Position statement and considerations for remotely delivered pulmonary rehabilitation services

Appendix 1 – ‘ACPRC pulmonary rehabilitation provision during COVID-19 and beyond! round 2’ – summary of survey responses

1. Which region do you work in?

2. Have you or any members of your pulmonary rehabilitation team been redeployed at any point since the outbreak of COVID-19?

3.  If you answered Yes to Q2, has your staffing provision now returned to pre-COVID-19/‘usual’ levels?

4. What form(s) of PR delivery is your service currently offering for exercise?

5. What form(s) of PR delivery is your service currently offering for education?

6. If you’re providing a ‘virtual’ rehab service, which video-conferencing platform are you using?

7. If you’re providing a ‘virtual’ rehab service, what challenges have you experienced in delivering this? (for example, upskilling staff, limited resources, poor uptake, and so on). (Please move on to Q8 if you’re not currently providing a ‘virtual’ service).

8. If you answered Yes to Q8, has your service been provided with any form of additional resources to support this? (for example, staffing, equipment). (If you answered No to Q8, please move on to Q10).

9. Is your service currently responsible for the provision of any form of post-COVID-19 rehabilitation? (not associated with ‘business as usual’ participants).

10. Are there any changes to your service) that have occurred as a result of COVID-19) that you think will either remain in place or continue to evolve long-term?

Appendix 2 – literature search strategy

An electronic literature search was conducted through AMED, CINAHL, Cochrane Library, EMBASE, MEDLINE, and PsycINFO for studies of remotely delivered pulmonary rehabilitation (PR), published since December 2020 (following the Cochrane review ‘Telerehabilitation for chronic respiratory disease’ (2). Key terms used included medical subject headings related to remote delivery, rehabilitation and chronic lung disease (full search strategy below). Searches were restricted to English language. Reference lists of identified studies were checked for additional references.

Search strategy:

• Remote* OR Distance* OR Telemedicine OR Telehealth OR Telecommunication* OR Telerehab* OR Videoconferenc* OR Virtual* OR App* OR Telephone OR Web*.

AND

• Pulmonary OR (Chronic Obstructive Pulmonary Disease) OR COPD OR (Obstructive Lung Disease) OR Asthma OR Bronchiectasis OR (Interstitial Lung Disease) OR (Pulmonary Fibrosis).

AND

• (Rehab* OR Exercise* OR Therap*).

In accordance with methods used by Cox et al. (2), randomised or controlled clinical trials of remotely delivered PR in people living with chronic respiratory disease were included. The rehabilitation intervention needed to include exercise, that could be group-based or individual, and at least 50% needed to be delivered remotely. Trials that compared remotely delivered models of PR to conventional, or no PR were included. Trials of maintenance rehabilitation (for example, aiming to maintain health benefits following a primary programme of PR) were included. Outcomes of interest included: exercise capacity, health­related quality of life, and adherence.

The lead author conducted the literature search in July 2022, and screened at abstract/title and full-text level as indicated. Following removal of duplicates and appropriate exclusions, four studies were identified for review (17–20).

