Respiratory Futures default Feature image for widescreen

Harefield Hospital: The road back to face-to-face Pulmonary Rehabilitation

Thursday, June 24, 2021

Stuart Clarke joins us to share his team’s experience of returning to face-to-face PR and tells us more about assessments, classes and education.

How did the pandemic impact the way you assessed patients on site?

At the start of the pandemic, the team at Harefield Hospital successfully introduced a virtual component to their Pulmonary Rehabilitation (PR) programme.

Historically, all initial assessments (both subjective and objective) were completed onsite at Harefield Hospital, however, the general message at the start of the pandemic was to reduce the footfall throughout the hospital.

There was a drive to return to seeing patients face to face and the gradual easing of restrictions was received with much joy within the team as some patients could now leave their homes (initially excluding the extremely vulnerable). This meant that IT skills were no longer a necessity to enroll into a PR programme.

Our initial quest to re-commence face-to-face PR started outside the hospital doors but still within the grounds in a ‘green testing area’.

We looked at hiring an open sided marquee and also using onsite tennis courts to complete objective assessments, whilst completing subjective assessments on the telephone. However, discussions with the Director of Allied Clinical Sciences and the Harefield Hospital Director resulted in these options being dismissed due to a risk assessment rendering the surfaces being unfit for purpose.

With onsite assessments being a no go, what other options did you explore?Our search moved to finding an off-site location but sticking to outdoors as this would provide a well ventilated environment. Initially, outdoor sports were ceased which meant that many sports facilities were left abandoned. Due to many of our team being members of sports clubs, it was very easy to locate a local all-weather hockey pitch.

What steps did you need to take to move the assessments off site?

Following the completion of a thorough risk assessment, which was signed off by the Associate Director of our department and discussed with Infection Control, we were able to create a standard operating procedure (SOP) to conduct objective assessments at this site.

The SOP included:

  • The wearing of PPE (surgical mask, visor, gloves and apron for staff and surgical masks for patients).
  • The cleaning of equipment with Clinell wipes and the disposal of all rubbish into double orange bags to be returned back to the hospital.
  • All patients completing a COVID screening questionnaires prior to their assessment and having a temperature check on arrival.
  • Baseline observations (heart rate, blood pressure and SpO2) being taken and a single Incremental Shuttle Walk Test (ISWT) completed to reduce patient contact time.

At this point, patients were either enrolled onto a Home Exercise programme or a Virtual Pulmonary Rehabilitation class depending on their IT competence.
Moving to an off-site location must have posed challenges.

Unfortunately, outdoor assessments had many challenges which included adverse weather conditions and CD player malfunctions whilst running on battery power. 

This meant that they were not sustainable. Despite this, they enabled us to provide individually tailored exercise programmes and ensured patients were safe to partake in an exercise programme of moderate to high intensity. Furthermore, they allowed exercise capacity, dyspnoea and health status to be assessed as per the British Thoracic Society Quality Standards (BTS, 2014).

How did you address these challenges?

We had to cancel multiple assessments due to adverse weather conditions, so we began to search for an appropriate indoor location. Government guidance for the safe use of multi-purpose community facilities (GOV.UK, 2021) was extremely useful in finding a COVID secure environment.

We were given access to a Baptist Church hall which ticked all the right boxes which included:

  • A one-way flow.
  • Good ventilation.
  • Adequate space to ensure social distancing.

Further risk assessments were completed following discussion with Infection Control and signed off by the Associate Director of our department.

Initially, we followed the same format we used at the hockey pitch. As restrictions eased, we gradually added more components to our objective assessments which included: a second incremental shuttle walk test (ISWT), Short Physical Performance Battery (SPPB), one minute sit-to-stand test (1STS), height and weight.

Have you now been able to return to on-site assessments?

As outpatient activity slowly increased back at Harefield Hospital, we were able to complete all objective assessments back on site. This means that we are now able to incorporate one-repetition maximum testing back into our protocol.

Risk assessments have highlighted that no more than two patients can have an assessment at the same time and appointment times are staggered by 30 minutes to prevent congestion on equipment/the walking course as we no longer use the corridor as a second walking course.

Before the pandemic you were holding classes in the community. Were you able to continue with them?Firstly, we had to carry out site visits to all our original community locations. Unfortunately, we were unable to return to public gyms where we once held classes; this was due to being unable to separate patients from members of the public.

However, we were able to identify three appropriate sites. Measures were put in place to ensure all patients could keep at least two metres apart at all times. Thus, a maximum number of patients was determined for each venue.
Can you outline the specific elements of your risk assessments for running in person classes?
Recently, classes have re-started onsite but have a very limited capacity due to the size of our gym. Further risk assessments were completed for each venue following liaison with Infection Control, and an SOP was written which was signed off by the Associate Director of our department.

Measures included:

  • Temperature check and completion of COVID questionnaire on arrival.
  • Patients have their own table, chair and exercise station - all equipment is brought to them.
  • Equipment is to be cleaned down with Clinell wipes.
  • One-way system throughout each venue.
  • Windows/doors to be open.
  • Patients to wear surgical masks.
  • Staff to wear surgical mask, visor, gloves and apron.
  • 30 minutes cleaning time between classes.
  • Double orange bags are used to dispose/transport rubbish back to the hospital and are sealed with a cable tie.

Education is an important part of PR, it would be really helpful to hear more about this element of your programme.Historically, education was provided in large groups e.g. by combining back-to-back classes. Unfortunately, this is no longer possible. Although we still provide a brief face-to-face session at the end of each class, to reduce patient contact time, we have significantly improved our online profile.

Patients can access pre-recorded multi-disciplinary talks and materials. They are also invited to attend question and answer sessions with different members of the multidisciplinary team. Furthermore, we have an education booklet which is issued to all patients at their initial assessment. These measures ensure our education programme remains defined and structured as per the BTS Quality Standards (BTS, 2014).