Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit The ingredients for success


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Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit The ingredients for success

  1. 1. NHSCANCER NHS Improvement LungDIAGNOSTICS Managing exacerbations in chronicHEART obstructive pulmonary disease (COPD): A secondary care toolkitLUNG The ingredients for successSTROKE
  2. 2. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successContentsBackground 4How to use the toolkit 6Available resources 7Non-invasive ventilation (NIV) 13PrinciplesCheck listCase studyResourcesAccess to specialist and clinical decision making 20PrinciplesCheck listCase studyResourcesCare bundles 28PrinciplesCheck listCase studyResourcesPulmonary rehabilitation 37PrinciplesCheck listCase studyResources 3
  3. 3. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success Background In 2011, the Department of Health published an Outcomes Strategy for Chronic The Outcomes Strategy for COPD and Asthma was published during a period Obstructive Pulmonary Disease (COPD) and Asthma and this was followed by of financial ‘belt tightening’ for the NHS, with an expectation that £20bn the NHS Companion Document which helped to translate policy into practice. savings would be generated over a five year timescale. COPD is the second most common cause of emergency admission to hospital, with about 100,000 The Outcomes Strategy identified that all people with COPD, across all social admissions for acute exacerbation every year at a cost of £236.6m. There is groups, should receive safe and effective care, which minimises progression, significant national variation in the nature of these admissions which may enhances recovery and promotes independence. During acute exacerbation of suggest inefficiency and waste in processes and services: COPD the Outcomes Strategy advocated a structured approach to hospital • There is four fold variation in admission rate between the highest and admission, with specialist care and proactive post-exacerbation follow up. lowest PCT areas in England. • Mean length of stay was 6.6 days (2011/12), but there is two-fold The NHS Companion Document highlighted three key approaches which could variation between best and worst PCT areas. be adopted to help people with COPD recover from their acute exacerbation: By reducing unwarranted variation in performance against these national i. Provide the right care in the right place at the right time: agreeing locally a measures the NHS in England could release capacity and resources, pathway of care for acute exacerbation, including timing and location of simultaneously improving the quality of care for patients: initial assessment and delivery of care (hospital, GP surgery/community • If the length of stay for PCTs with an average length of stay above the mean care, or in the individual’s own home). was reduced to the mean, 65,000 bed days would be freed, which would ii. Ensure structured hospital admission: ensuring people with COPD are seen be a reduction of 10% of bed days, with a financial saving of approximately by a respiratory specialist on admission to hospital and receive key £14 million. interventions – like non-invasive ventilation (NIV) – promptly. • If all PCTs could reduce their average length of stay to the level of the PCTs iii. Support post-discharge: ensuring people who have been admitted to in the top quartile, 146,000 bed days would be saved, a 21% saving, with hospital with a COPD exacerbation are supported back into the community financial saving of £32 million. to prevent readmissions. NHS Improvement – Lung worked with a number of sites to develop alternative approaches and models of care to improve the services available to patients. This toolkit has been designed to share the learning and show how to make change happen.4
  4. 4. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successWhere What they did ImpactYork • Implemented a new Early Supported Discharge (ESD) Team • 13 patients seen by Early Supported Discharge (ESD) per month • Implement a COPD discharge care bundle • Patients discharged home on average 1.43 days earlier • Increased access to specialist care. • Access to respiratory specialist improved from 1.27 days to 0.97 days • 100% of patients seen by specialist, 80% being seen within one day • Estimated savings of £40,000 from bed day reductionWolverhampton • Introduced respiratory ‘in-reach’ team to admissions ward • Increase in COPD admissions by 33% • Implemented a respiratory HOT clinic • Mean length of stay decreased from 8.56 to 7.07 days (median remained at 4 days) • Moving toward seven day respiratory physician cover. • 50% of Hot Clinic appointments avoided admission, approximately 48 patients a year • Estimate 48 avoided admissions. £106,000 per annum.Leicester – • Implemented a COPD discharge care bundle • Increase in proportion receiving specialist careGlenfield • Redeployed supported discharge team to increase front of • 69% of patients received care bundle house contact and access to respiratory specialist. • Improved quality of care without increased cost. Trust on target to achieve £960,000 CQUIN.Worthing – • Worked across the whole health economy to improve • Readmissions rate has decreased by 22 to 19%Eastbrook integration of services • The length of stay has reduced by 1.6 daysWard • Introduced new ways of working in the respiratory team to • Total admissions have increased from 651 to 727 increase access to specialist care and clinical decision making • Reduction in length of stay estimated savings saving £150,000. • Improved the discharge process.North Tyneside/ • Implemented a COPD discharge care bundle • 39% increase in number of patients seen by the respiratory nurse specialist teamNorthumbria • Redeployed supported discharge team to increase front of • 48% of current smokers given nicotine replacement therapy and 50% referred to smoking house contact and access to respiratory specialist. cessation services during the inpatient stay for exacerbation of COPD • 92% of patients received rescue medications on discharge - this was associated with a reduction in readmissions of 50% in some patient groups • Reductions in mean length of stay and readmissions at 30 and 90 days for acute exacerbation of COPD on all wards where the care bundle was introduced • Mean non-invasive ventilation door to mask time <3 hours. 5
