Transforming acute care in chronic obstructive pulmonary disease (COPD): Testing the case for change
NHSCANCER NHS Improvement LungDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - Lung: NationalImprovement ProjectsTransforming acute care inchronic obstructive pulmonarydisease (COPD): testing thecase for change
“People with COPD should receive specialist respiratory reviewwhen acute episodes have required referral to hospital.They should be assessed for management by early dischargeschemes, or by a structured hospital admission, to ensure that ”length of stay and subsequent readmission are minimised.
3Transforming acute care in chronic obstructive pulmonarydisease (COPD): testing the case for changeContentsIntroduction 4• Case for change: the current position for chronic 4 obstructive pulmonary disease in the UK• Improvement approach 4• Common challenges and solutions 5• Project outcomes: Emerging success principles 6 from project learning• Future ‘prototyping’ work 6Project case studies 8Acknowledgements 17References 18
4 IntroductionIntroductionCase for change: the current position to release resources, both in terms of This publication, which is aimed atfor chronic obstructive pulmonary capacity release and cost avoidance, but healthcare professionals, commissionersdisease in the UK also support the NHS to achieve the and other key stakeholders involved in Quality, Innovation, Productivity and respiratory health, draws together theThree million people in the UK Prevention (QIPP) challenge. evidence and learning from the past 12have chronic obstructive pulmonary months and highlights the workdisease (COPD). When a patient has an Further evidence for the need for this undertaken by the project sites in theexacerbation of COPD, it is important work can be found in the Royal College ‘Transforming Acute Care’ nationalthat the right treatment is given as early of Physicians 2008 NCROP studyii. It workstream.as possible in order to minimise the acute showed that access to early supportedand long term deterioration of the discharge schemes was limited with only Improvement approachcondition, and speed recovery. COPD is 18% of patients being discharged withone of the most common reasons for such schemes, despite evidence that In July 2010, NHS Improvement – Lungadmission to hospital, with 107,000 around 25% of patients having an invited NHS organisations to work inadmissions in 2009/10. admission for acute exacerbation of partnership on projects dedicated to COPD would be suitable for this improving the COPD patient pathway andExacerbations of COPD are inevitable for approach to care. to help address the geographical variationsome patients, particularly those with in care that patients receive. Projectsmore severe disease. During the first year The audit also demonstrated that more plans were submitted from a number ofof project work, NHS Improvement – than one in five patients admitted for sites including acute trusts, primary careLung through the ‘Transforming Acute acute exacerbation of COPD did not trusts (PCTs) and communityCare’ national workstream has focussed receive care from a respiratory specialist organisations.on developing services that deliver during their hospital stay. A more recentefficient, high quality care and support report by the King’s Fundiii has suggested The primary aims of the project workfor patients with acute exacerbation of that early specialist review can be were to:COPD both in the community and beneficial in reducing emergency andsecondary care settings. This focus unplanned hospital admissions, so it is • Define the patients pathwayreflects objectives three and five from the important to address this deficit in care to • Test the components of care that led torecently published Outcomes Strategy for raise quality and improve outcomes. an effective acute care modelPeople with Chronic Obstructive • Identify the success principles thatPulmonary Disease (COPD) and Asthmai: Many healthcare systems lack robust other organisations and teams couldto reduce premature mortality from COPD processes to ensure that patients are learn from and adoptthrough proactive care and management followed up after their exacerbation of • Inform future ‘prototyping’ work.and to ensure people with COPD receive COPD. A 2010 survey by the British Lungsafe and effective care. Foundation and British Thoracic Society[i] Focus was also given to improving the demonstrated that, whilst there is good patient’s experience and outcomes and toThe aim of the national workstream was evidence for the use of discharge plans, the removal of duplication and wasteto ensure that patients admitted to their introduction as a routine part of from the pathway and specific processeshospital with COPD receive timely patient care has been limited with less through different ways of working andspecialist care and assessment so that than one in three hospitals adopting service redesign. Productivity gainsthey are optimally managed along a them. In addition, the 2008 COPD audit achieved by sites were measured tostreamlined inpatient pathway most showed that only 53% of patients were identify the impact of the work in termsappropriate to their clinical needs. Work discharged from hospital under the care of reductions in bed days, avoidablealso included opportunities to identify of a respiratory physician. Improving hospital admissions and re-admissions.pathways that avoid admissions where these aspects of patient care during anpossible. A common objective of the acute exacerbation will improvework was to reduce length of stay for outcomes, reduce re-admissions and leadperiods of hospitalisation and to reduce to a better patient experience of care.subsequent re-admissions with a view