Appendix 3 – study characteristics and outcomes

	Methods	Participants	Interventions	Outcomes	Notes
Cerdan-de-las-Heras et al. (17)	Single-centre, non-inferiority randomised study comparing ‘telerehabilitation’ versus standard programme.	54 people living with COPD in Denmark.	Standard rehabilitation: twice weekly 1-hour group training sessions and 6 hours of COPD education for 8 weeks. Telerehabilitation: delivered through a ‘virtual autonomous physiotherapist agent’ (VAPA) comprising software, that serves as a platform for the HCP to create individualised telerehabilitation programme, the exercise session with the VAPA was 10–20 minutes, 3–5 times per week, with individually prescribed training aids (for example, weights, fitness step).	No significant between-group difference in 6MWT; trend for greater improvement in the telerehabilitation group (47 m, p = 0.14). Telerehabilitation was non-inferior to standard rehabilitation for 6MWT (margin 35 m) post 8-week rehab and after 3 and 6 months of follow-up. No differences in 7-day pedometry and QoL between groups. Telerehabilitation adherence was reported to be 82% (% training time performed) and participant satisfaction 4.27 ± 0.77 (465 responses) using the 5-point Likert scale.	Reported to facilitate the ‘highest workout intensity’ however no further detail regarding exercise prescription is provided. No comparative data for the standard rehab participants for adherence and satisfaction.
Cerdan-de-las-Heras et al. (18)	Single-centre randomised pilot trial comparing a ‘telerehabilitation’ programme to usual care (‘no rehabilitation’).	15 people living with idiopathic pulmonary fibrosis in Denmark.	12-week telerehabilitation programme delivered through ‘VAPA’ (as detailed in Cerdan-de-las-Heras et al. (17)) plus usual care versus usual care only (no defining characteristics detailed).	Statistically significant differences between groups in 6MWD favouring the telerehabilitation group at 3 months (+39.5 m, p = 0.03) and 6 months (+34.3 m, p = 0.02) post telerehabilitation, but not at 9 months (+40.0 m, p = 0.15). No significant differences between groups in 7-day pedometry and QoL. Telerehabilitation adherence (% training time performed) was reported to be 64% in 15 participants at 0–3 months, and 110% in 3 participants at 6–9 months (not accounting for drop-out) and participant satisfaction 3.8 ± 0.5 (168 responses) on the Likert satisfaction score (1–5).	No defining characteristics of ‘usual care’ detailed. The telerehabilitation group had less severe disease at baseline (significantly lower forced vital capacity % predicted) (mean difference-14.1%, p = 0.03) which could have led to greater improvements in 6MWD post rehabilitation.
Cox et al. (19)	Multi-centre assessor-blinded randomised controlled trial of centre-based PR versus ‘telerehabilitation’.	142 participants living with chronic respiratory disease in Australia.	8-week twice-weekly programme. Participants randomised to telerehabilitation received equipment for the duration of their programme including a step-through exercise bike, tablet with mobile data with a stand for video-conferencing, and a pulse oximeter. Initial assessment was conducted in the participant’s home.	No significant differences were reported between groups for any outcome at any time point and both groups achieved clinically significant improvements in dyspnoea and exercise capacity post rehabilitation. Equivalence of telerehabilitation for the primary outcome of dyspnoea (measured by the CRQ) could not be confirmed (mean difference (95% CI) -1 point (-3 to 1)) and inferiority could not be excluded. At end-rehabilitation, equivalence of telerehabilitation was demonstrated for 6MWD and the emotional and fatigue domains of the CRQ. Subgroup analysis of participants with COPD demonstrated a statistically significant difference in dyspnoea favouring the centre-based PR group at 12-month follow-up.	The authors conclude that telerehabilitation may not be equivalent to centre-based PR in all outcomes but is safe, confers clinically meaningful improvements, and may provide an alternative model when centre-based is not available.
Galdiz et al. (20)	Multi-centre parallel-group randomised trial to determine the efficacy of a maintenance ‘telerehabilitation’ programme (post in-person PR) in sustaining improvements in exercise capacity and QoL in comparison to usual care.	94 participants living with COPD in Spain. Exclusion criteria of note: ‘COPD patients with a bronchodilator response, history of severe coronary artery disease’.	8-week in-person PR programme consisting of three training sessions per week and four educational sessions. Participants randomised to telerehabilitation were provided with an equipment kit for the 12-month follow-up period. The control group were advised to exercise regularly (‘at least walking for 1 hour daily’) and provided with educational materials as per usual care.	No statistically significant differences between groups were reported in any outcome. Analysis of dyspnoea (measured by CRQ) demonstrated a significant interaction between baseline score and intervention group; participants with lower baseline scores faring better in the control group in comparison to those with higher scores (p = 0.023).	With recognition of limitations resultant from a pragmatic approach, the authors conclude that whilst the telerehabilitation maintenance programme was feasible and safe, no clinically meaningful improvements were demonstrated.

Appendix 4 – Participant feedback summary

Anonymous feedback from four services identified by the authors was collated and analysed to identify common themes. The risk of bias associated with this pragmatic method is duly acknowledged and should be considered. The summary intends to provide an insight into a selection of real-life data.

The summary includes feedback from 69 participants of remotely delivered PR programmes (all through video-conferencing platforms) from four PR services across England and Wales between November 2020 and April 2022. Methods of feedback reporting were varied; Table 1 provides further details.

Table 1: Details of PR service feedback.

Service	Service location	Time period	N	Non completers included	Feedback method
1	Urban England	November 2020	9	Yes	Telephone interview with patient experience team.
2	Rural Wales	November 2020–July 2021	18	No	Anonymous questionnaire.
3	Rural Wales	November 21–April 2022	27	No	Facilitated group discussion and individual interview.
4	Rural/ urban England	December 2020–August 2021	15	No	Anonymous questionnaires and thank you cards received.

Overall satisfaction with remote PR

High levels of satisfaction with the remote PR experience were reported by all participants from service three, as evidenced by good or very good (highest) ratings for the overall experience. All 14 participants asked from service two agreed that they would recommend remote PR to other people living with lung disease. All participant feedback described benefits in one or more of the domains of symptom management, self-efficacy, exercise tolerance, mood and motivation. Nine remote PR participants who had previously completed a face-to-face PR programme (in urban England) reported the face-to-face to be preferable (50).

Social elements

The social aspects of in-person PR have been reported to increase participant motivation, accountability and sense of belonging (48). Feedback received from the Welsh remote PR services frequently described improved motivation, and a feeling of support from peers and staff delivering the programmes. This is encouraging, but remote support may need more facilitation than it would in a face-to-face setting, where there is greater opportunity for private and spontaneous conversations.

‘It made me do the exercises I had been thinking about doing for months… it gave me the motivation to carry on and change my lazy ways!! I feel a lot better after doing the course’.

‘I know that I am not alone. Tutors were friendly and understanding’.

‘I was able to discuss and listen to people with the same problems’.

‘Seeing others in the same position and sharing difficulties is comforting’.

‘It would have been nice to talk to the other patients – a little bit of interaction’.

‘I don’t socialise very well but managed to talk to the people on the course’.