  5. 5. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success How to use the toolkit This toolkit will provide additional help for those specifically wanting to improve Getting started their inpatient services for people with an acute exacerbation in chronic obstructive pulmonary disease (COPD). Before implementing a solution and changing your service, it is essential to This toolkit will focus on: understand your current system by mapping the process, collecting and analysing the service data, along with asking patients and staff for their • Non-invasive ventilation (NIV) views: • Access to specialist and clinical decision making • Care bundles • The toolkit also includes tips on how to organise your projects • Pulmonary rehabilitation. Download First steps towards service improvement: a simple guide to improving services at: ServiceImprovementGuide.pdf Each section will cover: • The key principles - what the service should look like. • A check list designed to make you think about your existing service and suggested actions with space for you to write notes as you work through the toolkit. • Case study examples have been provided to show what the outcomes have been from sites that have implemented change in their service and other resources that you may find helpful. • The management of COPD should be integrated across primary and secondary care and we would strongly advise you to also refer to the Primary Care Toolkit.6
  6. 6. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successAvailable resources RESOURCESUnderstand ther methodology and tools PRIMARY CAREavailable for service improvement. SECONDARY CARENHS Improvement has worked with teams around the country over the lastthree years to provide tried and tested examples of improvement for TOOLKITSmanaging chronic obstructive pulmonary disease as a long term condition. MANAGING COPDWe have developed a suite of resources to help you improve your services INTERACTIVE PATHWAYwhich can all be found at: SUCCESS HOW TO MAKE A DIFFERENCE TO COPD AND ASTHMA SERVICES Action - It is recommended that you look at the DATA FOR CHRONIC OBSTRUCTIVE PULMONARY resources available starting with the First steps towards DISEASE AND ASTHMA: quality Improvement - A simple guide to improving MAKING A REAL DIFFERENCE services. This guide will give you a step by step guide to undertaking your own improvement project. It willprovide you with the framework for developing, testing and INTEGRATEDimplementing change following a five step improvement approachto provide a systematic framework which includes: CARE DVD• Preparation - define your project aims and objectives and FIRST STEPS IN collecting baseline data. MANAGING COPD• Launch - Developing project and communication plans and identify an executive sponser.• Diagnosis - understand the current process and define the real problem.• Implementation - test and measure - Plan, Do, Study, Act (PDSA).• Evaluation - Capture the learning. 7
  7. 7. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success Model for Improvement What are we trying to accomplish? The Model for Improvement How will we know that a This model for improvement change is an improvement? MANAGING CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AS A LONG TERM CONDITION provides a framework for IDENTIFY RIGHT PATIENTS What changes can we make that will AND INTERVENE EARLY developing, testing and result in the improvements that we seek? FINDING OUT RESOURCES PATIENT INFORMATION PHYSICAL ACTIVITY implementing change that leads DIAGNOSE PATIENTS EARLY AND ACCURATELY SERVICE IMPROVEM TOOLS ENT DATA PREVENTION ACROSS THE WHOLE PATHWAY NS KEY ACTION PLA to improvements. SUPPORT SELF MANAGEMENT CHALLENGES CHECKLIST CASE STUDIES CESSATION SMOKING SEVEN DAY SERVICES LIVING WITH... PROVIDE CLINICAL AND CO-MORBIDITIES First steps to improving LIVING WITH... COST EFFECTIVE TREATMENT HOME OXYGEN PATIENT SAFETY chronic obstructive pulmonary REVIEW AND SUPPORT PATIENTS MEDICINE AWARENESS S disease (COPD) care ACT PLAN RAISING MANAGE MENT GENCY EMER EN MANAGE EXACERBATIONS OXYG This publication comprises ! WHEN THINGS GO WRONG IN PRIMARY CARE potentially the most significant MANAGE EXACERBATIONS PULMON NUTRITION IN HOSPITAL REHABI ARY STUDY DO TED INTEGRA D LITATIO N quality factors along the COPD ADVANCE CARE PLANNING CARE DV pathway, but which are frequently TOWARDS THE END PROGNOSTIC INDICATORS missed. They are a basic guide to SUCCESS PRINCIPLES the key principles every area should be adopting to provide good COPD care – if you do nothing else, start with these ten things and Action - It is recommended that make sure they are in place for all your you also look Managing COPD as patients. The publication offers hands on a Long Term Condition interactive advice to health professionals who provide pathway. care and services for COPD patients as well as providing a helpful starting point for those new to commissioning COPD services, or for a Success Principles: How to make a real stocktake of a local respiratory service. difference to COPD and asthma services A series of mix and match cards providing practical examples of changes you can make and how to implement them to improve care and quality at every step of the pathway for patients with COPD and asthma. Case studies from all the sites can be found at:
  8. 8. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successPreparation - Find out where to start by asking What is the problem? Make sure you have understood what is really going on and identified thethe right questions cause, rather than the symptoms, of the problemWhy might you want to improve things? What does the data tell you?Do you have: You need to know how well are you doing things now; and how much better• Higher than average length of stay for acute exacerbation of COPD? can you get, rather than have you met a target for performance management.• High numbers of emergency admissions? Data helps you to target your improvement, helps you identify where it will• High readmission rates? have the most impact (pareto charts) and also shows you what is happening• High cost, poor outcomes for COPD in your area? over time (statistical process control (SPC) charts).• Complaints about care?• Long waiting times to access pulmonary rehabilitation? Data can help you answer these questions: • How does what you are doing now compare with;Where should you start? • last year?Start with the problem, not the solution: do not assume that the reason is • what others are doing?clear or that there is an obvious answer. • What do patients think of the service being provided? • What do staff think of the service they provide?‘‘ • Who gets the best results e.g. which speciality or consultant team has the lowest mortality, length of stay or readmission rates? • Where are you spending most? Achieving most? Wasting most? • How good could you be?For every complex problem For more information about using data forthere is an answer that is clear, improvement download the data guide at: ’’ managingcopd/Data_Guide.pdfsimple - and wrong.H.L. Mencken 9
  9. 9. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success Understand your current processes to identify your YOU NEED TO PROCESS MAP YOUR potential for improvement CURRENT SERVICE • Do you know what really happens every day, at every point? How? In any system, what people should do, think they do, or say they do, may not be the same as what they actually do most of the time. To improve things, you need to find out: • what happens? • why it happens? • how long it takes? • where it goes wrong? • what would make it work better? Map the process with those who know it best to understand what really happens, 80% of the time. When you have mapped the system, identify what the sticking points are • Where is there waste of time, resources, effort? Duplication? Risk? • Who does what? Who else could/should do it? • What gets in the way? • How long do steps take? Why? • Can you eliminate, combine, simplify or change the order of steps to make things flow better? For more information on process mapping download First steps towards service improvement: a simple guide to improving services at:
  10. 10. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successDefine what improvement will beBased on what the data has told you and what your process map has revealeddecide what your improvement aim is. What will you achieve? How much?By when? Compared to what? And why?Understand what is underlying the problemUse a tool that can help you to analyse the problem. In York, patients werebeing discharged late in the day meaning that new admissions were waiting toaccess beds on the specialist ward. The fishbone/cause effect diagram was usedto explore some of the reasons for this. PLANT PROCEDURES MEASUREMENT Bed space not EDNs a nursing priority cleaned quickly enough not a doctor priority Discharge lounge therefore not available staffed 8-6 only Discharge time on IT No senior medical staff system not accurate routinely available Transport arrives Wednesday and Thursday Travelling consultants on ward before TTO generate ad-hoc work drugs with patient Transport not reliable - comes to early/late/ not at all Ward round on Monday and Friday Patients moved from ward prior Key services not seven days to discharge (e.g. day before) OT not on every ward Pharmacists have two hours to see 30 patients Bloods not done until 11.30am Every rehab unit has different Junior doctors jobs take about 4 hours referral and transfer process work after ward round finished Pharmacy closes at 5.15pm 02 in taxis for home visits a problem Junior doctors start at 9am and not before POLICIES PEOPLE 11
  11. 11. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success Decide what to tackle first Manage your project Tools such as the prioritisation grid can help determine where to start, by To succeed you will need to actively manage your project. Key elements include: identifying what you can achieve quickly and what may take longer to plan • Align your project with local, corporate and / or national objectives and implement. • Identify a project manager • Engage stakeholders who are key to delivery and those who are interested Project portfolio • Have a plan and actively monitor and report progress. Sustain the improvement VERY HIGH • Share learning and feedback with your stakeholders to generate momentum. TIME WASTERS QUICK WINS STRATEGIC • Support them to maintain the improvement with ongoing review, training, measurement and feedback. HIGH • Your initial improvement may be focussed on tackling a backlog of work errors, but you also need to consider what to put in place to prevent the same problem emerging again over time. CHANCE OF SUCCESS MEDIUM Where do I start? Managing exacerbations of COPD well to optimise outcomes, experience and LOW use of resources is a complex process dependent on many different factors. All the elements in this toolkit will be relevant to your work to a greater or NO HOPERS lesser extent. VERY LOW GAMBLES We worked with five sites who covered a range of interventions. The broad learning from the projects have been included in the Success Principles, however, this tool kit provides a step by step guide to implementation for VERY LOW LOW MEDIUM HIGH VERY HIGH four key areas. SIZE OF BENEFIT Use a tool such as this prioritisation grid to help identify which of the ideas (PDSA cycles) should be tried first.12