Introduction 5During the ‘testing’ phase of the Common challenges and solutions • Early access to specialist respiratory careprogramme the project teams have has been demonstrated as an effectiveexplored the reality of making this Clinical teams at all sites have been means in reducing length of stay.happen by taking stock of current focussed on specific aims which have Colchester University Hospitals NHSpractice and understanding the process included: Foundation Trust demonstrated a meanof implementation towards ensuring reduction in length of stay of 0.4 dayspatients receive optimal care in a • Increasing the number of patients with and St George’s Healthcare NHS Trustchallenging environment. The project acute exacerbation of COPD who can achieved a reduction of 1.5 days bysites adopted a systematic approach to be safely and effectively managed in instigating early specialist reviewquality improvement to ensure that any the community through admissions • Within and between organisationschanges implemented were thoroughly avoidance schemes there is a lack of awareness by sometested and measured. Prior to • Ensuring patients admitted to hospital clinicians of all available services forcommencing the work the project sites with acute exacerbation of COPD are COPD patients and so reducedwere required to establish their service seen by a respiratory specialist opportunities for the provision of highbaseline through analysis of local data • Streamlining the inpatient stay for quality care. Improving communicationand to understand the variation in acute exacerbation of COPD so that is important in raising awareness ofservices. patients receive optimal care and can these services be discharged into the community as • Improving communication and serviceOnce the project teams were established, soon as clinically ready integration is effective in reducinga period of ‘diagnosis’ followed to allow • Ensuring patients who have an acute admissions. South Tyneside Foundationteams to understand the patient pathway exacerbation of COPD receive timely Hospital Trust prevented 66 admissionsand dispel a number of assumptions and appropriate follow up care. through closer working between GPabout the processes, its challenges and and Hospital at Home services.the solutions. Potential solutions were Whilst each project site has worked on a • Discharge plans which have beentested using the model for improvement different part of the acute pathway, a instigated at several project sites haveand Plan-Do-Study-Act (PDSA) cycles with number of themes have emerged across been proven as an effective way ofongoing measurement to evaluate the all sites: improving the quality of care in COPDimpact of the interventions and refine by helping the patient to be morewhere appropriate. • Implementing co-ordinated case effective in self management and also management for cohorts of patients facilitating a more integrated approachThe project sites worked for a 12 month with frequent hospital presentations is across primary and secondary careperiod and one of these sites, NHS West an effective way to reduce admissions. • Care bundles improve the quality ofSussex and Western Sussex Hospital NHS Several sites have demonstrated that care by ensuring key components ofTrust, will continue into the second year this intervention has directly improved care are implemented and that there isof project work. For most of these the quality of care delivered consistency in the care being delivered.projects this represented a starting point • A lack of clear and effective referral Several sites such as NHS West Sussexon the improvement journey for COPD mechanisms for specialist care leads to and Western Sussex Hospital Trust havepatients. This publication contains a increased variation in the quality of care successfully implemented COPD carenumber of case studies produced from and potential waste of resources as bundles into their COPD patientthe final ‘testing phase’ COPD project clinical time is spent ‘searching’ for managementreports, demonstrating the key learning appropriate patients • Developing an integrated acute carefrom the work that project sites have pathway for COPD is an important stepundertaken. in improving the patient care process, increasing the quality of clinical care and transforming the patient’s experience of care during an exacerbation of COPD.
