NHSCANCER                             NHS Improvement                                         LungDIAGNOSTICSHEARTLUNGSTRO...
NHS Improvement - LungImproving adult asthma care: Testing the case for changeContentsAsthma Project Pathway              ...
3                                 ASTHMA PROJECT PATHWAY                                BTS/SIGN ASTHMA GUIDELINE         ...
4   FOREWORD    Foreword    Asthma remains a major health burden in England. The    General Practitioner Quality of Outcom...
SUPPORT FROM ASTHMA UK       5Support from Neil Churchill,Chief Executive, Asthma UKThe successful projects demonstrate cl...
6   INTRODUCTION    Introduction    Case for change – the current                of asthma medications are wasted         ...
INTRODUCTION       7Through improving self-management,         teams a period of ‘diagnosis’ then          • Cleaning and ...
8   INTRODUCTION     ACUTE     Agree a mechanism for standardising and monitoring care     Standardised care which adheres...
INTRODUCTION       9PRIMARY CARE Work with other health professionals to maximise asthma self-management Community nurses ...
10   INTRODUCTION     Project outcomes: Emerging                All the asthma services mapped the        3. Clinicians an...
INTRODUCTION      11the project work with decision makers        Future work                                adherence to g...
14     CASE STUDIES - ACUTE TRUSTSGuys and St Thomas NHS Foundation TrustReducing adult asthma re-attenders atAccident and...
CASE STUDIES - ACUTE TRUSTS   15• a placebo box and an updated asthma       Key learning points  folder, which includes th...
16     CASE STUDIES - ACUTE TRUSTSMid Yorkshire Hospitals NHS TrustImplementation of an asthma care bundle to assist inthe...
CASE STUDIES - ACUTE TRUSTS            17                                                                                 ...
18     CASE STUDIES - ACUTE TRUSTSUniversity Hospitals North Staffordshire NHS Foundation TrustThe development and impleme...
CASE STUDIES - COMMUNITY RESPIRATORY TEAMS                   19Sandwell Community Respiratory TeamBack to basics for asthm...
20    CASE STUDIES - COMMUNITY RESPIRATORY TEAMSKey learning points                         • The team will continually ta...
CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE                         21Durham Dales Clinical Commissionin...
22     CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CAREKey learning points                            This ma...
CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE                            23ESyDocWhole system approach to ...
24     CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE2. Chronic disease managementPractice registers were s...
CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE   25Key learning points                               Contac...
26   REFERENCES     References     COPD and Asthma Outcomes Strategy for England and Wales (DH: 2011)     www.dh.gov.uk/en...
ACKNOWLEDGEMENTS   27AcknowledgementsNHS Improvement - Lung would like to     Prof Martyn Partridge, Professor of Respirat...
NHSCANCER                                                                                               NHS ImprovementDIA...
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Improving adult asthma care: testing the case for change


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This publication is aimed at healthcare professionals, commissioners, patients and other key stakeholders involved in asthma services. It draws together the evidence and learning from the work undertaken by the national asthma improvement projects over a 12 month period in 2011/12 as part of the asthma workstream within the NHS Improvement – Lung programme.

(August 2012)

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Improving adult asthma care: testing the case for change

  1. 1. NHSCANCER NHS Improvement LungDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - LungImproving adult asthmacare: Testing the case forchange
  2. 2. NHS Improvement - LungImproving adult asthma care: Testing the case for changeContentsAsthma Project Pathway 3Foreword by Professor Martyn Partridge 4Professor of Respiratory Medicine Imperial College London, Senior Vice Dean,Lee Kong Chian School of Medicine Singapore and Chairman DH Asthma Steering GroupSupport from Asthma UK 5Introduction 6Case studies 12ACUTE TRUSTSGuy’s and St Thomas’ NHS FoundationTrust (GSTT) 14Mid Yorkshire Hospitals NHS Trust (MYHT) 16University Hospitals of North Staffordshire NHS Trust (UHNS) 18COMMUNITY RESPIRATORY TEAMSSandwell Community Respiratory Team 19CLINICAL COMMISSIONING GROUPS AND PRIMARY CAREDurham Dales Clinical Commissioning Group 21ESyDoc Clinical Commissioning Group 23References 26Acknowledgements 27
  4. 4. 4 FOREWORD Foreword Asthma remains a major health burden in England. The General Practitioner Quality of Outcomes Framework Registers suggest that 5.9% of people were receiving asthma treatment last year and the 2010 Health Survey for England suggested a higher figure with as many as 9.5% of adults and children having asthma and being on treatment. Whilst we have some solid evidence that care has been improving in that death rates and hospitalisation rates have fallen, there is also some evidence that this decline is now plateauing. Any improvement that was achieved may reflect the efficacy of modern treatments and in the UK we have been helped by the presence of first class evidence based BTS/SIGN Asthma Guideline to direct and advise us as to optimal care. However, there is growing evidence We can see from the case studies the that we often fail to implement tremendous amount of work which is optimal care and this is perhaps most being done around the country to obvious in the non-prescription parts ensure best care for all. These projects of care. Living with a long term cover important aspects of asthma care Martyn R Partridge condition like asthma necessitates from: more accurate diagnosis to Professor of Respiratory Medicine, Imperial College London and Senior good support from a health care optimal prescribing to focusing on the Vice Dean, Lee Kong Chian School professional who listens, responds to most at risk to help them make the of Medicine, Singapore (A joint concerns, explains the condition fully most use of health service resources. school by Imperial College London and who involves the patient in We can all learn from these reports to and Nanyang Technological University) decisions regarding management. extend and extrapolate them and When care of this sort is offered the hopefully evaluate them in other parts outcomes are noticeably better. of the country. NHS Improvement has overseen a I offer my sincere congratulations to superb range of service enhancements all who have been involved in this work. to really ensure that best possible care is given to all with asthma and this report summarises those projects.
