Download Pulmonary Rehabilitation Services Referral form-V1-0064

Pulmonary Rehabilitation Services Referral form-V10064-ADM-SPEC-DCHS
Version No
1
Version Date
24.4.15
Review Date
24.4.17
Approved Date
DCHS Pulmonary Rehabilitation Services Referral form
Name:
Address:
NHS Number:
DOB:
Telephone number:
Post Code:
I have adhered to the
criteria listed below and
confirm that the patient
is suitable to attend.
Is Patient
“Fast
Track”?
Yes / No.
*See
below
For
criteria
State Respiratory
Diagnosis:
(Below details are mandatory)
Spirometry Date:
FEV1 …………..(………% pred)
FVC …………..(………% pred)
……………………………….
Referrers signature:
Print Name:
Designation:
Contact details:
Date:
FEV1/FVC ratio …………....%
GP Practice details
PLEASE ATTACH GP SUMMARY AND MEDICATION LIST
Please send referrals via secure Email: [email protected] or see contact details for each
base below.
EREWASH- Fax: 0115 9512411 or
By Post: Pulmonary Rehabilitation Service, Community Respiratory Team, Ilkeston Community
Hospital, Heanor Road, Ilkeston, Derbyshire, DE7 8LN. Tel No: 0115 9512440
NORTH DERBYSHIRE and HARDWICK- Fax: 01246 565053 or
By Post: Pulmonary Rehabilitation Service, Community Respiratory Team, St Mary’s Court, St
Mary’s Gate, Chesterfield, S41 7TD. Tel No: 01246 253067
SOUTH DERBYSHIRE “Breathe Ability” Fax: 01773 824155 or
By Post: “Breathe Ability”, DCHS Pulmonary Rehabilitation Service, Babington Hospital, Derby
Road, Belper, DE56 1WH. Tel No: 01773 824171
*Fast track patients
Fast Track patients are patients who have been admitted to hospital with an exacerbation of COPD (please
indicate date of discharge) OR patients with an exacerbation of COPD who have refused admission to
hospital and have been supported by their GP at home.
(For inclusion, exclusion and patient transport criteria see next page)
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INCLUSION CRITERIA
 Confirmed chronic respiratory disease is the primary diagnosis (COPD/Non CF
Bronchiectasis/Interstitial Lung disease)
 On optimum drug treatment
 In the event of a recent admission, the patient’s medical condition is sufficiently stable to attend and
participate in rehab sessions (to be confirmed on assessment by Pulmonary Rehabilitation
Specialist Team)
 The patient is functionally limited either by breathlessness or fatigue
 To be able to walk a minimum of 10 metres with or without a walking aid.
 Motivated to attend Pulmonary Rehabilitation and suitable for group work
EXCLUSION CRITERIA
 De-motivated/lack of compliance
 Mental or physical impairment with inability to exercise e.g. dementia, severe musculoskeletal or
neurological problems which limit mobility, falls
 Any serious cardiac event in the last 6 weeks
 Other cardiac pathology including: unstable angina, acute LVF, uncontrolled cardiac arrhythmias,
uncontrolled hypertension (either ≥ 180 systolic or ≥ 100 diastolic mmHg). Severe symptomatic
stenosis: aortic, left main coronary or stenotic valvular heart disease. Symptomatic heart failure.
Suspected or known aneurysm, Hypertrophic obstructive cardiomyopathy. Active or suspected
myocarditis or pericarditis
If the patient is undergoing investigations or is under the care of a cardiologist, permission needs to
be sought directly from the specialist as to whether the patient is suitable to attend Pulmonary
Rehabilitation.
 H/o of Abdominal aortic aneurysm (AAA) with unstable BP
 Patient should not have attended a Pulmonary Rehabilitation Programme within the last two years.
However patients can be re-referred within 2 years if their clinical condition deteriorated due to
repeated exacerbations or if additional benefits on a shorter timescale would be clinically valuable
(for e.g. Preoperative Lung Transplantation).
 It is unlikely that if the patient completed the pulmonary rehabilitation course originally and failed to
gain a benefit, that they would benefit a second time round; unless circumstances such as an
exacerbation/health issues interrupted the initial programme
 Active cancer with evidence of metastasis
 Uncontrolled metabolic disease
 Febrile illness, chronic infectious diseases
 Recent systemic or pulmonary embolism or thrombophlebitis
Pulmonary Rehabilitation Programme content
The Pulmonary Rehabilitation Programme, runs twice weekly for 6 consecutive weeks. Each session is 2
hours long. The course involves supervised exercise and education sessions to aid self management,
relevant to chronic respiratory condition. The Patient will also be given an exercise programme to be
continued independently at home.
There is an expectation that the patient will attend every session and follow a daily home exercise plan in
order to gain maximum benefit from the course.
Please inform the patient of the outline of the course by giving them a copy of our information leaflet.
Patient Transport Service (PTS) Criteria:
 Clinically stated medical need that prevents patient using private or public transport, and no
relatives or family members available/able to support patient to the appointments
 Have a diagnosed disability (physical and or psychological) which makes them medically unfit to
travel by any other means, and who have no alternative method of travelling to or from the
hospital/clinic(Escort will be provided by transport staff for the patient’s medical condition that
he/she requires constant supervision for safety).
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