6 Introduction Future ‘prototyping’ work Project outcomes: Emerging success principles from project learning In the forthcoming year of project work Through problem solving and a The routine collection and review of sites will be building on the learning from systematic approach to improvement, data was important in implementing the ‘testing’ phase of work. Sites will be all teams worked through a number of sustainable improvements and refining the components attributed to the challenges in order to achieve their understanding outcomes of any emerging care models and success project aims. Across the sites, a service improvements principles that demonstrated the greatest number of success principles have • Identifying the key levers and drivers impact on the patient pathway during the been identified that represents in the system by integrating local past year. The prototyping work will improvement opportunities towards and national priorities into the work define the structured admission for effective service provision in managing such as Quality, Innovation, patients with COPD, representing an the acute exacerbation of COPD: Productivity and Prevention (QIPP) efficient and high quality care model that raised the profile and priority of the reflects not only best practice, but also • Defining and gaining a good project work with decision makers demonstrates examples of practical understanding of the whole pathway and helped to achieve improved approaches towards sustainable of care supported by robust data to engagement from senior implementation. This will include work demonstrate current processes, management teams. that focuses on: performance and variation is • There was a need to identify and essential when embarking on understand the gaps, duplication • Individualised patient management improvement work. This allowed and waste in the patient pathway in plans (including a discharge plan on organisations to identify priorities for order to make best use of available admission) change and also to benchmark resources. It was essential to work • Daily decision making ward round and themselves against others locally and and communicate with colleagues, ongoing access to a respiratory nationally commissioners and other specialist • Issues and challenges viewed in stakeholders in service provision in • Incorporation of care-bundles into isolation without due consideration order to maximise these resources patient management to the whole patient pathway were and to ensure a consistent and • ‘Early exercise’ and ongoing referral to less likely to lead to sustainable co-ordinated approach to care. pulmonary rehabilitation services. improvements in care provision • Effective working relied on the Many of the issues and challenges met The past year’s work demonstrated that, commitment of teams in primary, by the project teams were similar to despite the findings from the NCROP secondary and community care to those faced in other specialities and reports in 2003 and 2008ii, the improve communication across the several of the success principles have proportion of patients who receive non- patient pathway. Integrated working been demonstrated to be effective in invasive ventilation within three hours of helped to build positive relationships other disciplines e.g. the daily decision admission remains low and many acute with health care professionals, making ward round that was trusts do not have the necessary departments and organisations, and introduced through the NHS processes in place to ensure rapid improve the critical interface Improvement - Cancer inpatient workv. assessment for and access to this between these organisations It was important for sites to recognise intervention. There is clearly more that • Access to and effective use of data areas where common principles and can be done to improve this position and through collaboration between practice meant that learning could be work will be undertaken to address the clinical and managerial staff enabled transferred across specialities. design and implementation of sustainable the project teams to better pathways to ensure early assessment of understand the patient pathway and respiratory failure and initiation of demonstrate the impact of any non-invasive ventilation. change.
Introduction 7Building on the findings from the King’s It is the aspiration of the nationalFundiii, the projects will also work to workstream to deliver a QIPP reduction inimplement emergency department triage emergency admissions by 20%, aby a respiratory specialist as this step reduced length of stay by 20% and aof the patient pathway in acute reduction in readmissions at 30 days byexacerbation was not actively addressed 20% by building on work undertaken bythrough work in the ‘testing’ phase. project teams in the ‘testing phase’ and continuing to transform acute careDespite existing evidence for the clinical services for patients with COPD. Insafety and cost effectiveness of early addition, the workstream will continue to Phil Duncansupported discharge in COPD many areas identify the key components of care that Director, NHS Improvement -Lungdo not currently offer this service. The improve the overall patients’ experiencenational workstream will be working with and outcomes, and further develop theorganisations that are developing these learning and key success principles thatservices by drawing on the published support effective commissioning of acuteevidence to date and practical examples respiratory services in England.found in respiratory services and otherspecialities. Catherine Thompson, NationalSeveral of the ‘testing’ sites implemented Improvement Lead,strategies to facilitate collaborative NHS Improvement - Lungworking with ambulance services andprimary / community care services, most Phil Duncan, Director,commonly by instigating cross NHS Improvement – Lung Catherine Thompsonorganisational multidisciplinary working. National Improvement Lead, NHS Improvement – LungThe impact of this still requires evaluationand ‘prototyping’ sites will assess theeffect such interventions have on highimpact service users and subsequentre-admission rates.