  5. 5. SUPPORT FROM ASTHMA UK 5Support from Neil Churchill,Chief Executive, Asthma UKThe successful projects demonstrate clearly howasthma outcomes can be improved in a shortspace of time if there is energy, integration andinnovation.They have shown the rest of the NHS what can be done.We will be working with the Department of Health, NHSImprovement and Regional Respiratory Boards to push for furtherchange, particularly in areas where emergency admissions are high.The projects are a model for the NHS to replicate. Neil Churchill Chief Executive, Asthma UK
  6. 6. 6 INTRODUCTION Introduction Case for change – the current of asthma medications are wasted evidence and learning from the work position of asthma services in through non-adherence and lack of undertaken by the national asthma England effective inhaler technique. improvement projects over a 12 month Asthma is a respiratory condition that period in 2011/12 as part of the affects approximately three million NHS Improvement – Lung worked with asthma workstream within the NHS people in the UK. Recorded prevalence clinical teams across England Improvement – Lung programme. is around 5.9% but estimates suggest supporting them in identifying, testing the true figure could be nearer 10% - and implementing the changes needed Improvement approach one of the highest in the world. to their asthma service in order to have NHS Improvement – Lung invited NHS The cost to the NHS is put at around the greatest impact on the patient organisations to work in partnership £1 billion with the majority of the pathway and improve the care for their on projects dedicated to improving the spending on respiratory medications patients. asthma patient pathway to help and about £61 million on emergency address the variation in care that admissions (DH: 2011). The first year of project work focussed patients receive. Successful sites on four key areas: diagnosis and included acute Trusts, primary care Although asthma cannot be cured it medicines management, chronic organisation and community providers can be effectively treated and disease management, transforming who worked over a 12 month period managed and the goal for nearly all acute pathways and an integrated with a variety of aims under four main asthma patients should be to lead a pathway approach. Local goals pathway areas. These were: symptom free life supported by health combined with the NHS Quality, care services in their local area. This is Innovation, Productivity and Prevention 1. Diagnosis and medicines reinforced in Objective Six within the (QIPP) agenda gave additional context optimisation Outcomes Strategy for COPD and to the work and provided an 2. Chronic disease management Asthma in England (DH: 2011). opportunity for clinical teams to 3. Transforming acute care engage commissioners and health care 4. Integrated pathways Variation in the provision of asthma providers in new and different thinking services and non-compliance with gold about asthma service delivery. Focus was given to the removal of standard guidelines increases the duplication and waste from the potential for poor quality outcomes This publication is aimed at healthcare pathway, improving specific processes and waste. For example, when looking professionals, commissioners, patients through different ways of working and at medicines use it has been estimated and other key stakeholders involved in to improving patient experience of that anywhere between 45 and 70% asthma services. It draws together the asthma services.