  12. 12. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successNon-invasiveventilation (NIV)Non-Invasive Ventilation (NIV) is an effective treatment for the management of PRINCIPLESacute hypercapnic respiratory failure in COPD and has been shown to reducemortality and improve patient outcomes. • Non-invasive ventilation (NIV) should be delivered within three hours of admission for those patients who require itAcute NIV services are widely available in acute hospitals throughout the (An Outcomes Strategy for COPD and Asthma, Departmentcountry, however data from the ERS COPD audit in 2012 suggest that patient of Health, 2011).outcomes for COPD patients receiving NIV in the UK in routine clinical practice • NIV services should have a pathway that is consistent 24may not be as good as those initially demonstrated in clinical trials. There maybe a multitude of reasons contributing to this, however, data from one NHS hours, seven days a week.Improvement Lung multi-centre project team in 2011 suggested that mean • One of the most significant delays in initiating non invasivedoor to mask times for NIV were in excess of five hours. ventilation (NIV) is inaccurate or slow clinical decision making. Rapid and correct identification of patients who areTimely access to NIV is important during an acute exacerbation of COPD and itis important that clear pathways and processes exist to enable this to happen. appropriate for NIV is essential; availability and location of equipment rarely contribute to significant delays in therapy, but this should not be presumed to be the case in every organisation. 13
  13. 13. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CHECK LIST Review your existing pathway Process map the pathway. The process map may start as part of Prospectively recorded data will be more accurate and a higher level COPD pathway mapping, but to implement reliable than retrospective time-point data. effective improvement work on the NIV pathway a much lower level of mapping will be required Identify the key bottlenecks and delays It is important to understand who is involved in every step of A tool such as statistical process control (SPC) or a the process and what each of the steps in the pathway involves patient pathway analyser (available FREE online to allow accurate identification of the bottlenecks and delays. at: - registration required) can be used to identify After mapping it is important to collect data on each step of where in the pathway the problems arise. SPC the pathway for analysis. allows the user to see which elements of the pathway always happen in a regular, timely manner (SPC refers to this as a Measure the time from the patient arriving in the emergency process that is ‘in control’) and which elements display large deparment or admissions unit (whichever is the first access amounts of variation. point and you may need to do both) until the NIV is applied and record timings for the following stages: NOTES Time of admission Time of medical assessment Time of arterial blood gas measurement Time of chest xray Time of decision for NIV (this may be the time that the NIV nurse/physio is called) Time of NIV team assessment Time NIV mask applied.14
  14. 14. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCHECK LISTProblem solve bottlenecks and delays From the time points, identify which steps take the longest time, the main delays in accessing NIV, and where there is potential to change. Undertake some root cause analysis to determine why it happens. This might take the form of notes review for each outlier on the charts or in-depth scrutiny of a particular pathway step that causes concern or delays. Use Plan Do Study Act (PDSA) cycles to try changes to address the delays, measuring continuously to determine whether there has been any improvement. Ensure any steps that are changed apply to the pathway in a way that is achievable out of hours as well as during normal working hours, so that further variation is not being introduced into the pathway.Implement new 24/7 pathways Ensure all people involved in the pathway are aware of the changes and engaged with the process of implementing them. Continue to monitor the pathway to ensure the standards remain high. 15
  15. 15. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success EXAMPLES OF SPC Admission to assessment chart Chart 2: The first time step recorded was the time taken from the CHARTS patient’s admission to being assessed by a doctor. The mean time is 26 minutes but there is significant variation in the process. The charts 1 to 6 represent the information for 54 consecutive patients for door to mask time, and then the data broken down into the pathway steps. Non-invasive ventilation (NIV) door to mask chart Chart 1: Time from admission to application of NIV for consecutive patients. The mean time is 144 minutes, but with significant variation. Medical assessment to ABG chart Chart 3: Time from medical assessment to the arterial blood gas being analysed. The mean time is 18 minutes, but with significant variation.16
  16. 16. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success ABG to non-invasive ventilation chart Chart 5: Time from the arterial blood gas analysis to the request for NIV being placed with the NIV service. The mean time is 54 minutes and represented the longest step in the pathway in this example.Medical assessment to CXR chartChart 4: Time from medical assessment to the patient having the chestxray completed (essential prior to the commencement of NIV, and as anaid to clinical decision making). The mean time is 37 minutes and whilstthere is some variation in this pathway step it is less than for other steps. NIV service contact to NIV mask application chart Chart 6: Time from referral for NIV to application of the mask and commencement of therapy. The mean time is 43 minutes, with significant variation. 17
  17. 17. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CASE STUDY Northumbria Healthcare NHS Foundation Trust conducted a piece of improvement work on their Analysis of each pathway step indicated that the acute non-invasive ventilation (NIV) service as part of longest step in the patient’s pathway was the time a wider improvement project for acute exacerbation from the arterial blood gas (ABG) being taken and of COPD. analysed, to the decision being made to use NIV and the NIV referral being made. The mean time for this Data was collected (see SPC charts on page16 and 17) step was 55 minutes, with significant variation and for each step of the pathway in order to identify with 12 patients waiting longer than an hour for a problems and bottlenecks which caused delays in the referral to be made for NIV after the ABG had been patient receiving timely NIV. To facilitate the analysed. Notes audit demonstrated that these delays collection of data the recording of the time for each were due to delays in clinical decision making or to pathway step was integrated into the patient incorrect interpretation of ABG findings. documentation for NIV, resulting in 51 out of 54 complete sets of data. The respiratory team addressed errors in clinical decision making through a programme of Analysis of their data indicated a mean door to mask one-to-one educational sessions. Individual feedback time of 144 minutes, which is well within the target was provided, delivered in a productive and timescale of three hours. However there was supportive manner, and led to improvements in significant variation within the process and 12 out clinical care. of 54 patients waited in excess of three hours to receive NIV.18