8 Case studiesProject case studies• NHS West Sussex and Western Sussex Hospitals NHS Trust: Improving the acute respiratory service in West Sussex• North East London, North Central London and Essex Health Innovation and Education Cluster (HIEC): Improving access to non-invasive ventilation for COPD• Norfolk and Norwich University Hospital NHS Foundation Trust: An integrated care model for patients with exacerbation of chronic obstructive pulmonary disease (COPD)• St George’s Healthcare NHS Trust: Process redesign improves services for acute exacerbation of chronic obstructive pulmonary disease (COPD) by reducing length of stay and readmission rates• South Tyneside NHS Foundation Trust: Improving the acute respiratory assessment service• South Tyneside NHS Foundation Trust urgent care team: Admissions avoidance through the urgent care team• Colchester Hospitals University NHS Foundation Trust: Access to specialist care for patients with acute exacerbation of chronic obstructive pulmonary disease requiring hospital admission
Case studies 9NHS West Sussex and Western Sussex Hospitals NHS TrustImproving the acute respiratoryservice in West SussexWhat was the problem? A simple one page ‘COPD Checklist’ was What are the key learning points?The project team at NHS West Sussex and designed for use by the community • Improved communication and jointWestern Sussex Hospitals NHS Trust, matrons as an aide memoire to help working across primary and secondary(Worthing Site) wanted to improve the ensure that COPD patients get the correct care has allowed patients promptquality of care for people with COPD assessments and treatments. access to a secondary care opinion. Theadmitted with an acute exacerbation to primary and secondary care teams nowWorthing Hospital. A discharge proforma was introduced feel that they are working as one team which is completed by the Respiratory for the benefit of the patientWhat was the aim? Nurse Specialist and sent promptly to the • Having a patient representative on theThe project aim is to reduce length of relevant community and primary care project group has been invaluable,stay, reduce admissions by ‘high impact services. providing a different perspective andservice users’, reduce re-admissions challenging the clinicians and managerswithin 30 days, and to increase the A COPD exacerbation care bundle was perceptions of what is ‘good’ or ‘right’proportion of patients assessed by a introduced for use in hospital to ensure about how care is delivered and tellingrespiratory clinician during their stay and best practice in line with clinical us what the priorities are for patientsthe timeliness of this assessment. guidelines and improve patient care. • Finding a data/information analyst. within the trust who is able to supportWhat has been achieved? A referral process is being developed to the project work has made the retrievalA monthly COPD multidisciplinary ensure that patients who have a first and analysis of data, and monitoring ofmeeting (MDM) was instigated, attended presentation for COPD receive an progress much easierby acute and community clinicians. This accurate diagnosis and appropriate • There is a wealth of dedicated skilledhas improved communication between follow up. people available whose energy can beclinical teams and led to more prompt, harnessed to work together to makebetter integrated and more proactive By improving communication within the significant changes.care. For example: acute hospital the percentage of patients under care of a respiratory consultant has Contact• Community COPD nurses can access increased from 38% to 57%. Dr Jo Congleton advice, ensuring the patient receives Respiratory Physician, Worthing Hospital the right care and without the need for Email: firstname.lastname@example.org an outpatient appointment• Patients who have been admitted more than once are now discussed systematically at the MDM and actions formulated aiming to prevent further avoidable admissions.
10 Case studiesNorth East London, North Central London and EssexHealth, Innovation and Education Cluster (HIEC)Improving access to non-invasive ventilation forchronic obstructive pulmonary disease (COPD)What was the problem? What has been achieved? ContactChronic obstructive pulmonary disease • Three of the seven trusts had a mean Swapna Mandal(COPD) is a leading cause of mortality door to mask time of less that three Respiratory Registrarand exacerbations of COPD are hours and only 44% of patients across Email: email@example.com with reduced quality of life all seven sites received NIV within theand increased mortality. Mortality across optimal time frame of three hoursthe UK for acidotic COPD patients • There was some variation in themanaged with non-invasive ventilation presence of an escalation plan (3 –(NIV) is 26%. This is much higher than 33% of patients did not have athe randomised controlled trial evidence documented plan) and resuscitationwhere the expected mortality is decisions (0 – 25% of patients did notapproximately 10%. Furthermore, about have a documented decision)30% of patients who fit the criteria for • There was a monthly improvement inNIV do not receive it and of those that do the number of ABGs taken at 4-6receive NIV only 49% do so within three hours. The proforma may have aidedhours. this improvement as there was a prompt on the proforma for ABGs toWhat was the aim? be takenSeven acute trusts across the HIEC region • Trusts with a 9-5 respiratory on-callagreed to audit their performance of system had the shortest door-to-mask Swapna Mandaldelivering NIV against a series of timestandards including: What are the key learning points?• Door to mask time • Prospective audit alone is not enough• The presence of an escalation of care to effect change in practice in the plan and resuscitation decisions delivery of NIV• Appropriate monitoring of therapy with • Acute trusts with a 9-5 respiratory arterial blood gas analysis on-call system had the shortest• Other medical therapy. door-to-mask time although further investigation is required to ascertainThe aim was to evaluate whether whyprospective monitoring and audit of NIV • When NIV was started in thecould improve practice in delivering NIV emergency department thethrough the use of a treatment proforma door-to-mask time was shorter than forwith educational prompts. therapy commenced elsewhere