  7. 7. INTRODUCTION 7Through improving self-management, teams a period of ‘diagnosis’ then • Cleaning and validating diagnosis instandardising care, training and followed in order to allow teams to asthma patient registers in primaryeducation and involving other health understand the patient pathway and careprofessionals with asthma services, dispel assumptions about the process, • Greater adherence to the goldthree of the six project teams its challenges and the solutions. standard BTS/SIGN Asthma Guidelinecollectively made savings of over Potential improvement ideas were • Educating and training respiratory£80,000 against agreed targets with tested using a plan, do, study, act cycle staff who come into direct contactthe Programme at the start of the with ongoing measurement to with asthma patients.work. There were also significant evaluate the impact of theadditional savings achieved by interventions and refine where Whilst each project site has worked onreaching locally defined targets. appropriate. a different part of the asthma pathway a number of key themes haveDuring this ‘testing’ phase of the Common challenges and solutions emerged across the asthma projectnational programme, the project teams Clinical teams at all sites have been sites which has enabled thehave explored the reality of making focussed on specific aims which have development of the following top tipslocal service improvements by taking included: for improving asthma services:stock of current practice andunderstanding which processes deliver • Improving self-management byoptimal patient care in a challenging increasing the use of self-environment. The projects adopted a management plans and optimisingsystematic approach to quality inhaler techniqueimprovement to ensure that any • Standardising care in the patientchanges implemented were thoroughly pathway - in primary care annualtested and measured. review, community team follow-up and during an acute episode e.g. inPrior to commencing the work the A&E and during admissionproject sites were required to establish • Utilising health care providers totheir service baseline through analysis support self-management – byof local data and to understand any increasing and standardising the usevariation present. Upon the of Medicines Use Reviews byestablishment of individual project community pharmacists
  8. 8. 8 INTRODUCTION ACUTE Agree a mechanism for standardising and monitoring care Standardised care which adheres to the BTS/SIGN Asthma Guideline increases equality of treatment, aids staff in patient management and improves outcomes for patients. It can also help to meet other standards and national audits e.g. the BTS/SIGN audit and College of Emergency Medicine audit. For further details on examples of standardised care such as proformas for A&E, bundles and integrated care pathways and how to monitor them see the ESyDoc, GSTT, MYHT, UHNS and Sandwell case studies. ACUTE Make sure every patient has had the key components of care on discharge Discharge ‘checklists’ are a key tool in reducing re-attendances and readmissions. A good discharge process would ensure every patient doesn’t leave without being: advised they need a follow up with their GP within two days, shown correct inhaler technique and had their medication checked, advised about other out of hours providers available and referred for smoking cessation – if needed. For examples of good practice on discharge see the ESyDoc, GSTT, MYHT and UHNS case studies. PRIMARY CARE PRIMARY CARE Validate your patient registers ‘Clean’ registers e.g. diagnosed Make sure every asthma patient has an annual review and patients with correct read coding chase up patients who DNA are essential in order to be able Annual reviews are an essential part of asthma patient management and to: run searches to identify should be standardised within practices so every patient receives equal time cohorts of patients, for example and input. Qualitative data suggests patients find their review more effective in order to stratify into degrees if conducted by a clinician with specialist knowledge in asthma – rather than of risk, call the correct patient for a generalist. For more information on review templates for clinical their annual reviews and to staff and self-management plans see the ESyDoc case study. analyse data for QOF purposes. There are tools available to help you understand your data. These PRIMARY CARE are available from pharmaceutical companies or from local data Consider limiting repeat prescriptions to patients who have had an analysts. Look at the number of annual review in the last 12 months with others continuing to patients on asthma medication receive prescriptions for regular preventative therapy but being without an asthma diagnosis or limited to a single SABA reliever inhaler until reviewed by telephone the number of self-management or face-to-face plans recorded as issued for Asthma medications cost approx £850million a year and it is estimated that potential areas to start with. See between 45-70% of this is waste and non-adherence. If your practice issues the ESyDoc case study for repeat prescription consider how your policy ensures that patients receive further information. their prescriptions but are also encouraged to have an annual review.
  9. 9. INTRODUCTION 9PRIMARY CARE Work with other health professionals to maximise asthma self-management Community nurses and pharmacists have a vital role to play in helping asthma patients self-manage For example, a Respiratory Nursing Service can support GP practices who do not have dedicated asthma services and the New Medicines Service and the Medicines Use Reviews Service offered by local pharmacists are prime examples of wider support. Pharmacists can appear less daunting to patients and often know the local community and cultures very well. Examples of case studies on this are Sandwell, Durham Dales and SW Essex.EVERYONE EVERYONE Involve asthma patients in the redesign of asthma services Set minimum levels of A fundamental principle of improvement work is to understand your awareness and competencies problem before you start implementing solutions. For example, if you have for non-respiratory clinicians high clinic DNA rates, A&E attenders or readmissions, look at individual who have regular contact with patient records and ask patients why they behave the way they do. This will asthma patients. help to really create solutions which will help to solve the problem. Asthma patients regularly come For more information on how to understand your problem, patient into contact, often in an involvement and how to test solutions on a small scale see the GSTT emergency, with staff who do not and ESyDoc case studies. routinely work in respiratory care e.g. A&E clinicians, paramedics. This can have a significant effect on patient outcomes. There areEVERYONE resources available for all levels of training, from ‘paid for’ Take a multidisciplinary approach to asthma management qualifications to free online If you want to improve your asthma service its vital to involve other guides. Case study examples organisations. Problems are rarely ‘stand-alone’ for a service or Trust and you of different levels of training may meet with limited success if the patient pathway relies on involvement in practice can be found in from other providers in primary or secondary care. For examples and ESyDoc, Durham Dales, GSTT integrated working see ESyDoc and GSTT case studies. and MYHT.
