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DCHS Pulmonary Rehabilitation Services Referral form

Name:
DOB: / Address:
Post Code: / NHS Number:
Telephone number:
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)
FEV1/FVC ratio …………....%
Referrers signature:
Print Name:
Designation:
Contact details:
Date: / GP Practice details

PLEASE ATTACH GP SUMMARY AND MEDICATION LIST

Please send referrals via secure Email: 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-Fax: 01246 565053 or

By Post: Pulmonary Rehabilitation Service, Community Respiratory Team, Welbeck Suite, Walton Hospital, Whitecotes Lane, Walton, Chesterfield, S40 3HW. 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.

INCLUSION CRITERIA

  • Confirmed chronic respiratory disease is the primary diagnosis (COPD/Non CF Bronchiectasis/ILD)
  • 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

besought 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 weeklyfor 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 adaily 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 membersavailable/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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