Case studies 11Norfolk and Norwich University Hospital NHS Foundation TrustAn integrated care model for patients with exacerbationof chronic obstructive pulmonary disease (COPD)What was the problem? • Patients are being offered aDeveloping an integrated care model for comprehensive patient-held recordpatients admitted with an acute which enables them to keep a record ofexacerbation of COPD is important for information about diagnoses,delivering high quality, holistic, patient treatment, medications, previouscentred care that is closer to the patient’s admissions, pulmonary function tests,home. The development of a local arterial blood gases, appointments andnetwork of clinicians involved in the health and social care professionalspatients’ care was seen as an essential, involved in their care. Patients areunderpinning element of this approach to encouraged to take these records to allcare. The advent of the Outcomes appointments and hospital attendancesStrategy for COPD and Asthma provided so that attending medical staff canthe impetus to redesign the way COPD make an assessment in the context ofservices were delivered at Norfolk and relevant historyNorwich University Hospital. • Closer links with the community matrons have been established through • Better management of a cohort ofWhat was the aim? regular meetings. These meetings frequent attendees / high impactThe project aim was to review the provide a framework for regular liaison service users could help to reducemanagement of patients admitted with and clinical support; enable sharing of admissions and readmissions in thisacute exacerbation of COPD, identify referral pathways and criteria and an group, however ongoing datagaps in service provision and improve opportunity for multidisciplinary collection will be required to determineintegration between primary and discussion of complex issues. the impact of changes in servicesecondary care services. Through this the Community matrons now have access provisionproject would: to electronic discharge summaries • The need for effective communication • A cohort of patients who are frequent within an organisation should not be• Reduce COPD admissions attendees and have recurrent underestimated. Open communication• Reduce length of stay admissions has been identified and plays a key part in successful working• Reduce rate of readmissions work is ongoing to liaise with relationships• Establish rapid GP access to COPD clinic community teams to target these • Involve an interested analyst at project• Establish a local COPD network people for support meetings to assist with obtaining and • A specialist COPD clinic has been analysing data. Working with a dataWhat has been achieved? established which has consultant and analyst is essential. It makes the process• The respiratory nursing team has raised specialist nurse appointments to of data collection and interpretation their profile within the admissions unit provide prompt specialist post- much simpler by increasing respiratory nurse presence exacerbation follow-up, rapid access • It is important to establish data and in the department and encouraging slots for GP / community team referrals analyse the patient pathway before referral of patients for assessment via and will provide a point of support for deciding what changes to implement in an electronic referral process the community teams. the service. This will ensure that the• Accident and Emergency (A&E) and right problems are addressed in the admissions staff can now access What are the key learning points? best way. This also helps with better electronic discharge summaries and • It is important to ensure effective understanding of the patient pathway / clinic letters which has improved access communication between all teams in process. to relevant clinical information order that appropriate patients are reviewed in a timely manner by the Contact respiratory nursing team and referred Sandra Olive appropriately to community services Respiratory Nurse Specialist Tel: 01603 289779 Email: firstname.lastname@example.org
12 Case studiesSt George’s Healthcare NHS TrustProcess redesign improves services for acute exacerbationof chronic obstructive pulmonary disease (COPD) byreducing length of stay and re-admission ratesWhat was the problem?Data from the 2008 COPD audit for therespiratory service at one NHS trustrevealed the number of patients with alength of stay (LOS) of between 4-7 dayswas higher than the national average.What was the aim?• To reduce the number of patients staying in hospital for four and seven days and to reduce length of stay• To improve the patient pathway for patients with acute exacerbation of COPD requiring hospital admissions.• To identify and resolve reasons for delayed discharge and improve discharge planning, providing support and review post discharge• To improve the patient experience• To provide integrated care.What has been achieved?The service was redesigned so that:• Closer working with key areas such as the medical assessment unit (MAU), The outcomes of this were: Improvement methodologies can identify geriatrics, and the respiratory ward bottlenecks and through effective service• Patients are seen by the respiratory • Mean length of stay was reduced from redesign productivity gains can be nurse earlier in their admission. 4.5 days to 3 days achieved without additional resources.• Daily e-mails from the acute admissions • Readmission rates within 30 days were The project requires engagement from ward outlining all patients admitted reduced from 3 per month to 2 per people in all key areas of the patient and daily attendance of respiratory month suggesting an improvement in journey / process map to eliminate nurse specialist at MDT meeting quality of care patient blockages.• Systems developed and implemented • Proportion patients seen by respiratory for data collection both manually and nurse 47.7% It is important to develop a system to electronically • Percentage of patients with 4-7 day capture and record data accurately.• Patients are reviewed, assessed, and length of stay reduced from 40% - Getting the process of data collection issued with a COPD discharge pack 22%. right early in the project will save a lot of with includes, a discharge checklist, time later on. action plan and information about their What is the key learning? condition Reductions in length of stay and re-• All patients on discharge are referred to admissions rates can be achieved through Contact the community respiratory team for integration of services and working across Samantha Prigmore follow up within 24 hours. organisational boundaries. Specialist care Respiratory Nurse Consultant delivered earlier in the patient’s inpatient Tel: 020 8725 1275 stay may reduce length of stay and Email: reduce length of stay for acute email@example.com exacerbation of COPD. Effective communication across the acute trust into the community is essential.
