within normal limits for the specific age of the patient, therefore recognising that a diagnosis of COPD may not be appropriate.
15 delegates were included in this pilot project; this is the number of delegates the funding allowed (£1,500 per delegate).
Sunderland CCG commissioned a standard course for 15 primary care nurses through ‘Education for Health’, a nationally recognised training body. The training package included two days of face-to-face training with e-learning available to further support. The additional element to the model aimed to provide specialist mentorship and clinical support. Following the first face-to-face training day, a Respiratory Specialist Nurse provided all delegates with three-half day sessions of mentorship and clinical support in their own practice, including:
- Support to ensure that their equipment was fit for purpose, in good working order and that they knew how to check this
- Opportunities to review the evidence gathered for their portfolio
- Opportunities to discuss case studies, considering how quality assured spirometry could impact on those discussions
- Opportunities to review asthma and COPD management strategies in practice in the context of local guidelines
- An understanding of national and local respiratory guidelines, and knowledge and competencies regarding inhalers and inhaler technique
- Bespoke respiratory support.
15 delegates were included in this pilot project. Of these, 13 delegates were awarded a pass at their first attempt. The two nurses who failed on their first attempt resubmitted and both subsequently achieved pass results. 100% pass rate was achieved for the group.
Delegates also completed a nine-question document pre and post course to ascertain their confidence levels, 100% of delegates felt more confident after the training.
This new approach resulted in an increased pass rate from 10% to 100% as well as increased confidence and more accurate diagnosis, which ultimately benefits both patients in their quality of life and the NHS financially.
The impact of this project means that the nurse delivering spirometry tests in practice is not only accredited to ARTP standards which will result in more accurate diagnoses for patients with respiratory disease, but they also demonstrated an increase in confidence in managing patients with COPD and asthma within a clinical context. This will directly improve quality of care and patient experience.
The financial impact will be demonstrated by locally reducing the current rate of misdiagnosis in COPD, which nationally sits at around 25%2 (but regionally has been demonstrated in up to 40% of cases).
Cost analysis (source: NHSE data team, 2019)
A GP surgery with approx. 10,000 patients will have around 250 patients diagnosed with COPD. (estimated prevalence of COPD is 2.5%) Assuming the suggested 25% misdiagnosis – 63 patients out of 250 patients may have been misdiagnosed.
If we consider one of the most used and first line treatments that a patient with COPD receives as a consequence of the diagnosis, i.e. a long acting muscarinic antagonist (LAMA) at an average cost of £28 per month per patient, there will be an annual cost of around £21,168 associated with this misdiagnosis in those 63 patients and this is of course cumulative. This is a very conservative cost calculation, as most patients are also provided with short acting beta agonists (SABA) and many patients have additional therapies and could be given three different inhalers before diagnosis is questioned, so the actual cost is likely to be much greater than this. This is without considering the risk and costs associated with litigation if a patient is misdiagnosed.
The added value of reviewing and getting the management correct in already diagnosed patients will also have a significant effect on cost reduction and more importantly, patient safety.
The ideal process to ensure outcomes such as these, is to have a primary care workforce skilled in spirometry and confident in its clinical application into practice.
The evidence is clear; pass rates improved, confidence levels have increased in clinicians, which will inevitably lead to improved outcomes in management for patients.
Benefits for the patient:
- Access to quality assured spirometry and diagnosis
- Improvement in diagnostic accuracy and subsequent quality of condition management
Benefits for the clinician:
- The clinician conducting the spirometry and subsequent management has more skill and confidence and can support colleagues in practice through updates and education in best practice respiratory management
Benefits for the NHS:
- Increased skill and confidence within the workforce leading to:
- Reduced financial burden due to incorrect diagnosis
- Reduction in inappropriate prescribing
- Reduced in hospital admissions where misdiagnosed conditions remain unmanaged.
The model was developed after the low pass rate of previous spirometry training; therefore, this model worked very well and would not need improvement due to the 100% pass rate.
Essential elements for success of this project included support for the model from the Academic Health Science Network Respiratory Lead. Subsequent practice visits to witness spirometry readings were also integral to the success of this project.
Engagement from the wider practice team to allow the nurse the time to spend in training and related discussions was critical to the success.
This project is now complete and to date a further 17 nurses have also been trained using this model, also with 100% success rate. A third cohort using the same model is currently in progress. While this is a more labour-intensive way to support clinicians to achieve the necessary insight and understanding to perform and interpret diagnostic spirometry accurately, the benefits of utilising such a delivery model suggest that this is a cost-effective approach
More people with ATRP accreditation and experience would be required to deliver this project at scale however, the emergence of Primary Care Networks offers a more practical solution for future delivery of this training model. If a PCN approach was developed for the management of patients with respiratory conditions practices would be able to share clinical expertise, resulting in then fewer nurses needing to be trained to this higher standard.
The learning from this study could be applied in any setting where multi-disciplinary teams undertake spirometry.