  18. 18. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successResourcesFor more details read the in-depth case studies which are available is also information about the Respiratory Atlas of Variation whichdemonstrates unwarranted variation in the use of NIV during exacerbation ofCOPD, web links to some published evidence about NIV service delivery andlinks to improvement tools and techniques in the NHS Improvement System. 19
  19. 19. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success Access to specialist and clinical decision making There is also evidence that increasing the frequency of consultant ward rounds, for example changing from twice weekly to twice daily, reduces average length of stay by half a day with no increase in mortality or readmissions. • Early discharge schemes or hospital at home can prevent hospital readmissions (COPD Commissioning Toolkit). Decisions are made by using a number of factors e.g diagnosis, intervention, interaction and evaluation not forgetting patient’s choice and evidence based PRINCIPLES literature. The Outcomes Strategy clearly identifies the importance of: • Make sure every patient admitted for exacerbation of Helping people to recover from episodes of ill health or following injury COPD is seen by a respiratory specialist within 24 hours of admission. • Provide the right care in the right place at the right time • Get patients better so they can go home safely and • Ensure structured hospital admission • Support post-discharge at the right time. • Deliver the right care at the right time in the right place. Specialist care is more likely to result in the patient receiving the right treatment • Clinical decision making should be made on a daily by having early interventions and a clear management plan. basis to promote proactive case management. • Have clear and effective referral mechanisms in place. Specialist care during the inpatient stay will help identify the most appropriate follow up care post discharge e.g. referral for pulmonary Agree clinical protocols or guidelines to support rehabilitation or follow up with the community respiratory team and can also decision making in the patient’s pathway. ensure the patient has had confirmation of their diagnosis and a review of • Ensure consistency in care being delivered. the long term management of their condition. • Share local data to identify problems and improve patient’s outcomes. Outcomes have been shown to be improved in hospitals where specialist respiratory physicians are present, however a recent audit showed that only • Ensure clinical decision making is a collaborative 50% of people admitted with an acute episode of COPD were under a process between teams of health care professionals respiratory team at the time of discharge from hospital (National COPD and with the patient. audit 2008).20
  20. 20. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCHECK LISTAccess to specialist to ensure a structured hospital admission: Patient assessment: more than 25% of patients admitted withearly access to specialist respiratory care, prompt management exacerbation of COPD have not been diagnosed with COPDof COPD and co-morbidities in line with the NICE guidelines Do you check every patient has had a quality assured Do you have a structured approach to ‘finding’ or referring diagnosis – spirometry test? patients admitted with exacerbation of COPD? Do all patients have pulse oximetry within an agreed time Are all your patients reviewed by a specialist within frame on admission? 24 hours? Do all patients have an arterial blood gas if necessary? Have you process mapped? Is this done within an agreed time frame on admission? Have you followed a patient on admission? Managing the appropriate length of stay Consider daily ‘in-reach’ by a respiratory physician or other Have you looked at the length of stay by the day member of the respiratory team into the medical admissions of admission. unit or emergency department. Does your data show peaks in length of stay on certain days? Consider patients alerts e.g via electronic PAS system/phone alerts. Have you identified what is different about these days? Do you have a checklist or care bundle in place? Who makes the decision that patients are able to go home? What is your process to ensure prompt assessment on Do you have an agreed discharge criteria? admission to hospital, including blood gas analysis and provision of NIV within one hour of decision to treat being Do you consider planning for discharge on admission? made, where clinically indicated. Arterial blood gas and acid base balance analysis can contribute significantly to Do you have nurse led discharge? managing patients who are in respiratory failure and the effectiveness of any treatment? Can patients be discharged at the weekend? Have you audited your current practice? 21
