Respiratory Futures recently spoke to Dr Avinash Aujayeb of Northumbria Healthcare NHS Foundation Trust, and incoming chair of the British Thoracic Society Pleural Specialist Advisory Group. Dr Aujayeb helps us break down what aligning a pleural service with the Getting It Right First Time (GIRFT) recommendations looks like, including information on coding and Best Practice Tariffs (BPTs).
The pleural service at your trust meets the GIRFT recommendations for pleural services. Can you tell us a little bit about what your pleural service looks like now?
The Respiratory GIRFT report (ref) includes the following recommendation for pleural services:
Reduce acute admissions and length of stay, and deliver a high-quality pleural service which achieves the Best Practice Tariff by addressing workforce and infrastructure requirements
The GIRFT recommendations focus on two main areas; 1) Reduce acute admissions and length of stay, and 2) Deliver a high-quality pleural service which achieves the Best Practice Tariff. Through this, the GIRFT programme aims to help reduce unwarranted variation between services and facilitate improvements to support delivery of care and the pleural workforce.
BPTs provide an incentive to move from usual care to best practice by creating a price differential between agreed best practice and usual care.
At the Northumbria Healthcare NHS Foundation Trust, the local pleural service has a pleural lead, who only does pleural disease, as well as three other consultants with a specialist interest and a trust grade doctor. We run weekly pleural clinics on two sites (the trust has multi-site working) and have day case/procedures units on all sites where procedures can happen, with pre-prepared procedure packs, ultrasound devices and nursing support. GPs and Urgent treatment centres can refer directly via email or advice and guidance to the pleural services, with waiting times being usually less than a week. We have dedicated admin staff who look out for procedures and code the instances appropriately. We do not accept pleural procedures onto the medical ambulatory care unit (with liaison with the acute medicine department) as those are coded differently. We provide a day case thoracoscopy and indwelling pleural catheter service, which was put in place during times of COVID-19 as we lost inpatient beds. This is supported by the anaesthetic team. We also provide an ambulatory pneumothorax pathway.
Were there any challenges that you faced in aligning your service with the GIRFT recommendations?
The two main issues we faced were ensuring patients did not attend medical ambulatory care, as sometimes patients are booked in from A&E as walk-in cases and sometimes from GPs. There is an ongoing piece of work to educate those working in those environments and those who triage the referrals to refer the pleural work as described above.
The other issue is linkage of the thoracic ultrasound images to the local PACS system, as there is a multi-site working with many different ultrasound machines. We have a Point of care ultrasonography (POCUS) steering group locally and a project manager has been allocated to this so that we can start developing this recommendation. The important aspect to consider here are the governance issues to ensure the U/S findings are recorded and the images are available for subsequent review.
Locally we have just opened up a lung cancer virtual ward (as well the well-established COPD/airways ward), and quite a few of the pleural patients go into this, for example those with post biopsy pneumothoraces, or those who have had a thoracoscopy and have gone home on who need just some point of contact but are in the community. This is staffed by our lung cancer nurses.
Where should someone start in relation to improving their service to meet the Best Practice Tariff (BPT)?
A Best Practice Tariff (BPT) is a national price paid to providers in England and is designed to incentivise high quality and cost-effective care. BPTs provide an incentive to move from usual care to best practice by creating a price differential between agreed best practice and usual care.
At the Northumbria Healthcare NHS Foundation Trust, the additional income that comes from securing the BPT supports service development and the quality aspects of the pleural service, including staff. Having a dedicated admin team to support and code properly helps us achieve this, and this is where someone starting their service should begin. Ensuring the correct person knows what to code for is a vital part of improving a service in this way.
Activity in respiratory medicine falls under a Treatment Function Code (TFC) of 340. This code specifically indicates the specialty, and in turn activities associated with respiratory. Unfortunately, some hospital activity is recorded under other TFCs such as general medicine, (TFC 300). If pleural work is done by respiratory teams but in say an acute care unit then that activity, and the associated income, will be attributed to that TFC and as such represents a spend by respiratory departments but no income. This is especially so for pleural work if we are to attract the Best Practice Tariff.
Why is coding correctly important in pleural services, and do you have any tips for understanding how to code things correctly?
The BPT was developed and introduced to provide optimal care for patients with pleural disease. This increases the premium paid for managing pleural disease provided a series of criteria are met. These include:
1] activity recorded as being performed by the respiratory team, ie the activity is coded under TFC 340;
2] the activity is performed as an elective procedure in a day case setting in a nominated day case area;
3] procedures are performed under ultrasound. Examples of the infrastructure needed can be found in the GIRFT respiratory report, including staffing.
Recording the activity is important and whether the patient is formally admitted and discharged on the hospital system or there is clear annotation in the notes will depend upon the hospital process. To ensure there is clarity it is recommended the lead clinician discusses the process in detail with the hospital coding department to ensure the correct system is employed to trigger the recordings to achieve the BPT.
From discussions with colleagues they are often unsure if they are achieving the BPT and this can be viewed on the Model Health System. The common reasons seem to be failing to record the activity under the correct TFC. So in the same way that when a patient attends for a bronchoscopy when an in patient the activity is recorded under 340 and a similar recording should occur with pleural procedures. The other common reason is performing the procedure in an outpatient setting. It is important that pleural services are recognised and there is an appropriate day case infrastructure available.
Related links:
A review of a pleural service - PubMed (nih.gov)
Ambulatory pneumothorax management in a district general hospital - PubMed (nih.gov)