Case studies 13South Tyneside NHS Foundation TrustImproving the acute respiratoryassessment serviceWhat was the problem?South Tyneside has a high prevalence ofpeople diagnosed with chronicobstructive pulmonary disease (COPD)and patients in this area are more likely tobe admitted to hospital during anexacerbation of their COPD than the UKnational average. The acute respiratoryassessment service (ARAS) were given theopportunity to extend their care pathwaysfrom 1 April 2010 to provide a ‘seven dayurgent care service’ for patients with anexacerbation of COPD. The ARAS teamalready provided a Monday to Friday non-urgent care service to people with anacute exacerbation of COPD in theirhome setting working closely with theintermediate care team.What was the aim?The project aim was to reduce admissionsfor acute exacerbation of COPD at SouthTyneside NHS Foundation Trust. What are the key learning points? team has improved which has led to Effective working relies not only on the improvements in the quality of careWhat has been achieved? service provided in secondary care but offered to people with acute exacerbation• Monthly reflective practice meetings also on the committment from our of COPD. were arranged with ARAS, community community based health professional matrons and Intermediate care to teams. Regular meetings with The use of a structured approach has discuss frequent users/admissions and stakeholders and full involvement in the given all involved a clear direction and how best to manage these change process by all staff will help to staff within the team have a clear focus,• In future, the staff member responsible reduce uncertainty and maintain focus . feel valued and have been given a greater for the urgent care referrals will work opportunity to develop their skills and across the emergency department and The development of a standardised knowledge base whilst contributing to the community to maximise the impact clinical pathway of care and the use of service development. on admission avoidance reflective practice meetings with primary• By targetting GP practices the team has care colleagues have helped to increase Contact increased the numbers of direct GP their knowledge of a wider range of Pauline Milner referrals, resulting in further avoided treatment and referral pathways for Respiratory Nurse Specialist admissions. From April 2010 to July patients with COPD. Tel: 0191 404 1062 2011, this accounts for 66 admissions Email: firstname.lastname@example.org avoided and a total of 462 hospital bed Integrated working helps to build positive days relationships with other health care• By moving to a 7-day service 106 professionals, departments and weekend assisted discharges occurred organisations. Communication between between April 2010 and March 2011, primary care services such as the saving 206 bed days. community matrons and urgent care
14 Case studiesSouth Tyneside NHS Foundation TrustAdmissions avoidance through theurgent care teamWhat was the problem? What has been achieved? What are the key learning points?The nurse-led Sunderland urgent care An innovative approach to delivering • Take opportunities and think out of theteam (UCT), part of South Tyneside NHS acute home oxygen therapy was box. Initially the North East AmbulanceFoundation Trust, provides a 24 established through collaboration with Service had not been considered forhours/seven days a week service the North East Ambulance Service. oxygen provision and considerable timedelivering acute care to people in their was spent trying to negotiate withinown homes, avoiding hospital admission Near patient testing of capillary blood gas the national oxygen contract which didwherever possible. To support provision analysis in the community has facilitated not meet the needs or cost resource ofof this rapid response and assessment, a rapid assessment of the patient’s clinical the service. It was a chancestep down facility exists within the status and implementation of appropriate conversation with a director in theintermediate care structure, which also short term oxygen therapy. ambulance service that led to theincludes physiotherapy and social work. outcome that was secured Close collaboration with secondary care • Work with the local and nationalWhat was the aim? allowed the team to expand the agenda. Understand and share withThe Urgent Care Team wanted to develop boundaries around which patients can be stakeholders ongoing work such asa more integrated care pathway for safely managed in a community Quality, Innovation, Productivity andpeople with COPD across community environment. Prevention (QIPP) initiatives, practiceservices and secondary care. based commissioning group work, and During the first four months of the pilot strategies to reduce readmission inThe aim was to prevent avoidable 20 patients were initially managed at order to