  21. 21. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CHECK LIST Clinical decision making - what is your process? Do you have daily ward rounds? If not why not? Do you have agreed clinical guidelines and protocols for Have you tried virtual ward rounds /paper ward rounds/board care coordination? rounds? Are COPD patients frequently admitted to wards other How do you record outcomes of your ward round. eg. than respiratory wards? sticker/stamp in notes? Do you know the reasons for this? Do your ward rounds include members of the multidisciplinary team? Have you contacted your IT department for your local data? How long does it take for the outcome of the decision to be implemented. Have you process mapped the time it really takes Have you involved your bed manager? to see how things could be done differently? Do you have multidisciplinary team meetings? Ensure the respiratory ‘specialist’ (e.g. physician, nurse or physiotherapist) has the level of competency, to know what range of interventions is required) NOTES Do you have agreed clinical guidelines or protocols to support clinical decision making in the patient pathway? Do you have agreed clinical guidelines or protocols for pathways for people with complex needs and comorbidities? Do you have agreed clinical guidelines and protocols for social care and other community services?22
  22. 22. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCHECK LISTSeven day working: Ensure that the respiratory service operatesover seven days so that patients can access specialist care wheneverthey are admitted, including weekends and holidays Do you have seven day working? Do you have a discharge lounge that you could use? Compare numbers of admissions and discharges by day of the Do you use your discharge lounge as much as you could? week. Do you discharge as many patients each day at the weekend as you do between Monday and Friday? Do patients know who to contact if they have a problem at home? Compare the number of admissions by the time of day. Know when your peak admission and discharge times occur. Could your Do you have mechanisms in place to support patients at discharge time move earlier in the day? home if they have a problem? Process map your pharmacy distribution of discharge Do all your patients receive follow up within two weeks? medications to fit with your peak discharge times to prevent patients having to wait for tablets. What is your follow up process: who, when and where? Have you got good links within the community to ensure patients are able to go home with support? NOTES How do you communicate with GPs so they know when patients have gone home? Do you have a process to contact patients at home to provide support for early discharge? 23
  23. 23. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CASE STUDY NHS Improvement has worked closely with a number sites Poor clinical decision making due to lack of specialist looking at ways to improve the respiratory pathway for patients knowledge was the main delay identified in patients accessing with COPD. Timely clinical decision making can make a non-invasive ventilation (NIV). Northumbria Healthcare NHS significant impact on quality improvement, efficiency and the Foundation Trust improved their access time to less than three inpatient experience, but often requires a change of mind set, hours (see case study on page 18). practice, system and behaviour in order to gain the benefits. Within six months University Hospitals Leicester NHS Trust has Reduction in length of stay seen an increase from 5% to 100% of patients receiving self- • Proactive clinical decision making management plans. Providing more respiratory specialist nurse • Effective use of bed capacity support whilst the patients are in hospital has reduced the • Valuing patient’s time support required in the patient’s home following discharge. This • Enhance clinical governance and reduce risk. has released the respiratory nursing team’s time to see even more inpatients, with no increase in readmission rates. Patients The Outcomes Strategy for COPD and Asthma clearly are more confident to self- management and know when and how identified that: to seek help. • People with COPD, across all social groups should receive safe Royal Wolverhampton Hospitals NHS Trust were fundamental in and effective care, which minimises progression, enhances the development of a Respiratory Action Network (RAINBOW) recovery and promotes independence. which has looked at a number of interventions along the patient • People who are admitted to hospital with an exacerbation of pathway to improve care for patients. They introduced COPD should be cared for by a respiratory team, and have respiratory in-reach where respiratory physicians would access to a specialist early supported-discharge scheme with proactively see all respiratory patients on admission, improving appropriate community support. the clinical decision making process at the earliest opportunity. This resulted in an increase in patients being discharged earlier Notes reviews and continuous monitoring of data are a good way with the necessary interventions and support to return home of identifying how effective your improvements have been. In sooner. York Teaching Hospitals NHS Foundation Trust, 80% of patients were seen by a specialist within 24 hours and by implementing an early supported discharge programme, mean LOS has reduced by 1.5 days per patient.24
  24. 24. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCASE STUDY Number of COPD admissions by length of stay Percentage patients seen by a specialist on Eastbrook WardA HOT clinic was also introduced where patients could bereferred to be seen by a respiratory physician. This avoided 46unnecessary admissions. Early data suggests that only 11% ofpatients referred to the HOT clinic required admission. Thisservice is now being extended to seven days a week.Eastbrook ward in Worthing Hospital (Western Sussex NHS Trust)reduced patient length of stay by one day. Contributing factors By changing the way the team worked the average length of stayincluded improved clinical decision making. Improved patient reduced from 9.8 days to 9.1 days and readmissions fell fromflow meant that more patients were admitted to the respiratory respiratory consultants now flex their working to review all newward, allowing more patients to be under the care of a respiratory patients on consultant ward rounds, and to have ward rounds onphysician. The respiratory nursing team also used an admission four rather than just two days of the week.proforma/safety check list to ensure adherence to the NICEguidelines. A new discharge form ensures that GPs are informedof all patients’ admissions to hospital in a timely manner. 25
