A Physiologist-led Approach to Using Home Spirometry in Adult CF Care
At Liverpool Adult Cystic Fibrosis (CF) Center, physiologists are responsible for the quality of lung function tests. Before Covid-19 and its repercussions on the ability to meet face-to-face, patients routinely met a physiologist to perform spirometry before meeting their doctor.
In the fall of 2020, the CF Center transitioned to virtual care as the norm with over 300 patients now using the NuvoAir platform to perform lung function tests at home and in coordination with scheduled virtual clinics. Scott Hawkes, Senior Chief Respiratory Physiologist at the Liverpool CF Center, shares more about the Center’s new processes for managing spirometry results.
Can you describe the new processes in place?
Here at Liverpool Heart and Chest Hospital, we have revamped our model of care for our individuals with cystic fibrosis. Previously, they would attend clinic face-to-face regularly to perform spirometry and meet physicians and the wider CF team. Spirometry would be performed by a member of the physiology staff and this result would be transcribed into a patient’s electronic health record. Previously, patients would be asked to perform spirometry alongside published standards with a particular focus on FEV1. If a patient’s spirometry results had fallen and the patient was experiencing symptoms consistent with an exacerbation, he/she may get admitted to the hospital for around 2 weeks for a course of IV antibiotics. During this time, their spirometry would be serially monitored for improvements prior to discharge. As such, high quality spirometry assists in a range of clinical decision making.
Moving to a virtual care model can be daunting for clinicians. As a team of physiologists, our responsibility is to ensure high quality spirometry is performed safely in the patient’s own home. We, therefore, developed a physiologist-led model for home spirometry services. We disseminated over 300 NuvoAir devices and with either face-to-face or virtual training, we set out our process for quality assured spirometry. Our aim is to ensure that hospital quality spirometry can be performed at home to assist clinical decisions made by our medical team. Therefore, our adult patients are tasked with performing spirometry at home prior to every virtual or face-to-face clinic consultation.
Every morning before clinic, a physiologist checks the list of patients due to attend and then checks the NuvoAir clinician portal to see if they have performed spirometry. Now that we can send an SMS directly to patients via the NuvoAir clinician portal, our home spirometry adherence rates have drastically improved to 90-95%. The new feature makes our life a lot easier! Patients know that they should take a test within 48 hours of their scheduled virtual clinic and we send out an SMS reminder a few days before scheduled appointments.
As we check our clinic lists, one of our physiologists quality assures the spirometry performed against American Thoracic Society (ATS)/ European Respiratory Society (ERS) guidelines. Spirometry sessions are graded from A to E and session grades assess the quality and reproducibility of the session. Within our CF Center we ask all patients to perform high quality spirometry of grades A-B.
We then filter out acceptable tests and transcribe them into the electronic health record (EHR). We ask patients to repeat a test or meet with us virtually so we can observe and coach their technique if:
- results are not acceptable due to low quality,
- incorrect technique is seen in results, or
- if there is a variance from previous results, within a +/-10-20% difference.
Around 70% of those with NuvoAir spirometers are able to produce grade A-B spirometry independently without significant coaching from our team. However, a small proportion need close monitoring. If they struggle with technique or have persistent issues, we offer both virtual or face-to-face appointments to coach and improve their technique so it meets high standards.
What have been your key challenges?
We initially had some concerns about how to start patients on the new system. About half of our patients were onboarded face-to-face. With the others, we had to find a good way of communicating how to get started. We developed an onboarding process via email, which aims to standardize instructions and key messages. We also set up a specific support email address so physiologists could help patients with their technique and ongoing issues. The onboarding email includes a one-page PDF with info on:
- How to download the NuvoAir Home app and set-up an account with the provider code, the patient’s height and weight is provided from clinic records;
- How to prepare and connect the spirometer;
- Conducting tests and requirements for session grade quality;
- Expectations for when to perform spirometry and when one could be asked to repeat the test; and
- How to get support from NuvoAir on technical or device related issues or support with technique from the Center’s dedicated support email address.
In addition, patients are asked to email in once they have completed their first home spirometry test, which completes their onboarding process. We then quality assure their spirometry and make sure the individual is content with the process expected from them.
Do you have any tips for clinics starting to work with the NuvoAir Home Platform?
With clear outlined processes, it is possible for physiologists to support patients with home monitoring of lung function data and quality results, and our adherence rates proves they can!
- Give clear instructions to patients with expectations and a way to get support when needed.
- Send reminders to perform spirometry, we all need a little nudge sometimes!
- Provide coaching to help patients get the right technique, when needed.
- Meet regularly with the physiologists involved in your service – we meet monthly to discuss issues specific to individual patients, service engagement, research and service improvements.