Communication

Video and audio communication between PR sites were identified as challenges in a study, in hub and spoke PR model in rural Wales, but this improved as more sessions were delivered (49). However, staff suggested that appropriate training with video-conferencing equipment could have prevented the difficulties arising (49). Experiences reported by service one also conferred initial technical difficulties with videoconferencing platforms and communication but the extent to which this impacted completion and outcomes is not known. Only four of 21 participants from service three reported technical concerns, all of which were resolved with all participants reporting good or very good audio and visual communication in their final feedback, and high levels of satisfaction with the service.

‘Considering quality of (my) equipment results were surprisingly good’.

Access and inclusion

Remote rehabilitation can make access to PR possible for participants who may otherwise have been excluded due to travelling distances, time constraints, disability or psychological status. Feedback from service one suggested that people with greater physical disability, may feel less safe exercising remotely (50), and highlighted the need to ensure that the model of rehab offered inspires confidence, is effective and keeps participants safe.

‘I don’t socialise very well but managed to talk to the people on the course’.

‘I found virtual sessions better for me as I didn’t like going to the sports centre, because of the risk of infection’.

‘I liked being able to do the course online, as I was able to do it in the comfort of home surroundings’.

‘I like my solitude and I don’t think I'd have done it face-to-face. I would not have made it (attended F2F), because of the weather and my lung condition’.

‘I found face-to-face pulmonary rehab was better than virtual and with others in the room, I could push myself more’.

‘Taking part virtually I was able to join in… without feeling awkward’.

Staff survey

The impact of delivering remote PR on staff workload and the technological competencies required have been identified as concerns by PR staff (48). In the same research, staff acknowledged that remote PR had potential to improve access to previously underserved populations, and could have positive effects on their job satisfaction. The ACPRC conducted a PR staff survey in 2021 (Appendix 1) and received feedback on the experience of delivering remote PR from 13 services. Most survey respondents identified that remote PR is labour intensive, and required more resources in terms of time and staffing than face-to-face PR. Courses may take more time to organise and deliver. Training and support with the technology are required for both staff and participants. Other areas of concern highlighted were reported poor uptake of remote PR, with two services reporting 20% and 25% of patients on waiting lists accepting remote delivery. Challenges with participant access to exercise equipment and concerns regarding achieving good clinical outcomes were also mentioned.

For participants who chose remote PR, staff reported uptake was better when support was provided, for example, posting or emailing literature guides. Additionally, a clear theme emerged regarding remote PR remaining in place to support personalised care through a ‘menu of options’.

Conclusions

• The overall experience of remote PR appears to be positive for people who have completed courses. When asked, most participants agreed that they would recommend remote PR to others, although those who had experienced both models of PR expressed a preference for face-to-face.
• Social support and enabling progression to independent self-management is an important component of the rehabilitation process, and often needs more facilitation during remote PR than in a face-to-face setting.
• Personal communication needs, access to appropriate equipment for communication and monitoring bioparameters, training and adequate internet speed all need to be considered when considering whether remote PR will be a positive experience for participants and staff.
• More information describing the participant and staff experience of remote PR could inform better service development. Anonymisation and inclusion of standardised patient and staff experience measures could improve the validity of information gathered and ensure services develop to meet the needs of both participants and providers.
• Finally, more research needs to take place to establish how the experience and clinical outcomes compare to traditional face-to-face PR, so service providers and participants can make better informed choices about their rehabilitation options.

Appendix 5 – Remote delivery of pulmonary rehabilitation services

Whilst the delivery of a remote pulmonary programme may be different compared to face-to-face delivery, the desired outcomes should remain the same. This section will consider what we need to do differently in these remote programmes in comparison to face-to-face.

It is the responsibility of services to keep up-to-date with current clinical governance and guidelines, especially with regards to any future COVID-19 surges or pandemics.

Although this document includes practical guidance in what should be considered when offering remote PR, services must ensure they put suitable processes in place for risk mitigations that are appropriate for their local area, participant populations and inline with local policies and procedures. Special considerations need to be made when delivering remotely to ensure safety, efficacy and accessibility. The information below is considered best practice but not exhaustive.

Assessment

Some services may decide to conduct a pre-initial assessment phone call to check for suitability and interest whilst participants are on the waiting list. The following topics might be useful to address at this point:

• Whether a participant is digitally confident and capable with access to appropriate equipment, or has a willingness to be supported to use any loaned equipment.
• Any prehab/ground rules.
• Please ensure you check the most up to date NHS infection control guidance (51), to assist with clinic/home visits if the participant is assessed as requiring additional support.
• Screening of the referral for potential exclusion criteria or concerns, that may affect ability to participate in a remote programme such as:
  1. Communication: visual, hearing or literacy issues.
  2. Safety: balance, clinical frailty or physical mobility problems which may result in a falls risk or a history of falls.

Initial assessment: subjective

The participant may be invited to complete their subjective initial assessment in a variety of ways that may include telephone, virtual consultation or face-to-face in a clinic, or on a home visit, as it might be deemed appropriate to separate this from the objective assessment.