  25. 25. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CASE STUDY The respiratory nurse specialists now cross cover each other and Discharges by day of the week run a ‘virtual respiratory ward’ for non-Eastbrook patients. An electronic tagging system was adopted allowing an efficient way for the nurse specialists to identify respiratory patients who had been admitted. They improved their patient flow by strengthening the discharge process, and improved multi professional working by including consultant presence at ward ‘social meetings’. They also introduced bi-monthly cross organisational COPD multidisciplinary meetings to allow joint protocols to be agreed for high impact users with phone calls to patients three days post- discharge resulting in a 6% reduction of readmissions. By looking at the data on discharges by day of week and time of day, they identified fewer discharges occurring on Wednesdays and at weekends. Proactively managing patients increased discharges on these days. By moving discharge times earlier in the day they have benefited patients and staff.26
  26. 26. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successResourcesThe Royal College of Physicians has a useful website outlining the questionsthat need to be considered for healthcare delivery over the next 20 years.The site has a section that focusses on ‘People’ and asks questions aboutthe right mix of generalist and specialist KIng’s Fund has a a publication called Avoiding Hospital Admissions (2010).The document discusses the benefits of disease specific, multidisciplinary casemanagement and early senior review in A& 27
  27. 27. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success Care bundles Such an approach can reduce re-attendances and readmissions. Several NHS organisations have successfully used COPD care bundles to help implement some of these interventions. Care bundles and checklists can be valuable tools for improving the quality and safety of patient care, and ensuring standardisation of care i.e. that all patients receive the core interventions that are appropriate for their condition. Many PRINCIPLES examples are already in use in the NHS and have been successful in reducing infections (e.g. the sepsis care bundle and ventilator care bundle) and reducing A good admission for acute exacerbation of COPD would ensure every mistakes in surgical interventions (e.g. the safe surgery checklist). patient receives high quality care that addresses the key components of long term condition management in COPD. This would typically include: What is the difference between a care bundle and a checklist? Care bundles were developed by the Institute for Healthcare Improvement to • Early (within 24 hours) and on-going access to specialist help healthcare providers more reliably deliver quality patient care. The care. components within an individual care bundle do not represent advances in patient care, rather they are accepted best practice and have been • Timely and appropriate access to non-invasive ventilation. demonstrated to make a difference to patient outcomes. The point of a care • Confirmation of diagnosis. bundle is to make sure that these elements of care are delivered uniformly and • Ensure medication is optimal and appropriate to disease consistently for every patient. Each care bundle is usually made up of three to severity. five evidence based interventions. • Advice on stopping smoking and referral for support A checklist can be a very important and reliable way to improve patient care. A to do this. checklist may contain many items, and they may not all be evidence based • Being shown correct inhaler technique. interventions but they are all important and need to be done reliably, uniformly • Referral for pulmonary rehab within two weeks of discharge and for every patient, every time. from hospital. • Advice on how best to manage future exacerbations to How do care bundles work? They work by ensuring standard work, facilitating ownership and responsibility avoid secondary care admission. for making sure each element is completed to make sure each element of care • Follow up with an appropriate professional within is delivered. two weeks.28
  28. 28. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCHECK LISTBe clear about what it is you are trying to achieve Ensure clarity about the aspect of patient care that is to be Consider how you will measure its implementation and improved before starting to develop the care bundle, otherwise completion of each component – these requirements may it will be difficult to agree on the right components to include. influence the physical design of the bundle. For example the bundle may address the admissions process or the discharge process. One bundle cannot address both as it Engage the help and support of other people in the trust would become too complex and difficult to administer. who may have implemented care bundles previously e.g. team who introduced venous thrombo-embolism bundle, Tools such as driver diagrams / action effect diagrams can help to service improvement/service transformation team. determine the core elements that should be included in the bundle or checklist. Does the information in the bundle need to be communicated to health care professionals outside of Will the outcomes of the care bundle / checklist be linked to a your organisation? Consider how this will be done. local CQUIN? This may influence monitoring requirements and hence the design. Identify any elements of the care bundle that are time critical e.g. access to chest x-ray, arterial blood gas analysis, non-invasive ventilation, antibiotics for acute/Develop the bundle: Identify the core elements of care that admission bundles, and how the time will be recorded.must be delivered Don’t reinvent the wheel – there may already be a bundle you Regular communication and project team meetings could adopt/modify (see examples in the resources section) will aid the development of the care bundle. Several iterations may need to be tested before reaching a Consider what it will physically look like, where it will be placed final version. in the patient’s notes How simple will it be to complete the care bundle in real time (i.e. not retrospectively)? The key to successful implementation is making it easy, and preferably easier than what currently happens. 29
