Introduction and Education,Training & Research
Introduction
The Respiratory Department at Basildon and Thurrock Hospital is at the forefront of many pioneering procedures to ensure that patients obtain the best possible care, both efficiently and effectively.
The Department has many sub-specialty areas led by clinical leads to ensure that patients receive the very best care possible. This ethos extends to the rest of the hospital as staff are readily available for advice and assessment of patient symptoms as appropriate.
The sub-specialty areas include:
· Non Invasive Ventilation (NIV) Service
· Pleural Disease (access to ward-based ultrasound machine)· Medical Thoracoscopy
· Oxygen Clinics and Oxygen Assessment Services
· Pulmonary Physiology and Sleep Medicine
· Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS-TBNA)
· Asthma and Chronic Obstructive Pulmonary Disease (COPD)
· Lung Cancer including Specialist Palliative Care
· Interstitial Lung Disease (ILD)
In-patient facilities for respiratory patients include the Acute Respiratory Care Unit (ARCU) and Florence Nightingale Ward.
Education,Training & Research:
There is a significant emphasis on multi-professional training in the department which regularly hosts specialist training programmes for respiratory trainees in the East of England and London Deaneries
Current medical trainees include two higher specialist respiratory trainees from the East of England and North East Thames Deaneries; two core medical trainees from the East of England Deanery and three foundation trainees from the North Central Thames Foundation School. In addition seven to ten nursing students from the Anglia Ruskin & Essex Universities are regularly posted and trained in Florence Nightingale Ward.
Besides regular teaching and audits within the respiratory department and the pulmonary physiology lab, the staff are actively involved in teaching and training medical and allied medical professionals across the trust.
The department has been involved in a number of multi-centric research trials and national audits. There is a good track record of departmental work being published in peer-reviewed journals and international meetings.
Acute Respiratory Care Unit (ARCU), Florence Nightingale Ward and Non-invasive Ventilation (NIV)
Acute Respiratory Care Unit (ARCU)
The Acute Respiratory Care Unit (ARCU) is an eight-bed specialist respiratory unit (four male and four female) and focuses on the management of patients with acute/chronic respiratory illness with higher dependency or critical care needs, including those requiring non-invasive ventilation.
The unit is covered by a consultant respiratory physician 24 hours a day, seven days a week along with a nurse assigned to every two patients as it is providing specialist attention, classed as ‘level 2 care’.
In addition an outreach nurse visits patients in A&E likely to benefit from this kind of specialist care and they are able to fast-track suitable patients directly to the unit. Consultants from other wards are also able to refer their patients.
Dr Kirsten Wadsworth, Consultant Respiratory Physician and Clinical Lead for ARCU, said: “ARCU will continue to develop, but is already providing high level care and improving outcomes for very unwell respiratory patients. Many of our patients already know us through out-patient clinics, so they feel safe coming to an area where they know they will get high quality care.” Clinical staff rotate shifts on the main Florence Nightingale ward, as well as ARCU, which allows the whole clinical team to use their specialist knowledge when treating and caring for a wide group of patients.
Florence Nightingale Ward
Florence Nightingale is a 28 bed acute respiratory ward (including the 8 bed ARCU) and is the centre of care for respiratory patients, some of whom require treatment with non-invasive ventilation and on occasion transfer to a High Dependency Unit (HDU) or Intensive Therapy Unit (ITU). Staff work closely with the Respiratory Nurse Specialists, Lung Cancer, Sleep Services and TB Nurse Specialists.
Non Invasive Ventilation (NIV) Service
A 24 hours, 7 days a week Non-invasive Ventilation Service is provided by the Acute Respiratory Care Unit (ARCU) and staffed by senior medical and nursing staff as detailed above.
In this procedure the patient is ventilated via a cushioned mask connected to an air pump machine; the mask can be placed either over the nose or both nose and mouth and is easily removable to allow for food, drink and physiotherapy. This avoids the need for invasive ventilation and the need for patients requiring treatment on the intensive care unit, thereby eliminating associated complications.
Pleural Disease and ward–based ultrasound machine
In recent years NICE have advised that all pleural procedures for the aspiration or drainage of pleural fluid be done with ultrasound guidance for patient safety reasons. It is more reliable than a CT scan or a chest radiograph in identifying pleural fluid and thereby enables the clinician to locate the optimal entry point for fluid aspiration or drainage.
Success rates for these procedures have improved and the incidence of procedure-related complications reduced.
Florence Nightingale ward has invested in its own ultrasound machine and as a result, all of these procedures are now done with real time ultrasound guidance in a dedicated treatment room.