• Obtain a good quality medical, holistic history from participant, their supporters and/or other healthcare professional as required. Use existing clinical records where possible to verify information including whether there are outstanding medical investigations or treatments (52).
• Consider whether any other onward referrals and/or screening tools may be required at this point, such as Nijmegen questionnaire for breathing pattern disorder.
• If unable to complete physical observations, screening to identify red flags/onward referrals must include:
  • Headaches.
  • Diplopia.
  • Dizziness.
  • Blackouts.
  • Palpitations.
  • Chest pain.
  • Falls screening.

Objective assessment

The first part of an objective assessment should be screening for safety before proceeding to field exercise testing. A face-to-face objective assessment is the gold standard where circumstances permit. If this is not possible (rurality, isolation, for example), then consider the following:

• Consider the use of Make Every Contact Count (MECC) (24). For example, streamlining appointments. Can other staff members be utilised if they are visiting the participant to obtain baseline observations as part of their visit, rather than have multiple visits?
• Consider using the participant’s own equipment to obtain readings, or the use of loaned equipment for this purpose.
• Consider looking at previous trends in physical health measurements on shared record systems.
• Complete a blood pressure and manual pulse check to assess cardiac status/rhythm, in the month prior to starting the programme if possible.
• If a participant has a home oxygen prescription, check oxygen usage pre-physical assessment/course commencement, using concordance data.
• Can you support the participant to risk assess their physical environment, or have you completed a risk assessment? The assessment may include questions on the following (see the section Governance: Risk assessment and mitigation for further details):
  • Is there space and the area free of clutter?
  • Suitable flooring and check for trip hazards, for example, loose rugs.
  • Does the patient have suitable clothing and footwear, for example, no flip flops.
  • Pets put away to minimise trips or interruptions.
  • Do they have appropriate exercise equipment including suitable seating to use during classes?
  • What access arrangement are there in case of emergency, including next of kin/emergency contact details, especially for those exercising alone.

The BTS PR Quality Standards (5) list 3 outcome domains (to include as a minimum): exercise capacity, dyspnoea and health status.

Field exercise testing (exercise capacity)

Field exercise tests such as the six-minute walk test (6MWT), incremental (ISWT) and endurance walk test (ESWT) have multiple purposes (3):

1. To ascertain the physiological response to exercise.
2. Use as an outcome measure to assess participant’s progress.
3. To provide a baseline for exercise prescription.

Completion of a face-to-face physical exercise test in accordance with technical standards (3) is the gold standard. If physical exercise testing cannot be completed face-to-face, then consider the following:

• Ability to monitor the participant:
  • Observing or listening for audible breathlessness (for example, use speakerphone on telephone consultations).
  • Where required, ensure the participant has someone available nearby in case of emergency.
  • Ensure the team and participant are clear of the emergency procedures, if an incident was to occur during appointment, including loss of communication.
• If no physical observations are available, clinical judgement should be used to determine if the test should go ahead, and the participant instructed to stop the test if they experience any adverse symptoms, for example dizziness, chest pain, intolerable breathlessness, pain, for example (participants will usually self-limit their activity level as required).
• Ensure participants on home oxygen are fully optimised with therapy prior to starting the programme.
• For participants not on home oxygen, good practice would be to obtain an oxygen saturation at baseline where possible.
  • If this is not possible use clinical judgement to determine whether it is safe to proceed with testing, or whether the participant would require onward referral for further assessment/investigation (53), (refer to local guidelines/pathways).

Functional outcome measures

In instances where it may not be possible to conduct a technically correct field walking test, (see Technical Standards (3)), clinicians may choose to conduct a functional outcome measure. The 4-metre gait speed has been reported to have the highest correlation, with routine measures of exercise capacity, but standardisation in a remote assessment and ability to prescribe exercise may be limited (54). Commonly used as a measure of functional capacity, sit-to-stand (STS) tests (for example, one-minute STS) may be easier to standardise in a remote assessment. Evidence supports the validity, reliability and responsiveness of STS tests, as an alternative measure of exercise capacity in people living with COPD (55, 56).

Consider:

• Reference to instructions (for example, the Primary Care Respiratory Society One-Minute STS Test Protocol).
• Ensure the participant has been appropriately monitored, for recovery after test completion, returning to baseline parameters.
• Encourage active recovery in participants with increased cardiac risk (57).
• Ensure standardisation (for re-assessment purposes).

Measurement of dyspnoea and health status

Services will need to consider how participants can be supported to complete valid and reliable outcome measures, if completed remotely.

Consider:

• Selecting self-reported questionnaires wherever possible, for example CAT, PHQ-9/GAD-7, Clinical Frailty Scale and MRC Dyspnoea.
• Methods to support participants with learning and communication needs to ensure they can complete the questionnaire and the answers that are reflective of their personal perception of their condition (without undue influence on anyone helping to complete them).
• The delivery mode and method of return, for example, by post, by email, web-based or over the phone.