  10. 10. 10 INTRODUCTION Project outcomes: Emerging All the asthma services mapped the 3. Clinicians and managers success principles and project patient pathway in order to reviewing data together - access to learning understand where and how their and effective use of data through NHS Improvement - Lung provided improvement work was needed. All collaboration between clinical and structured support to project teams sites collected 12 months baseline data managerial staff enabled the project enabling them to solve problems by relevant to the aim of their projects teams to better understand the patient addressing root causes and by e.g. admissions, A&E attendances. pathway and demonstrate the impact undertaking a systematic approach to Primary care asthma projects used GP of any change. The routine collection service improvement. Teams across the asthma patient registers and searches and review of data was important in different workstreams of the national of medications usage to identify implementing sustainable programme worked through a number patients to target whereas acute Trusts improvements and understanding of different challenges in order to and community providers used patient outcomes of any service achieve their project aims. However administration systems and case note improvements. some common principles have audits to gain a good understanding emerged as critical success factors in of the target cohort. All sites had Asthma teams worked with non- all national lung projects: patient and public involvement. clinical colleagues to understand the local data relevant to their target e.g. 1. Defining and gaining a good readmissions, number of MURs understanding of the whole 2. Taking an integrated approach completed, number of annual reviews pathway of care - having a complete to service development - issues and completed. Data was collected on a understanding of the care pathway challenges viewed in isolation without monthly basis to determine if supported by robust data to due consideration to the whole patient improvements were impacting upon demonstrate the effectiveness of pathway were less likely to lead to outcomes so that project plans and current processes, quantifying sustainable improvements in care actions could be adjusted accordingly. performance and variation is essential provision. when embarking on improvement 4. Identifying the key levers and work. This allowed organisations to Individual asthma project work needed drivers in the system – by identify priorities for change and also to be viewed within the context of the integrating local and national priorities to benchmark themselves with others wider respiratory care pathway in into the work such as Quality, locally and nationally. order to maximise the opportunities Innovation, Productivity and Prevention for integrating with services to ensure (QIPP) raised the profile and priority of patients receive optimal and coordinated management of their asthma overall.
  11. 11. INTRODUCTION 11the project work with decision makers Future work adherence to guidelines, optimisingand helped to achieve improved In the forthcoming year of the NHS patient medications and standardisingengagement from senior management Improvement – Lung programme care in both primary and secondaryteams. project work sites will be building on care settings. the learning from the ‘testing’ phaseThe QIPP agenda and the publication of the work on both COPD andof the Outcomes Strategy for COPD asthma. Emerging principles fromand Asthma (2011) provided an work in both these disease areas willopportunity for clinical teams to be refined and successful principlesengage other clinical and non-clinical that demonstrated the greatest impactstakeholders in a new dialogue about on the patient pathway during theasthma services. past year will now be combined and prototyped in the following key areas5. Value for money - there was a of the patient pathway.need to identify and understand thegaps, duplication and waste in the • Medicines management andpatient pathway in order to make best optimisation for respiratory Phil Duncanuse of available resources. It was conditions Director - NHSessential to work and communicate • Risk stratification and identification Improvement Lungwith colleagues, commissioners and of patients for regular standardisedother stakeholders in service provision review in primary carein order to maximise these resources • Acute care pathways andand to ensure a consistent and co- standardising the patient journeyordinated approach to care from A&E to discharge.Commissioning and medicines The testing phase work demonstratedmanagement colleagues worked that there are many potential costclosely with some of the asthma efficiencies which can be realised inservices to identify prescribing policies. practice. It is anticipated that theAll sites worked on their pathways to prototype phase of work will furtheraddress waste and to reduce variation. demonstrate the importance of Hannah Wall National Improvement Lead
  12. 12. 12 CASE STUDIES