get senior buy inhospital admissions and reduce re- home, with continuous oxygen therapy to • Have the right people around the table;admissions for COPD in Sunderland. The correct hypoxaemia associated with their early engagement with stakeholders istarget patient group for this pilot where acute exacerbation of COPD. crucial. Do not underestimate thethose who require continuous oxygen impact and influence of bringingtherapy in the short term to assist the Of these patients, only three together all the stakeholders in onerecovery from an acute exacerbation. subsequently required hospital admission. room to discuss the patient pathwayPrevious to the pilot such patients would The team were able to prevent 17 and appropriate health contact pointshave always been admitted to secondary patients being admitted. This represents and access. It’s a slow process but wellcare. an 85% success rate in admission worth building those relationships in prevention in the target group. order to enhance patient focusedThe project would also involve: quality care delivery.• Introduction of near patient capillary The service was initiated as a six month blood gas analysis into the urgent care pilot and work is now in progress to Contact team as a resource to provide improved consider extending the service in Marie Herring patient information for safe clinical response to its success. Modern Matron, Urgent Care decision making Email: email@example.com• The collaborative development of a medical management plan so that timely, appropriate, information could assist decision making in community care and also expedite admission to hospital from the urgent care service, where this was necessary.
Case studies 15Colchester Hospital University NHS Foundation TrustAccess to specialist care for patients with acuteexacerbation of chronic obstructive pulmonary diseaserequiring hospital admissionWhat was the problem? What has been achieved?Over the past few years significant effortshave been made to improve the care for Baseline data period - June to August 2010 Improvements to datepeople with chronic obstructivepulmonary disease (COPD) in the • Number of admissions with acute exacerbation • 30 and 90 day re-admissionscommunity in the Colchester locality. It of COPD 132 12.3% and 19.8% respectivelywas identified that improvements could • 30 & 90 day readmissions 9.4% and 17.7% • Length of stay 7.2be made for patients who require a respectively • Deaths (% admissions) 4%hospital admission for acute exacerbation • Length of stay 10 days • % patients treated onof COPD in particular around access to • Deaths (% admissions) 7.8% respiratory ward 57%specialist care as Colchester Hospitals • % patients treated on respiratory ward 47%University Foundation Trust had notperformed well in this field in the 2008National COPD Resources and Outcomes • Introduced daily (Monday - Friday) What are the key learning points?Project (NCROP) study. consultant review of patients with • Early specialist review may impact on COPD which has reduced length of stay patients’ length of stay for acuteWhat was the aim? by 0.4 days. This will be continued with exacerbation of COPDThe project aim was to improve the daily ward rounds for COPD in the • An inpatient care bundle for COPD mayproportion of patients with an acute Emergency Admissions Unit and the be an effective way to drive up theexacerbation of COPD who receive Accident and Emergency department. quality of patient care, reduce length ofspecialist care in hospital and within the • Developed and implemented an in- stay and reduce readmissions forsix weeks post discharge, and evaluate patient care bundle, which was exacerbation of COPDthe impact of this service change on adapted from North West London • Data has been a constant challenge.length of stay, re-admission rate and Hospitals NHS Trust to ensure all Whilst data drives change, accessingpatient mortality. patients with COPD receive high quality the relevant data can be difficult. By care talking to the organisations leaders • A discharge care bundle will be and the information department the developed as a next step from the project team in Colchester found that project work much of the data was already being • Developed a written self management collected, albeit in a different form. plan in collaboration with community • If it works somewhere else then try to colleagues, which is given to all focus on implementing it rather than patients on discharge from the chest changing the innovation e.g. care ward. This will be extended to include bundles. If it has worked elsewhere ask patients in Accident and Emergency why it is not being done already rather (A&E), the emergency assessment unit, than why it can not be done! on other wards and patients being managed in the community Contact • Developed a patient experience Peter Hawkins questionnaire to help to evaluate the Respiratory Physician quality of the patient’s experience and Email: indentify areas for further firstname.lastname@example.org improvement. Lianne Jongepier Respiratory Services Manager Lianne.Jongepier@acecic.nhs.uk