Exercise

Delivery of remote exercise and remote exercise prescription present specific communication, supervision and safety challenges for participants and staff. The following should be considered:

1 Emergency protocols

• Services must have an emergency protocol, to follow if a participant becomes unwell. This includes actions to take during in the event of chest pain, severe shortness of breath, sudden severe pain or any other medical emergency.
• Clear red flag symptoms should be identified as part of a participant information leaflet, to support self-escalation of concerns before, during or post exercise session as well as on completion of home programme.
• Services should consider how to mitigate increased risk of adverse cardiac event for a certain period after the exercise class has ended if there are no further supervised activities planned, for example, a subsequent education session.
  • Therefore, services should be mindful to adapt programmes to include graduated cool-downs of at least 15 minutes, and working within an appropriate heart rate training zone, (no more than 80% maximum heart rate, or lower for very deconditioned individuals), plus use of the BORG scale to monitor perceived exertion (57).
• Services must have a plan for technology failures, and staff and participants must be aware of the protocols.
• A next of kin or emergency contact for the patient, should be documented in the patient’s notes.
• Services must have up to date service details in an easily accessible format, to ensure participants are able to contact the service, if the service is unable to contact the participant.

2 Staffing

Ratios

• Staffing ratios should ensure that all participants can be seen on screen at the same time, if using video-group.
• Screen size may affect group size due to ability to safety supervise for example, using a laptop screen compared to a large TV screen.
• Participant peer supervision, may be limited in remote groups which may be less effective compared to face-to-face groups.
• There should be a minimum of 2 members of staff to run a group, and consideration must be made with regards to risk mitigation in larger groups. For example, the group can continue to run with 1 member of staff, and there should be capacity for 1:1 support for group members.
• Consideration of staff confidence to use the chosen platform, and ability to provide basic troubleshooting advice to participants.
• Consider reducing group sizes when inducting new staff.

Communication

• One staff member should be designated as lead for the duration of the session.
• Each staff member should be given a specific role/task(s) for the duration of the group, to ensure clear lines of responsibility and communication for example:

1. Demonstration of exercise.
2. Exercise progression, modification and technique/performance supervision.
3. 1:1 participant support/communication, to include escalation/emergency responses.
   • Agree private means of communication between staff members during sessions.
   • Agree private means of communication with individual participants during sessions, if needed (please refer to the section Governance: information governance for further information).
   • Patients should be provided with a contact number, for the staff in case of any issues that may arise during the session.

3 Equipment

• Participants and staff should be comfortable using their IT equipment, and the remote platform. The device should be positioned appropriately (see the section Governance: placement of video equipment).
• Participants must have the appropriate equipment to perform and progress their exercise programme. For example, chairs/free weights/resistance band, for example.
• As per individual assessment, if prescribed essential medical equipment such as reliever inhalers, GTN and oxygen, participants must ensure these are easily accessible.
• An alternative means of communication should be easily accessible, such as mobile phone/land line in case of emergency, or support for technical issues.
• Participants should ensure they have water nearby, for adequate hydration.
• Blood sugar monitoring kits – participants with diabetes who routinely monitor blood sugars should check their blood sugar levels, before starting exercise classes. If a diabetic participant who does not routinely check their blood sugars feels unwell, they should not exercise and contact their GP or Diabetic nurse for a review.
• Those who are diabetic should have their rescue diabetes kits available, in case of hypoglycaemic event.

4 Environment

General

• It is good practice to support participants to risk assess their environment and themselves at the beginning of each session (see Appendix 6 checklist, for example). In addition, participants are not to exercise after drinking alcohol and leave at least one hour after completing exercise before having any alcoholic drink.
• Physical environment assessment needs to be as per local risk assessment guidelines.

Temperature

• The American College of Sports Medicine (58) recommend a temperature of 68–72°F (20–22.2°C) in a gym environment (with consideration of appropriate humidity and air circulation levels).
• People exercising in their home environment may not monitor or consider this. Appropriate precautions and advice must be given, that includes considerations for clothing, hydration, exercise intensity and duration (including frequency of monitoring). This will help to maintain the expected physiological responses that would normally occur within the more ideal and recommended environmental parameters (57, 58).

5 Programme content

• All programmes require suitable exercises supported by an appropriate warm-up and cool down suitable for a remote platform.
• Consider how the service will offer individualised programmes to maintain motivation, and allow for participant progression. Some services may consider stratifying participants according to diagnosis/condition severity/exercise tolerance.
• If new participants are joining an existing a cohort programme or a rolling programme, consider an individual induction prior to attending the main group.

Education

The BTS Quality Standards (5) state PR programmes must include ‘defined, structured education’, that is typically included within the same session as the exercise component in a traditional face-to-face programme. The COVID-19 pandemic accelerated the focus of technology-enabled learning including in the context of PR. There is some evidence to suggest improved patient experience with technology-enabled learning for people with chronic respiratory disease, however the variability in approaches and methods of evaluation and barriers affecting access limit interpretation and generalisability (59).

Considerations for delivery of remote education

• Digital literacy and equipment access for both participants and staff including ‘how to use guides’ or providing technical support to participants who require help (please refer to the section Health and digital inequalities).
• Clinicians must have an appropriate workspace to deliver remote education for example, a shared office is not an appropriate space due to potential information governance breaches.
• Consideration must be given to staff providing remote services in terms of health and safety/DSE assessments.
• Inclusion of resources/ability for carers/families to ask questions and be supported.
• Consideration must be given to those who do not have remote access. They should not be disadvantaged because of lack of access.
• Consideration of sight or hearing difficulties that might be exacerbated by poor sound quality/small screens, dependant on device.
• Plan sufficient time for responding to participant questions when delivering remote education.
• Any new forms of educational material must be checked for readability, clarity, and appropriateness (see health inequalities section).
• Consideration of available material for participants who cannot speak English, or use sign language.
• Remote delivery gives opportunity for utilisation of extensive learning tools to encourage active participation, motivation, and peer support rather than didactic delivery methods.
  • Tools might include interactive quizzes, live voting, live whiteboards, polls, short video clips, gameshow quizzes/trivia, for example.