  14. 14. 14 CASE STUDIES - ACUTE TRUSTSGuys and St Thomas NHS Foundation TrustReducing adult asthma re-attenders atAccident and Emergency (A&E)What was the problem?Early in 2010, the respiratory nursing 28 day adult asthma re-attenders at GSTTteam at St Thomas’ undertook asnapshot audit of asthma attendances to 10A&E, and this revealed a surprisingly high30 day re-attendance rate of just below 830% and this highlighted a problemwhich they wanted to improve upon. Patients 6What was the aim? 4The primary aim of the project was toreduce adult asthma re-attendances at 2A&E within 28 days by 20% of 2010/11baseline as an indicator of better control 0 MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APRand quality of life. Additional aims were: Month• to improve patient control through self 2010/11 2011/12 management plans;• to increase healthcare provider knowledge and confidence; and• to reduce unscheduled hospital attendance. the best possible care for this cohort of • an A&E asthma proforma within the asthma patients. This was achieved by department to ensure that patients areWhat has been achieved? in depth diagnostic work to reveal the cared for as per BTS/SIGN AsthmaRe-attenders at A&E have fallen by 45% causes of re-attendance through: Guideline, which includes a dischargefrom the previous year. examination of A&E data to establish the checklist with referral to GP within 48 target cohort, an audit of A&E casualty hours, an Asthma UK co-brandedEqually important is the legacy of the cards and a telephone interview with re- ‘Asthma Patient to GP’ letter and blankproject. Asthma now has a high profile attenders to understand behaviours and self-management plan for the patientacross primary care and A&E and systems motivators. Some of the key to take to a GP follow-up appointmenthave been put in place that will facilitate interventions which have now been put and an Asthma UK’s After Your in place include: Asthma Attack leaflet;
  15. 15. CASE STUDIES - ACUTE TRUSTS 15• a placebo box and an updated asthma Key learning points folder, which includes the recently • Inclusion of all stakeholders and updated local asthma guideline; regular communication was vital to• an internal referral pathway into the project success. severe/difficult asthma clinic when • There was a strong correlation patients have experienced an acute between use of the proforma and severe asthma attack or have difficult actions that would lead to a decrease asthma and have been reviewed; and in re-attendance e.g. inhaler technique• an external referral pathway has been check, referral back to GP. reviewed and updated by way of an • Testing of innovation on a small scale electronic flag on the patient record really helped to refine some of the that prompts the hospital staff to give interventions and make them more information on discharge including the successful. GP referral letter. • Data – both qualitative and quantitative was key to understandingThe project team consisted of the problem and informing solutions.representatives from A&E, the respiratorynursing team in the hospital, primary Contact detailscare (a GP and a Practice Nurse), Karen Newellambulance staff, junior doctors, an A&E Specialist Respiratory NurseConsultant and patients. The team met Email: karen.newell@gstt.nhs.ukmonthly for 12 months to discuss issuesarising.
  16. 16. 16 CASE STUDIES - ACUTE TRUSTSMid Yorkshire Hospitals NHS TrustImplementation of an asthma care bundle to assist inthe delivery of a structured inpatient care process anddischarge checklist for adult patients admitted with anacute exacerbation of asthmaWhat was the problem? respiratory inreach service. This provided Stickers one and two contain all theIn 2010/11, NHS Wakefield District had an opportunity to implement change of elements within the locally agreedthe highest admission rates for acute the asthma service, including creating a asthma CQUIN (Commissioning forexacerbation of asthma in Yorkshire and difficult asthma clinic, and introduce an Quality and Innovation) payment.the Humber. The 2009 BTS adult asthma asthma care bundle to standardise care Sticker three is used for all patientsaudit revealed that that Pinderfields asthma patients received in the admitted from ED with an exacerbationGeneral Hospital (PGH) re-admissions Emergency Department (ED), acute of asthma. This again promotes(within one month) were twice the medical wards and at discharge. appropriate treatment, education, selfnational average. The same audit aslo management and follow up.highlighted a lack of education and What was the aim?instruction to patients. Only 19% were The main aim of the project was to ED staff have received training from theadvised to see their GP following reduce 28 day adult asthma readmissions respiratory team in the use of theadmission and only 16% received a by 20%. bundle, with specific teaching of acutewritten action plan, compared to asthma severity assessment and inhalernational figures of 34 and 38% What has been achieved? technique assessment and training.respectively. An asthma bundle comprised of ‘three stickers’ has been introduced at PGH. An audit of patients admitted withPinderfields General Hospital is one of Sticker one is used for all adult patients asthma has demonstrated that since thethree district general hospital that forms attending the ED with an acute introduction of the asthma care bundleMid Yorkshire Hospitals NHS Trust, along exacerbation of asthma. This there has been a marked improvement inwith Pontefract and Dewsbury General component of the bundle focuses on the recording of inhaler techniqueHospitals. Pindefields and Pontefract accurate and timely assessment, review, provision of self managementacute inpatient medical services merged treatment and reassessment of patients. plans and advice to see GP or Practiceand moved into a new hospital in Sticker two is implemented when Nurse (see table). There has also been aFebruary 2011. This coincided with the patients are being discharged from ED, 60% reduction in readmissions at theappointment of a respiratory consultant focusing on inhaler technique, education Pinderfields site since March 2011 (seewith a specialist interest in asthma and and self management and GP follow-up. the graph on the following page).establishment of a seven day a week
