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Auteur Grey N
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Collectif, Stewart K, Grey N
2009, p. 71
Titre : Community critical care outreach – A model for the UK (Poster) Type de document : Article Auteurs : Collectif ; Stewart K ; Grey N Année de publication : 2009 Pages : p. 71 Langues : Anglais (eng) Résumé : The concept of community critical care within the UK is fairly new. Pockets of this type of care and management exist across the country but it is often carried out on an informal or limited basis even though there are over 3000 patients who are registered as receiving home mechanical ventilation (excluding continuous positive airway pressure) invasively and non invasively.1 These patients are a heterogeneous group and include those with neuromuscular disease, rib cage deformity, spinal injury, COPD and obesity. Their numbers have increased exponentially over the past few years and this trend is set to continue form any reasons such as technical advances, increased understanding of such disease processes and survival from prolonged critical illness. These patients, there fore, will require input at home or in an intermediate care facility from a critical care team to support and manage symptoms, give psychological support, change ventilatory requirements during exacerbations, facilitate a weaning programme when appropriate and support palliative care issues. Sending patients home from acute care who require invasive ventilation is fraught with obstacles, anxiety, lack of understanding and prejudice from all areas of the healthcare system with the largest driving force being how cost effective is home mechanical ventilation (HMV)? However, this nilhistic approach to HMV is no longer acceptable and a change in attitude from health care professionals and society as a whole needs to be realised. Developing community critical care as a model of care for the 21st century in order to meet the needs of this patient group is paramount and requires a partnership between primary and secondary care trusts, the independent sector and industry. At all times it must aim to maintain quality in terms of process, patient quality of life and life satisfaction and equality across disability. Reference : 1 Lloyd-Owen et al (2005) Patterns of home mechanical ventilation use in Europe. Eur Respir J 25 : 1025-1031Collectif, Weston N, Scaffardi A, et al.
2009, p. 65
Titre : Mortality and ventilator adherence in patients on home mechanical ventilation (HMV) Type de document : Article Auteurs : Collectif ; Weston N ; Scaffardi A ; Grey N ; Field D ; Miah H ; Williams AJ ; Hart N ; Davidson AC Année de publication : 2009 Pages : p. 65 Langues : Anglais (eng) Mots-clés : étude transversale Résumé : The Lane-Fox Respiratory Unit (LFRU) is a 14-bed unit with a specialist multidisciplinary team of physicians, nurses and therapists and an 'in-house' technical department. We currently manage 792 patients on HMV in the community. These include patients with chronic respiratory failure as a consequence of neuromuscular disease (NMD), chest wall disease (CWD), chronic obstructive pulmonary disease (COPD) and obesity-related respiratory failure (ORRF). The patients range from those who are tracheostomy ventilator dependent to those requiring only nocturnal ventilatory support. The aim of this study was to ascertain whether the recent change in HMV user demographics (increasing proportion of ORRF with and relative reduction in NMD, CWD and COPD) had influenced ventilator use and mortality. The data was collected prospectively and cross-referenced with the electronic discharge summary database. The results are shown below. Other = post surgical, Prader-Willi syndrome, acute lung injury, cystic fibrosis. Within the NMD and CWD group, 4 deaths (15%) related to Duchene Muscular dystrophy with an average age of 20.5 (1.2) years. There were 5 deaths (19%) in the post poliomyelitis group, 5 (19%) in the motor neurone disease group and 2 in the Guillain Barré group. In the group as a whole, 36% died at home and 64% died in hospital. We observed the highest mortality in the NMD and CWD group, which was the group with the longest use of ventilatory support and the greatest adherence to ventilation reflecting increasing ventilator dependency with disease progression. Ventilator adherence at almost 10 hours per day was unusually high, compared with our previous data, in the COPD group. In OHS ventilator use was the lowest whilst gas exchange was relatively well preserved. These findings are similar to previous review in our unit with mortality being closely related to underlying cause of respiratory failure. brochure_80p_xp :Mise en page 1 12/03/09 20 :16 Page 65
A pathway home : discharging the complex ventilator dependent patient into the community. A UK perspective (Poster)Collectif, Doherty Y, Perry A, et al.