It is encouraged to consider different learning styles within a group to make learning more effective and efficient for the patient. There are many different learning theories and learning styles (60). Using VARK (61) as an example, a combination of different strategies can be used to enhance learning in PR classes:

• Visual: for example, pictures, videos, models, colour, shapes.
• Auditory: for example, video/podcasts, lectures, discussion.
• Reading/writing: for example, written information, looking at data, lists, rewriting ideas into own words.
• Kinaesthetic: for example, trial and error learning, task-based learning, case studies.

Studies do show that learners adapt their learning style dependent on the task, just as educators can adapt their teaching styles to become more holistic and facilitatory (62). By doing this and using a range of tools and other strategies, this allows for adaptability and a richer learning experience for patient and keeps education more interesting for staff:

• Reflection.
• Problem solving.
• Role play/simulations.
• Group discussions using different delivery methods.
• Coaching.
• Reinforcing key messages.

Resources to support the remote delivery of education can be found in Appendix 6.

Managing waitlists

It is acknowledged that variation in approaches in managing waiting lists during the height of the pandemic and beyond has been required due to factors such as:

• Staff redeployment (ACPRC survey Appendix 1) showed >70% services had some staff redeployment).
• Services shutting down completely and/or closed to new referrals for a period.
• Many services required to offer face-to-face PR upon resumption to those who completed a remotely delivered programme (and some services already have 12 month recalls as part of standard contracts).
• Some services held participants who declined, or were inappropriate for remotely delivered PR in a separate caseload, and some services discharged these participants.
• Some services had additional contract variations added such as post-COVID-19 related activity, with/without additional resource.
• Some services have multiple waiting lists according to suitability, preference or other factors now facing the challenge of how to prioritise or merge lists (if appropriate), as face-to-face services resume.

Possible solutions (identified by authors)

• Caseload cleansing activity (particularly if not using an electronic shared record system) – check for any participants who may be deceased or have moved out of area. Use admin/support staff where possible.
• Send out an opt in/activation letter: participant sent a letter, detailing service offerings and contacts service to provide preference. Discharged if no response. Requires admin support to receive and log calls and maintain waiting lists.
• Pre-calls: telephone call by support/admin staff member (ideally with some training in motivational interviewing/health coaching, and with an understanding of PR models, risks and benefits) to discuss PR and the offerings the service has available, encourage participant motivation for participation and ascertain model/offering preference.

For awareness: services need to consider how they might manage participant expectations about potential start dates. When a participant is initially contacted by a service, they often expect to receive an appointment shortly thereafter, or they may enquire about wait times and hang on to timescales provided. The timing of the calls should be considered, particularly where waiting lists are lengthy. For example, an opt in letter or pre-call on referral, will need greater consideration around how to deal with wait times as participants may have a longer wait, whereas the same activities carried out when the participant reaches the top of a waiting list, may mean that the participant can be immediately booked into an appointment slot on contact with the service; this may also help to reduce DNA’s if the wait to appointment time is short, however it will likely not reduce waiting lists significantly, at the point of referral.

Considerations

• If sending an opt in letter, health literacy and identification of health inequalities need to be taken into account (see Health and digital inequalities section).
• Where referrals are longer than 3 months old, up-to-date medical information should be sought prior to assessment – this will vary per service as to how this is obtained. For example, request updated summary care record from primary care or review shared record if available, such as SystmOne or EMIS (if share agreement in place – consider adding consent to open share section to referral form, in areas where shared record systems are used).
• Consider case stratification to identify priorities for the waiting list, such as:
  • Post-admission for respiratory exacerbation (particularly in the last 4 weeks).
  • Post-respiratory exacerbation related A&E attendance, 999/111 call.
  • Referral following admission avoidance for respiratory exacerbation.
  • Recent respiratory exacerbation (managed at home).
  • Recurrent respiratory exacerbation.
  • Pre/post lung surgery.
  • ILD diagnosis.
  • Routine – 1st attendance.
  • Routine – repeater (>12 months since previous course).
• Consideration should be given to who is available to support and who has responsibility for waiting list caseload management. Does the service have sufficient administrative support?
• Where waiting lists are lengthy, and there is a requirement for updated medical information to be sought prior to the assessment appointment, clinicians need to be given appropriate time to review and potentially follow-up this new information for any changes to participant suitability in order to avoid wasted appointments.

Appendix 6 – example consent form and self-assessment checklist for remotely delivered pulmonary rehabilitation services

Example consent form - please see link at end of appendices to download

Example self-assessment checklist - please see link at end of appendices to download

Appendix 7 – resources for remote delivery of pulmonary rehabilitation services

Video-conferencing platforms:

• Microsoft Teams.
• Attend Anywhere.
• Zoom.
• Webex.
• OneConsultation.
• AccuRx.