One of the best tests for identifying a pleural malignancy is a thoracoscopic biopsy of pleura either by video assisted thoracoscopic surgery (VATS) or by Medical Thoracoscopy; the Respiratory Department work closely with the surgeons at the Essex Cardiothoracic Centre (CTC) and are able to refer those patients suited for Surgical VATS to the surgeons there
For patients undergoing the Medical Thoracoscopy procedure they need only to be sedated and have a local anaesthesia thereby avoiding the complications associated with general anaesthesia.
The procedure involves Trocars being inserted into the pleural cavity, any pleural fluid is drained and the pleural is visualised and biopsied . Pleurodesis can also be attempted at this time. Patients require a chest drain and a short admission following either of these procedures until the affected lung has fully re-expanded.
Patients with unilateral effusions of unknown aetiology should be referred via the target wait route if pleural malignancy is suspected.
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Image showing Thoracoscopy performed in sterile conditions |
Medical Thoracoscopy has been performed in the department since 2005 with an excellent safety record. Our findings have been presented in the European Respiratory Conference.
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Image showing that abnormal pleura can be biopsied under direct vision with high diagnostic yield. |
Medical Thoracoscopy is now a popular investigation in management of plural effusion and is part of BTS guideline.
The respiratory department are happy to accept urgent referrals for Medical Thoracoscopy.
Oxygen Clinic and Oxygen Assessment Service
Oxygen is prescribed to approximately 85,000 patients in England for a range of conditions. It is important that the prescription is correct and appropriate for the individuals receiving this therapy.
The oxygen service at Basildon Hospital uses the most up to date evidence to ensure that patients are offered a gold standard service and manages adult patients requiring oxygen.
The department operates a proactive and responsive service for oxygen assessments. All newly referred patients are seen within one month although patients, who have evidence of low oxygen saturations, on referral are prioritised and seen urgently which may include a review either the same or next day.
Patients identified as potentially requiring oxygen in another chest clinic will be assessed within that appointment, where possible, to ensure that the individual is not subjected to any unnecessary delays and enables an enhanced patient experience with a one stop service.
The entire service is patient focused, as such the staff undertake an education programme with patients and their families to ensure that they are fully aware of the treatment, equipment, expectations and their responsibilities; this is in addition to the home safety assessment reviews. Written guidelines are issued to patients, in an easy to read format, which includes a list of common misconceptions, and the reasons why the instructions are in place. They are given their own personal record of results and plan for therapy.
The oxygen service is consultant led with nurse led clinics and home visits; it is fully equipped including full evaluation equipment with point of care blood gas machines. Ambulatory oxygen assessments are carried out as patient need indicates.
Patients have a choice of three locations to attend clinics.
· Orsett Hospital
· Brentwood Community Hospital
· Basildon University Hospital
The staff make home visits to undertake oxygen assessments and oxygen safety reviews. All patients have access to telephone support.
The team have developed a close working relationship with community teams and other local services (e.g. smoking cessation) and will refer patients to these as appropriate
Pulmonary Physiology and Sleep Medicine
Pulmonary Physiology
The Pulmonary Physiology lab based in the Essex Cardiothoracic Centre is a fully equipped, state of the art facility providing patients with a comprehensive service. In addition to full lung function tests, a variety of specialised investigations including cardiopulmonary exercise tests (CPEX), bronchial and exercise provocation tests, tests of muscle strength, flight assessments and reversibility tests are performed.
The service is used by respiratory, surgical, anaesthetic and other medical specialists across the region. An open access service for general practioners is being developed.
Basildon University Hospital is one of 33 centres in the UK (19% of NHS trusts) performing Cardiopulmonary Exercise Tests (CPEX). This non-invasive test simultaneously investigates the cardiovascular, respiratory and muscular-skeletal systems during exercise to assess exercise capacity.
It is used to evaluate causes of breathlessness, assess fitness for surgery, suitability for transplantation and in exercise programmes. A rapid access pathway for patients referred for surgery at the Cardio-Thoracic Centre from around the region helps expediate treatment. We perform about 200 CPEX tests per year and our referral base includes Essex and North London.
Our results and intepretation are highly valued by specialists regionally.
Sleep Medicine
The sleep service was started in 2008 to diagnose and treat sleep apnoea and other sleep disorders. These conditions are often unrecognised and under-diagnosed but affect about 4% of the middle aged population. Patients who are treated for other medical conditions in Basildon Hospital and around the region are referred to the service.Domiciliary diagnostic tests are performed, following which patients are treated individually and in groups in the department. In addition to diagnosis and treatment, patients are offered lifestyle advice and health education.
