The COPD and heart failure services gathers patient readings including blood pressure, oxygen, temperature, weight heart rate, and C02.

We have worked with a number of NHS organisations across the UK to deliver remote monitoring for individuals who have recently been diagnosed or admitted to hospital with Chronic Obstructive Pulmonary Disease (COPD).

The COPD monitoring pathway that we have developed with NHS organisations has been specifically designed to allow healthcare professionals to automatically capture daily vital sign measurements from patients including SP02, Blood Pressure, Body Temperature and Heart Rate and in addition responses to a health questionnaire.

The vital sign measurements and responses to the health questionnaire are captured from patients and if they fall within expected thresholds the patients are contacted according to their next schedule.

If vital sign measurement and responses to the health questionnaire indicate the patient has fallen outside of thresholds but is within agreed levels then patients are notified that they will be requested to resubmit their vital sign measurements in 30 minutes time to see if there has been any improvement. The patient is able to resubmit their vital sign measurements and if the results now fall within thresholds the patients are automatically contacted according to their next schedule. Patient results which show deterioration are raised as a high priority alert, those which are still outside of threshold result in an alert for the triage team to investigate and patients who do not respond to the secondary contact have an alert created based upon their initial results.

Any vital sign measurements and responses to the health questionnaire which are outside of patient thresholds and outside of agreed levels result in the automatic creation of high priority alerts for the triage team to investigate.

This automated triaging of results have produced significant efficiencies for staff and allowed them to focus their attention on patients which have the highest need for their contact and clinical services.

Patients using the pathway have access to a suite of behavioural change content and information on their condition which they are able to access and use at their own convenience. 

Norfolk Community Health and Care NHS Trust have deployed the Heart Failure monitoring pathway and reported the following outcomes for patients:

● 88% reduction in bed days

● 89% reduction in A&E admissions

● 65% reduction in GP visits

● 45% reduction in Out of Hours appointments

Benefits of the COPD and heart failure service
Improves clinical outcomes & reduces A&E admissions

Our evidence shows enhanced monitoring of the long term condition has reduced hospital admissions

Increases clinic capacity

Home monitoring reduces face to face appointments, enabling clinicians to prioritise time with more complex patients

Improves patient satisfaction

The service is easy to use for patients of all technical abilities and patients do not have to take time out of their day to attend routine appointments

This is a fantastic new service which will help people to monitor their health at home, bringing peace of mind while making sure that doctors and nurses can step in early if there is a sign something might be wrong.

Norman Lamb, MP for North Norfolk and ex minister of state in the Department of Health.

This has made a considerable difference to my life. I feel that I’m in control of my illness now, rather than my illness being in control of me. I wish more people with long-term heart and lung diseases knew about this service. My condition is more stable and I am more active than I used to be.

Ruth Bean, a 62-year-old patient from Hull

We would like more people living with long-term heart and lung disease in Hull to join the free service and benefit from the opportunities to improve quality of life.

Clinicians can monitor trends and intervene if readings move outside expected parameters. This allows for timely intervention and also assists patients in recognising changing symptoms and promotes self-management.

Rhona Macpherson, heart failure nurse at Norfolk Community Health and Care NHS Trust.
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