Workforce training and support

Training

• Health Education England: training and educating the workforce: https://www.hee.nhs.uk/our-work/population-health/training-educational-resources.
• https://www.e-lfh.org.uk/programmes/coronavirus/. 
• https://learninghub.nhs.uk/.
• https://learninghub.leadershipacademy.nhs.uk/.
• https://transform.england.nhs.uk/covid-19-response/technology-nhs/web-based-platform-which-offers-video-calls-services/ (NHSE Transformation, 2022b).
• Digital Health Academy: foundation level modules freely available at orcha-academy.com, and on the Health Education England NHS Learning Hub (learninghub.nhs.uk) at learninghub.nhs.uk/Catalogue/ORCHA.
• https://www.hee.nhs.uk/our-work/digital-literacy.
• https://www.e-lfh.org.uk/programmes/digital-learning-solutions.
• https://www.vc.scot.nhs.uk.
• www.makingeverycontactcount.co.uk.
• https://www.personalisedcareinstitute.org.uk.

Well-being

• England: https://www.england.nhs.uk/supporting-our-nhs-people/support-now/staff-mental-health-and-wellbeing-hubs/.
• Northern Ireland: https://www.publichealth.hscni.net/covid-19-coronavirus/guidance-
  hsc-staff-healthcare-workers-and-care-providers/questions-and-answers.
• Scotland: https://wellbeinghub.scot, https://www.nhs24.scot/staff-information/staff-wellbeing/, https://www.nes.scot.nhs.uk/news/staff-wellbeing-resources/.
• Wales: https://heiw.nhs.wales/support/colleague-health-and-wellbeing/.
• NHS People Plan: https://www.england.nhs.uk/ournhspeople/.

Health and digital literacy

Health equity assessment

• Health Equity Assessment Tool (HEAT): https://www.gov.uk/government/publications/health-equity-assessment-tool-heat/health-equity-assessment-tool-heat-executive-summary.
• Training to use Health Equity Assessment Tool (HEAT): https://www.e-lfh.org.uk/programmes/health-equity-assessment-tool-heat/.
• Equality Impact Assessment toolkit for research: https://arc-em.nihr.ac.uk/clahrcs-store/equality-impact-assessment-eqia-toolkit, https://forequity.uk/.

Health literacy

• Public Health England: Improving health literacy to reduce health inequalities: https://www.gov.uk/government/publications/local-action-on-health-inequalities-improving-health-literacy.
• Health Education England: Improving health literacy: https://www.hee.nhs.uk/our-work/knowledge-library-services/improving-health-literacy.

Digital literacy

• Barclay’s Digital Eagles.
• Vodafone’s Buy One Give One commitment.
• Digital Poverty Alliance.
• National Literacy Trust.
• Department of Education – essential digital skills framework.
• Royal College of Nursing – improving digital literacy.
• The Good Things Foundation – learn my way, make it click.
• Department for Digital, Culture Media & Sport: Digital Skills and inclusions – given everyone access to the digital skills they need.

Delivery of education

• ACPRC: patient information leaflets https://www.acprc.org.uk/publications/ patient-information-leaflets/.
• Asthma and Lung UK: www.blf.org.uk/support-for-you.
• Asthma and Lung UK: www.asthma.org.uk/advice/inhaler-videos.
• Stay Active and Stay Well (Asthma and Lung U.K.): www.blf.org.uk/support-for-you/keep-active/exercise-video.
• British Thoracic Society: PR resource pack: https://www.brit-thoracic.org.uk/covid-19/covid-19-information-for-the-respiratory-community/.
• European Lung Foundation (ELF): www.europeanlung.org/en/lung-disease-and-information/ lung-diseases/.
• Lung Foundation Australia: https://pulmonaryrehab.com.au/importance-of-education/education-topics/.
• Supporting Someone with Breathlessness: https://supporting-breathlessness.org.uk/.
• Living well with COPD: https://www.livingwellwithcopd.com/.

Digital resources

• UCL Partners: Digital resources for Asthma and COPD.
• myCOPD app: NICE medical technologies guidance MTG68.
  • Related evidence: Bourne et al. (2017), Crooks et al. (2020), North et al. (2020), Platt & Jackson (2022).
• SPACE for COPD: Self-management Programme of Activity, Coping and Education for COPD – manual and online self-management programme.
  • Related evidence: Chaplin et al. (2017), Horton et al. (2018), Bourne et al. (2020), Houchen-Wolloff et al. (2021). 

Other resources 

• Example programme: https://www.uhdb.nhs.uk/pulmonary-rehabilitation-virtual-pulmonary-rehabilitation.
• Examples of PR standard operating procedures: https://www.respiratoryfutures.org.uk/resources/regional-and-local-resources/pulmonary-rehabilitation-standard-operating -procedures-sops/.
• Managing questionnaires online:
  • LimeSurvey: www.limesurvey.org/en/.
  • Microsoft Forms (requires purchase of Office 365): www.microsoft.com/en-gb/microsoft-365/online-surveys-polls-quizzes (can be used for surveys, polls, and quizzes).
  • REDCap: www.project-redcap.org (secure web application for building and managing online surveys and databases).
• Student placement guidance: https://www.csp.org.uk/professional-clinical/practice -based-learning.