With increased awareness of sleep disorders, referral numbers have significantly increased and around 600 new patients are treated every year with non-invasive ventilation (CPAP). Patient satisfaction surveys indicate patients are very satisfied with the care provided.
The Pulmonary Physiology & Sleep Deparment is lead by a consultant respiratory physician and a chief physiologist who work with a team of dedicated physiologists, nurses and admin staff. Work done in the department has been presented at international, national and regional meetings. Teaching and training is an integral part of the department. The department is committed to training physiologists and nurses, updating expertise and in the process, expanding service provision.
Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS-TBNA)
The technique of Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS-TBNA) in the sampling of mediastinal and hilar lymph nodes provides an alternative to surgical biopsy. Basildon Hospital started offering this service in September 2009 and is currently the only centre providing this service within the Essex Cancer Network.As of April 2012 the Trust has undertaken more than 270 cases.
An audit of this procedure has shown very good results with very high diagnostic sensitivity and specificity with no major complications.
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This picture shows the two screens one showing video of the bronchus the other showing ultrasound images of mediastinal lymph nodes in real time |
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Picture showing real time needle aspiration of a lymph node under ultrasound guidance |
The needle used is a special needle with suction syringe tailor made for this procedure.
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All the lymph node stations labelled red and red-blue stripes can be biopsied by EBUS-TBNA.
The technique of EBUS-TBNA is:
- Safe
- Minimally invasive
- Reduces hospitalisation and costs
- Is very sensitive to detect malignant lymph nodes
- Has a positive impact on patient management
Asthma and Chronic Obstructive Pulmonary Disease (COPD)
AsthmaThe Trust provides a comprehensive Asthma service working closely with our primary care colleagues to ensure that the care of these patients is optimum.
Patients with difficult asthma are seen regularly in clinic.
All in-patients admitted with asthma exacerbations are identified by the Respiratory Team and each patient is reviewed by a senior member of the Respiratory Team prior to discharge.
Chronic Obstructive Pulmonary Disease (COPD)
Basildon and Thurrock Hospitals manage a large number of patients with COPD in conjunction with our primary care colleagues and the Community COPD team. All COPD patients admitted to Basildon Hospital are reviewed by a respiratory nurse and a dedicated respiratory consultant. A management plan is provided to the patient prior to the patient’s discharge and appropriate follow up arranged.
Lung Cancer and Specialist Palliative Care
In men, lung cancer is the second most common cancer after prostate cancer and is responsible for 15% of all new male cancer cases. For women, it is the second most common cancer after breast cancer accounting for 12% of all new female cases*.Lung cancer remains prevalent in our locality. At Basildon and Thurrock Hospital, around 200 new lung cancer patients (including mesothelioma) are diagnosed and managed every year.
We have a well established multi-disciplinary lung cancer team of professionals. Our aim is to provide in-patients and out-patients with lung cancer and other lung malignancies with the best possible care and experience. The lung cancer service has been subjected to annual National Peer Review assessment and the feedback scores and comments have been exceptionally good.
In 2007, the Orsett Cancer Medicine Ward was set up at Basildon Hospital. All staff members on the ward are committed to providing our in-patients with cancer a holistic and optimum care and support. Specialist palliative care is provided on the ward with the ward staff working in conjunction with the Hospital Macmillan Team.
*Cancer research UK
Interstitial Lung Disease
Interstitial Lung Disease (ILD), also known as diffuse parenchymal lung disease (DPLD) describes several diseases that affect the interstitium and are less common respiratory conditions. The term ILD is used to distinguish those from obstructive airways diseases, there are different types of ILD including:· Idiopathic pulmonary fibrosis (IPF) is the most common type of ILD
· Nonspecific interstitial pneumonitis (NSIP)
· Acute interstitial pneumonitis (AIP)
· Cryptogenic organizing pneumonia or bronchiolitis obliterans organizing pneumonia (BOOP)
· Desquamative interstitial pneumonia (DIP)
· Lymphocytic interstitial pneumonia (LIP)
· Respiratory bronchiolitis interstitial lung disease (RBILD)
Patients with this group of illnesses are usually referred to the respiratory physicians for the condition to be diagnosed and managed.
It is recommended that when establishing a diagnosis the patient is discussed in a Multidisciplinary Meeting which is attended by a histopathologist, radiologist, respiratory and rheumatology physicians who have an interest in this condition. Basildon hospital has adopted this recommendation and the team meets on a monthly basis to discuss these patients.
Contacts:
Florence Nightingale Ward: 01268 524900 / 0845 155 3111 ext 8421
Lead Nurse Respiratory Service Pager: 07659 135276