16 Case studiesNorth East London, North Central London and EssexHealth, Innovation and Education Cluster (HIEC)Implementing the use of self management plansWhat was the problem? What has been achieved? What are the key learning points?There are high levels of chronic • Each Trust developed local strategies in Patients felt more ‘empowered’ to takeobstructive pulmonary disease (COPD) order to distribute the self control of their COPD as they whereadmissions and re-admissions in the East management plans and rescue given the ‘responsibility’ to manage anLondon Acute Hospitals. This has been medications. These included respiratory acute exacerbation and after the selfhighlighted as particularly prevalent/high specialist nurses, pharmacists and management advice had more awarenessdisease burden across North East London, respiratory outreach staff of the signs and symptoms of an acuteNorth Central London and Essex. Five • Each Trust was able to continue to use exacerbation.acute Trusts in the sector agreed to take its own patient information andpart in the project: Homerton University protocols for prescribing in an acute The cultivation and development of aHospital Foundation Trust; Barts and the exacerbation. Those Trusts without network of healthcare professionalsLondon Hospital (The Royal London and existing self management / action plans across the local boroughs enabled theLondon Chest); Whipps Cross University were able to learn from others project team in each trust to overcomeHospital; Basildon and Thurrock Hospital examples barriers and resolve issues relating toNHS Trust and Newham University • 200 patients received discharge implementation of the self managementHospital NHS Trust. information and rescue medications in plans in an effective and timely manner. a six month periodWhat was the aim? • Through the success of the selfThe five hospitals had varied strategies in management plans and effective Contactplace which aimed to avoid admission for engagement with primary care Matt Hodsonacute exacerbation of COPD, but there colleagues, some PCTs have adopted COPD Nurse Consultant,wasn’t a unified regional strategy in place the self management plans for patients Homerton Hospitals NHS Trustfor the distribution of self management in primary care. As a result, a consistent Email:plans and rescue medication packs action plan has been developed email@example.com(antibiotics and steroids) to all patients between Barts and the London anddischarged with COPD. The project aims Tower Hamlets PCT. Hasanin Khachiwere: Highly Specialist Pharmacist – Specialist Medicine• To increase the distribution of self Barts and the London NHS Trust management plans and rescue packs to Email: more than 80% of all patients hasanin.khachi@bartsandthelondon. discharged following a COPD admission nhs.uk• To reduce re-admission rates within 30 days of discharge• To assess the effect of self management plans and rescue medications on re- admission rates across this patch.
Acknowledgements 17AcknowledgmentsNHS Improvement - Lung would like to thankall national improvement project sites fortheir hard work and dedication to improvequality and care for people with COPD, andfor their contributions to this document.In addition, the following people haveprovided a source of expertise and supportand their help is gratefully acknowledged:Phil Duncan, Director,NHS Improvement - LungCatherine Blackaby, National ImprovementLead, NHS Improvement - LungOre Okosi, National Improvement Lead,NHS Improvement - LungHannah Wall, National Improvement Lead,NHS Improvement - LungZoë Lord, National Improvement Lead,NHS Improvement - LungAlex Porter, Senior Analyst,NHS Improvement - LungFor more information please contact:Catherine Thompson, NationalImprovement Lead for Transforming AcuteCare in COPDcatherine.firstname.lastname@example.org
18 ReferencesReferencesOutcomes Strategy for People with Chronic Obstructive Pulmonary Diseasei(COPD) and Asthma; London; Department of Health Royal College of Physicians Clinical Effectiveness & Evaluation Unit (2008) Report ofiiThe National Chronic Obstructive Pulmonary Disease Audit 2008: clinical audit of COPDexacerbations admitted to acute NHS units across the UK; London; Royal College ofPhysicians. Purdy S (2010) Avoiding hospital admissions. What does the research evidence say?;iiiLondon; The King’s Fund. Available on-line at www.kingsfund.org.uk British Lung Foundation, British Thoracic Society (2010) Ready for Home?; London;ivBritish Lung Foundation.vNHS Improvement (2008) Transforming Inpatient Care Programme for CancerPatients – The Winning Principles; Leicester; NHS Improvement.