Appendix 8 – practical information governance considerations

Data Protection Impact Assessment (DPIA)

Information and guidance on conducting DPIAs, can be found on the Information Commissioner’s Office website: Data Protection Impact Assessments (DPIAs) | ICO.

General IG equipment

All devices require a minimum of password and or biometric protection. Other secure methods include a physical USB device, or external security card.

• Passwords should be unique and used only once. Use long passwords, a minimum or 12 characters are recommended, with a mixture of characters and punctuation marks.  Phrases that incorporate characters and punctuation marks, are easier to remember.
• Use a secure password manager with two-factor authentication, to store passwords or store any written password in an offsite secure site.
• Do not save passwords in an unencrypted file, or on an unencrypted device.
• Ensure that any anti-viral and anti-malware is up-to-date, or preferably on automatic updates on all devices.
• Ideally all devices should be encrypted, this includes desktops, laptops, phones, tablets or any other mobile device.
• If any recording or transferring of personal data is to occur, then the device must be encrypted.
• Devices should be set to automatically time out if not accessed, however, this time needs to be extended when using for a remote session, to prevent lock-outs occurring during a remote session.
• It is advisable not to use your personal devices for remote sessions unless they meet the IG standards of your organisation.  Check with your local IG policy documentation, if it is permissible to use your own personal device. 
• Each user must have an individual account on each device.  Accounts must not be shared between different individuals.

Placement of video equipment 

Consider using a mains-powered laptop with either a built-in camera or an external USB camera (plugged into the laptop) that will provide greater freedom of camera placement.  An external USB camera with a tripod offers the greatest flexibility.

• Consider the use of a hands-free headset and earphones, to reduce the likelihood of participants being overheard.
• Ensure that displays and video equipment are not visible to the public. The use of screens may be useful, if a closed room is not available.
• Ensure that video equipment is placed to prevent photo bombing opportunities.
• Place video equipment at a suitable distance to allow participants to see a full body view of the physiotherapist, if appropriate. Ensure that the field of view minimises the recording of the external environment, to protect external individuals from being seen or participants being overseen.
• Ensure the area visible on screen presents a professional setting and role models a safe working and exercise environment.
• Advise participants to place their video equipment in order that carers, or relatives are unable to see other individuals on screen as much as is practical.
• It is difficult to guarantee that no other individual will be able to oversee or overhear a remote session, as participants often require additional support when accessing IT equipment at home, or do not have a separate area to access equipment.
• The fact that other participants or carers maybe able to see individuals must be discussed with all participants at the initial assessment, and practical advice on how to minimise this should be given.

Participant modesty

Advise participants on appropriate clothing and placement of cameras, to minimise the potential for embarrassing situations to arise.

• An additional staff member should be available to discontinue a remote session immediately, should inappropriate behaviour be noticed.  A follow-up phone call, can then be made to correct the behaviour.
• Participants may be tempted to use blurring of their own backgrounds. If this is the case, then they must be reminded to stand closer to the camera to avoid being blurred out themselves.

Recording sessions

If a session is to be recorded, you must ensure that the local recording device is encrypted, and password protected.

• Consent must be sought from each individual and discussed before any such recording occurs.
• External recording must be discouraged by participants and will need to be discussed before commencing sessions.  Most remote services will warn that an external recording has been started. In this instance the assistant or physiotherapist should immediately discontinue the remote session with the individual recording the event, and follow-up with an explanatory phone call.
• If a remote system is used that does not warn of external recordings occurring, then an alternative remote system must be used.  Microsoft Teams has been validated as secure by the NHS, and should be used as the gold standard when comparing remote services. 

Emergency access  

• To reduce the effect of power failures an uninterrupted power supply (UPS) maybe used, in combination with a mains-powered laptop. In the event of a temporary power failure, the laptop will automatically switch to battery backup, and the UPS will allow power to remain to the router device, thus allowing the remote session to continue. The UPS will provide power for a limited time dependent on the wattage of the router, however, this should be sufficient to allow for a seamless switch to another device, or for a temporary glitch in power to be corrected.
• If a remote session is interrupted, then a switch to an alternative remote device maybe indicated such as a phone or tablet device. However, this device must be encrypted and password or biometrically protected, if any recording of a session is to occur.
• Individuals must have access to an individual account, with an individualised password on the back-up device to prevent multiple users accessing sensitive material.
• Conversations on encrypted social media are only protected end-to-end, meaning that the conversations cannot be read whilst in transit. However, if either of the receiving devices are not encrypted then the entire conversation maybe read if access is gained to either of the devices. The device must be encrypted.
• Social media also allow access to be gained to messages through web access, that will be password protected. However, if any device that is used that is not encrypted, then access to those messages maybe possible. Examples are internet cafés or home computers, that allow guest user access. Do not use any device that allows for guest users and ensure that accounts are individually accessible through a secure password.
• Check your local IG policy documentation for permitted devices, as personal devices are often not allowed to be used within local organisations.