  17. 17. CASE STUDIES - ACUTE TRUSTS 17 Key learning points Yes (%) No (%) N/a (%) • As part of the project a number ofSticker ‘3’ used 84.4 13.3 2.3 audits and notes reviews were undertaken. The audits repeatedlyInhaler technique checked 75.6 22.2 2.3 highlighted coding errors with over 25% of patients being incorrectlyAsthma review (SMP/Education) 88.9 12.1 2.3 coded. This has led to work within the respiratory team to improve thePrednisolone on discharge 97.8 0.0 2.3 accuracy of coding.ICS and B2 agonist on discharge 97.8 0.0 2.3 • The time it would take to fully implement the care bundle wasAdvised to see GP/nurse within two days 80.0 13.3 2.3 underestimated. It has taken considerably longer than anticipated toFour week follow up arranged 93.3 4.5 2.3 engage with staff and train them where necessary.A&E commenced bundle 43.2 40.0 17.8 Contact details Lisa Chandler Respiratory Programme Manager – Public28 day re-admissions at Pinderfields General Hospital Health NHS Wakefield Email: lisa.chandler@wdpct.nhs.uk 8 7 6 5 Patients 4 3 2 1 0 Apr11 May11 Jun11 Jul11 Aug11 Sep11 Oct11 Nov11 Dec11 Jan12 Feb12 Mar12 Month 2010/11 2011/12
  18. 18. 18 CASE STUDIES - ACUTE TRUSTSUniversity Hospitals North Staffordshire NHS Foundation TrustThe development and implementation of an integratedasthma care pathway alongside the provision of anasthma education package to emergency care staffWhat was the problem? UHNS (%) National (%) Target (%)A College of Emergency Medicine (CEM)2009/10 asthma audit highlighted areas PEF on arrival 48 53 98for improvement in both patient Respiratory rate 70 100 98assessment and treatment. SABA nebuliser 85 88 100What was the aim? Steroids 65 66 90The aim of this project was to improve Admitted 67 52and standardise care delivered to asthmapatients presenting to the emergencydepartment with an asthma The new pathway was officially of paramedics as 73% of A&E asthmaexacerbation. launched in A&E in April 2012 and attenders arrive by ambulance. usage is monitored through a monthlyWhat has been achieved? audit. Key learning pointsWith involvement from respiratory 2.Development of an asthma database • Initial data always requires furtherspecialists and emergency care personnel of all patients presenting to the A&E interrogation/root cause analysis.the project was divided into three main on a monthly basis with an aim to run • Improvement project work requires aworkstreams: quarterly reports to monitor for any team big enough to undertake specific improvements in care delivery. roles.1.Development of an asthma care 3.An asthma education package within • Regular meetings are essential to pathway - Initial research looked at A&E /Acute Medical Unit - ensure progress happening. casualty card records for asthma A resource file which included the • Plans and progress should be patients, Trust data around attenders, ‘step wise management of asthma’ documented. re-attenders and admissions and the (BTS/SIGN Asthma Guideline 2011), • Face-to-face engagement is best. outputs from an asthma patient focus pictures of inhalers with their names group. The current pathway was and the correct method of delivery is Contact details process mapped and a project team now available for A&E staff. In addition Angela Cooper who met twice a month refined the 12 training sessions have been held for Asthma Clinical Nurse Specialist content for the new integrated care clinical staff and more are planned up Email: angela.cooper@uhns.co.uk pathway which conforms to the to December 2012. Work is also BTS/SIGN Asthma Guideline. underway to support the education
  19. 19. CASE STUDIES - COMMUNITY RESPIRATORY TEAMS 19Sandwell Community Respiratory TeamBack to basics for asthmaWhat was the problem? What has been achieved? Asthma Guideline for asthma patients. ASandwell has the third highest admission To achieve their first aim the team mined demand and capacity exercise was alsorate within the UK and a high prevalence local data on admissions and held a completed to determine the impactrate of asthma in the area of 7.5% with process mapping event to understand increasing referrals might have onapproximately 21,233 people having been the current pathway for referrals. They workload and refresher sessions werediagnosed. Despite this low numbers of then put together a plan for raising held. An electronic ‘SystmOne’ templatereferrals for asthma were being received awareness with GPs e.g. referral was then created which clinical staff useto the Community Respiratory Service algorithm, promotional materials, visits for all patient assessment and follow-upfrom GPs and secondary care. The team to the practice etc. They also spent time appointments (which contains the golddecided the time was right to heighten in A&E with staff offering support and standard features) and any patients withtheir profile for asthma and emulate the highlighting their service in order to aid an unconfirmed diagnosis are nowgood work they already did in other ease of referral. referred for spirometry.respiratory diseases. For the second aim one year’s worth ofWhat was the aim? case notes were audited to determineThe main aims for this project were: current compliance with the BTS/SIGN• To increase the number of asthma referrals into the service by 50% by improving links with the acute sites (to 2010/11 2011/12 % change receive more referrals following Admissions 180 143 ↓21% patients attending A&E and admissions) and GP practices which Attendances in A&E 520 368 ↓29% had high admission rates. Total referrals into CRS 106 185 ↑75%• To ensure 80% of the patients on their Self –management plans given to patient 19 35 ↑21% asthma register were managed in accordance with the BTS/SIGN Asthma Self-management plan amended for patient 13 31 ↑22% Guideline on managing asthma in Diagnosis confirmed with spirometry 26 17 ↓6% adults, to include ensuring all patients: were diagnosed with the preferred Asthma education given to patients 44 52 ↑16% initial test of spirometry, had an easy to Inhaler technique reviewed 62 60 ↑8.2 understand self-care plan in place, received appropriate asthma education and had inhaler technique check.