  29. 29. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CHECK LIST Develop an implementation plan: who, what, where, when, how The best way to start is with a process mapping event. This will Consider starting with one ward e.g. the admissions engage all the relevant teams and people, and help to identify ward or the respiratory ward for the first stage of problems and challenges with the patient pathway. It may help implementation and then spread to other wards, lessons with stakeholder engagement to do this before the design of learned about implementation can shape the future the care bundle is complete, to allow all those involved to have a stages of ‘roll out’. voice and feel included. Define the target patient group. Identify whether the The care bundle must be completed in ‘real time’, not care bundle will be for all patients who are admitted retrospectively so it is essential that the design and with COPD, or for a particular cohort, e.g. for those who implementation plan facilitate this to happen. have a primary diagnosis of exacerbation of COPD as their reason for admission. Consider whether current Who will deliver each element of the care bundle – all the staffing arrangements need to be revised to capture relevant people need to be involved from the beginning patients admitted over the weekend or during out of hours periods. Consider whether all elements will be delivered while the patient is an inpatient. Consider how completion of all elements will be ensured/recorded if delivered following discharge. NOTES Engage with all the people / professionals who will be involved in the delivery of the bundle Engage with all the people/professionals who will be affected by introduction of the bundle. Use stakeholder mapping to identify who should be involved and what format their involvement should take.30
  30. 30. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCHECK LISTEmbed into practice, evaluate and monitor impact Ensure there is a reliable mechanism for monitoring implementation/adoption of the care bundle on a month by month basis. Have a clear plan for how the monitoring information will be disseminated, and to whom. Staff groups implementing the care bundle require this feedback in a timely manner to know how they are doing. Determine whether the care bundle helped to achieve the desired goals. If not, analyse the reasons why (e.g. the wrong interventions were chosen, implementation is patchy etc.) Ensure support for implementation continues until use of the bundle becomes standard practice (over 80% of the target population receive the bundle consistently, month on month). 31
  31. 31. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for success CASE STUDY NHS Improvement – Lung worked with a number of sites who implemented care bundles for COPD as part of their project work. Designing a bundle In Leicester and York, the care bundle was implemented by the Rather than starting from scratch, the project teams in Leicester respiratory nursing team and was a separate, coloured sheet that and York modified existing care bundles to meet their own was inserted into the patient’s notes. needs. University Hospitals Leicester NHS Trust based theirs on one developed by the North West London CLAHRC which was a Other teams have produced care bundle paperwork as sticky COPD discharge care bundle designed to ensure every patient labels which could be inserted into admission clerking received five key components of care prior to discharge from documents with additional stickers for the front of the patient hospital. Both bundles included smoking cessation, inhaler notes to alert health care professionals to look for the bundle technique, self-management plans, pulmonary rehabilitation and document. follow up. However the North West London CLAHRC bundle included rescue medications as part of the self-management Implementing the bundle plan and this was not included in the Leicester bundle. By engaging the whole multidisciplinary team in the design and implementation of their COPD care bundle the project team at York Teaching Hospitals NHS Foundation Trust adapted a bundle Northumbria Healthcare NHS Trust secured involvement of the developed by the team in Northumbria, which addressed core pharmacists to deliver several aspects of their care bundle. The elements of the inpatient stay, and added in spirometry pharmacists issued the patients with their rescue packs and assessment to ensure each patient had a confirmed diagnosis of explained to the patient how and when to use them. They also COPD. Modifying existing bundles saved significant amounts of completed this with a follow-up telephone call two weeks after time in the planning stages of the project, allowing them to move discharge to ensure the patient was confident about the swiftly to implementing the care bundles. appropriate use of the rescue medications. The project teams developed a range of approaches for the physical design of their care bundles. In Wolverhampton a large rubber stamp was developed which was placed directly into the patient’s notes.32
  32. 32. Managing exacerbations in chronic obstructive pulmonary disease (COPD): A secondary care toolkit: The ingredients for successCASE STUDYEmbed into practice, monitor and evaluateContinuous monitoring of completion of Leicester - patients referred for pulmonary rehabilitationthe COPD care bundle in Leicesterdemonstrated improvements in referralsto pulmonary rehabilitation (PR). Initiallyless than 20% of patients were beingconsidered for PR and around 10%referred but by the end of their project allpatients were being considered for PRand over 60% being referred. Similarimprovements were seen in theproportions of patients receiving self-management plans and smokingcessation advice. 33