2009, p. 73
Titre : A pathway home : discharging the complex ventilator dependent patient into the community. A UK perspective (Poster) Type de document : Article Auteurs : Collectif ; Doherty Y ; Perry A ; Bayker E ; McGee L ; Grey N ; Boysen N ; Dicks C ; Cumming N ; Stewart K Année de publication : 2009 Pages : p. 73 Langues : Anglais (eng) Résumé : Introduction Advances in life prolonging and life saving interventions over the past 30 years have lead to a rapidly growing subgroup of patients who are unable to be weaned from mechanical ventilation in the long term. These patients, therefore, will either require invasive mechanical ventilation for the rest of their life or a protracted weaning plan outside the acute care facility. The plight of these patients is often difficult as there are limited resources within the community, no national guidelines to direct the process of care and management of this group of patients and a lack of appropriate intermediate care facilities to discharge the patient to outside the acute care setting. Background The Lane Fox Respiratory Unit (LFRU) is a national weaning centre for Greater London and the South East of England. It is very experienced in discharging the complex ventilator dependent patient back into the community. It is through this experience that a pathway of care has been developed to help guide all healthcare professionals in an adult critical care setting to successfully discharge the complex ventilator dependent patient. The Pathway The pathway should be used as a guide/framework in the process of discharge. The key to its success is nominating a dedicated coordinator throughout the discharge process. The pathway has 4 phases (see Figure 1). This is not a prescriptive framework and will require adaptation based on the needs of the individual patient and family, the availability of resources and local practice. Summary With careful planning and use of the pathway, discharge to the community can succeed but the healthcare team need to be aware of the common difficulties that often thwart the process and include : • Delays in funding • Unsuitable housing • Lack of appropriate intermediate care • Failure to recruit appropriately trained carers or qualified nursesCollectif, Harmer S, Williams AJ, et al.
2009, p. 71
Titre : Reason for non-admission to a UK regional weaning centre (Poster) Type de document : Article Auteurs : Collectif ; Harmer S ; Williams AJ ; Grey N ; Davidson AC ; Hart N Année de publication : 2009 Pages : p. 71 Langues : Anglais (eng) Résumé : Background : Weaning failure occurs in up to 10% of patients weaning from mechanical ventilation. Such patients are transferred to our centre as a step-down facility to ascertain if successful weaning can be achieved. Previously presented data detailed the outcome of the patients referred (Thorax 2005; 60 : 187-192). However these, and other similar published data, have not reported on the patients that are referred but not transferred. Method : We prospectively collected data using a purpose designed database from January 2006 to January 2008 to coincide with the formal introduction of a consultant nurse outreach weaning service that provides on site assessment and advice and arranges transfer to our unit as necessary. Results : There were 163 referrals (102 M). 85% of these referrals were accepted for admission and 15% were declined admission. Only 67% of those accepted were admitted. We divided the patients who were not transferred into 4 groups : (1) weaning centre unnecessary (2) patient 'unweanable'; (3) weaned prior to transfer; and (4) died prior to transfer. Of 25 patients declined admission, 12 (48%) were identified as 'weanable' in their referring unit and 6 (50%) of these died. Furthermore, 12 (48%) were 'unweanable' with 8 (67%) of these patients transferred to an intermediate care facility and the remainder died. Of 46 patients accepted but not admitted, 25 (54%) were weaned whilst waiting for transfer by the nurse consultant and 21 (46%) died. The reason for a transfer delay was limited bed availability caused by a combination of discharge delay following successful weaning (11.3 ± 5.8 days) and discharge delay of tracheostomy ventilated patients out of our unit (93 ± 5.8; range 26-208). As a consequence mean delay in transfer to our unit was 18 ± 16 days (1-65days). Conclusion : This is the first report detailing the reason for non-admission of patients to a regional weaning centre. As expected, patients were declined admission when identified as requiring longterm tracheostomy ventilation in an intermediate care facility or were deemed to be 'weanable' in their referring centre. However, half of these 'weanable' patients died in the referral unit during the weaning process which highlights the difficulty in predicting weaning outcome from an initial assessment. More importantly, of those patients accepted but not transferred, almost 50% died prior to transfer. The reason for non-transfer was lack of level 3 bed availability.Collectif, Grey N, Field D, et al.
2009, p. 63
Titre : The evidence for change in home mechanical ventilation (HMV) user demographics Type de document : Article Auteurs : Collectif ; Grey N ; Field D ; Williams AJ ; Hart N Année de publication : 2009 Pages : p. 63 Langues : Anglais (eng) Résumé : Although HMV is useful for the management of chronic respiratory failure complicating neuromuscular disease (NMD) and chest wall disease (CWD), the Eurovent survey (Lloyd-Owen et al, 2005) demonstrated differences in underlying diagnosis of HMV patients with increased use in COPD patients in Southern EU countries, despite limited evidence. However, the survey did not focus on obesity-related respiratory failure (ORRF) in patients with obstructive sleep apnoea (OSA) and obesity hypoventilation syndrome (OHS). The aim of this study was to assess changes in HMV-user demographics in a regional unit from September 2005 and September 2008. The data was collected prospectively from the electronic discharge summary database. The results are shown below. 341 patients were commenced on HMV over 3 years with an overall increase of 27%; 35% increase in males and a 6% fall in females. Emergency admissions and inpatient transfers from other hospitals to the unit for initiation of HMV increased by 82%. There was no change in the absolute number of NMD, CWD and COPD. We observed a 50% increase in ORRF patients from 2005 to 2008. In conclusion, COPD and ORRF comprise around 70% of the patients initiated on HMV with a substantial increase in the ORRF patients over a 3-year period. As there is limited evidence to support this practice, we must undertake well designed randomised controlled trials to assess the effect of HMV in these two common conditions.