  20. 20. 20 CASE STUDIES - COMMUNITY RESPIRATORY TEAMSKey learning points • The team will continually target GP• The relationships that the team have practices that have a high proportion developed with those in the Trust that of registered patients attending A&E as can provide and help them understand well as high admission rates. data has been invaluable.• Electronic templates not only Contact details standardised their care and processes Kelly Redden-Rowley but also assisted the team in data Respiratory Physiotherapist/Clinical Lead collection. Email: kelly.redden-rowley@nhs.net• The team conceded they didn’t really utilise the media as much as they might have and would improve upon this next time.• The whole team have improved their skills in delivering care and treatment to those with asthma through applying the BTS/SIGN Asthma Guideline to clinical practice.• Although the project did not meet the target with regards to confirming a diagnosis through spirometry the reason was mainly due to patients not attending their appointments. It may not have been appropriate for some patients to attend clinic, possibly due to an exacerbation, and the team are now in the process of looking at additional ways in which to improve clinic attendance.
  21. 21. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 21Durham Dales Clinical Commissioning GroupDurham Dales Clinical Commissioning Locality, localpharmacists and medicines use reviewsWhat was the problem? What was the aim? The key outcomes related to theDurham Dales has an asthma prevalence The aims of the project were to: completion of 174 MURs.of 6.6% (5.93% national prevalence) • educate pharmacists to deliver high • 60 patients were recorded as non-which equates to 5,957 patients. quality, asthma-specific, MURs to compliant and pharmacistDurham Dales currently spends £64,918 increase patient awareness and interventions were delivered ason asthma hospital admissions all of understanding of their condition and appropriate.which are non elective. Work between improve their own management of • Patient education was delivered tocommunity pharmacies and GP practices the disease; 32% of patients.was sporadic and the Medicines Use • improve relationships between • Device check and advice was givenReview (MUR) services were not practices and pharmacists to ensure was to 32% of patients.consistently utilised in a coordinated way. more asthma patients are treated • 14% of patients were referred back to consistently in line with the BTS/SIGN GP practice for further intervention.In 2010, a small scale pilot between one Asthma Guideline; and • 19 patient surveys were received backGP practice and one pharmacy was • improve patient quality of life and (11% response rate) and the feedbackundertaken over a three month period in health outcomes by ensuring patients was that patients found the serviceBishop Auckland where pharmacists understand their condition and very beneficial with 57% of patientsoffered an MUR to asthma patients who prescribed medicines thereby rating the service as excellent and 57%had missed their annual review and who improving self management. finding the service extremely valuable.were over using reliever inhalers. Theresulting data suggested that over half What has been achieved? Other measures are still being reviewedthe patients benefited from the service A monthly steering group met from the e.g. Asthma Control Test (ACT) scores,and this evidence supported a bid to roll outset to determine the target cohort of reduction in inhaler use (via a case notethe project out to other surgeries in the asthma patients, formulate standard audit) and a pharmacist / practicelocality through a joint working paperwork for the pharmacists to feedback survey.agreement between GlaxoSmithKline complete (MUR template, reportingand Durham Dales Clinical form, schematic) and which pharmacistsCommissioning Group (CCG). to target. Pharmacists were also given training at two events (September 2011 and January 2012) and were individually mentored and supported with appropriate equipment for the duration.
  22. 22. 22 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CAREKey learning points This may have been in part due to the• There were initial problems with additional activity the New Medicines patient confidentiality as the Primary Service had created which also began Care Trust (PCT) would not allow on 1 October 2011. practices to generate patient lists of • The number of MURs was changed the three target cohorts of patients for from the original target of 500 to 200 the pharmacists to work from. in February when it became clear that Pharmacists had to produce their the 500 would not be reached. It was own lists for over use of reliever also decided to focus on the inhalers by patients and high dose pharmacists who had already steroid use patients and each practice conducted the greatest number of was asked to write to patients who MURs. hadn’t attended their annual review to • The steering group decided to remove explain the MUR was available at their the completion of Self Management local pharmacy. Plans from the MUR criteria in February• Educational meetings (one in as it was observed that very few were September and one in January) were being completed and they took a well attended and the pharmacists substantial time to complete. appeared to find them useful. One-to- one mentoring, delivered by a local Contact details pharmacist with an asthma specialism, Vikki Reed received very positive feedback. Project Manager – Durham Dales Clinical• Engaging with the pharmacists was Commissioning Group challenging as email communication Email: victoriareed@nhs.net did not generate a wide response so it was difficult to ascertain the level of Alison Newbolt engagement. The team began to use Area Business Manager - other communication methods e.g. GlaxoSmithKline phone calls and pharmacy visits early in Email: alison.j.newbolt@gsk.com 2012 when it was clear that the number of MURs were not being delivered.
  23. 23. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 23ESyDocWhole system approach to improving care for patientswith asthma within East Surrey localityWhat was the problem? What was the aim? What has been achieved?ESyDoc had successfully completed an The guiding principles which informed 1. Diagnosisimprovement project for COPD patients the aims were that: asthma is Practice registers were searched toand decided to apply the principles they controllable, there should be no identify the number of patients whohad established in this work to their unnecessary deaths from asthma and have received asthma medication, butasthma service. that a secondary care respiratory clinician were without a formal diagnosis (Cohort should be consulted if there is a decision 4 – see table for figures). In order toThe 18 GP practices who form the to admit an asthma patient who presents have a standardised approach, theCommissioning Group were aware that at the Emergency Department. workstream lead produced an invite toprevalence in practice lists was around review template letter for practices and5.3% (national average 5.8%) and that The project was focussed on four key also an algorithm to enable consistency.the majority of their 9285 registered work streams with their own aims. These Those patients identified were targetedasthma patients did not have a self- were: by letter to a review appointment.management plan. Diagnosis was obtained following 1. Diagnosis – increasing the prevalence prescribed spirometry and/or peak flowWorking in conjunction with of asthma from 5.3 to 5.8%. pathway and the patient was stabilisedAstraZeneca (through a joint working 2. Chronic disease management – accordingly and received an asthmaagreement) and Surrey and Sussex stratifying patients into three cohorts action plan in line with the BTS/SIGNHospitals NHS Foundation Trust also and performing structured reviews in Guideline. Early evidence suggests thatsupported an opportunity to address line with the BTS/SIGN Asthma by implementing this targeted approachadmissions and medicines as part of a Guideline. of identified patients local prevalence haswhole systems approach. 3. Medicines optimisation. increased to 5.5% and at least 154 4. Transforming acute care – patients were diagnosed with asthma standardising care pathways and during the project duration. reducing admissions by 10% in the acute trust.
  24. 24. 24 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE2. Chronic disease managementPractice registers were searched byQuintiles and patients with an asthmaread code were stratified into threecohorts in descending order of priority. Cohort ESyDoc Total 3. Medicines optimisation Collaboration was encouraged between 1: Asthma QOF, Age >18, Read Code hospitalisation, Read Code 1,765 community pharmacy colleagues who Exacerbation, >1 Oral Steroids, >2 Respiratory antibiotics. have provided strategic support when implementing the NHS Surrey asthma 2: Asthma QOF, >12 SABA, >8 SABA <12 SABA, >6 SABA <8 SABA 378 guidelines. Pharmacy colleagues have also assisted with reinforcing effective 3: Asthma QOF, SAMA, LAMA, LABA only (no ICS) 222 inhaler technique when implementing 4: No Respiratory Read Code, >1 SABA, >1 ICS, >1 LABA/ICS 2,761 a medicines use review within that combination specific setting. Total 5,126 4. Acute care An Integrated Care Pathway has now been introduced at Sussex and SurreyPatients were invited by letter to attend a • BTS step recording went from 4% Hospitals NHS Trust and usage is beingnurse-led review which was conducted to 20%; monitored. In addition, the Respiratoryusing a standardised template. The • compliance recording increased Consultants notified GP practices onreview adhered to the BTS/SIGN Asthma by 7%; patient discharge in order for timelyGuideline and included inhaler technique • Recording of inhaler technique follow up as per the BTS/SIGN Asthmacheck and a self-management plan. increased by 813 patients; Guideline. This primary and secondaryAlthough there were high DNA rates for • 454 extra patients had a self- care combined approach hasthe clinics final data from 15 practices management plan; and demonstrated that, in comparison with(92% of the asthma population) showed • 58 additional patients were referred the previous 12 months, admissions havethere had been a big impact. Highlights for smoking cessation. dropped by 21%.included:
  25. 25. CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE 25Key learning points Contact details• Initial data between the QOF and Dr Vijay Kumar Quintiles search conflicted and needed GP - Birchwood Practice re-running to enable increase in data Email: Vijay.Kumar@gp-h81037.nhs.uk integrity. This was vital to establishing the correct patients to target in cohorts but did create unforeseen delays in starting the review clinics.• A&E data was not easily visible creating difficulties defining baselines, benchmarking and monitoring.• Poor standardisation and utilising of clinical management plans prompted all the practices to have and utilise a standard self-management.• The buy-in from all 19 (initial) practices and a motivated project group which met regularly created the highly successful and focussed workstreams.
  26. 26. 26 REFERENCES References COPD and Asthma Outcomes Strategy for England and Wales (DH: 2011) www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_127974 Asthma UK www.asthma.org.uk NHS Atlas and NHS Right Care (Problems of the Respiratory System, Atlas of Variation: 2011 version) www.rightcare.nhs.uk/index.php/nhs-atlas/atlas-downloads/ British Guideline on the Management of Asthma (BTS/SIGN: 2011) www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx Professor Martyn Partridge asthma action planning software www1.imperial.ac.uk/medicine/people/m.partridge/
  27. 27. ACKNOWLEDGEMENTS 27AcknowledgementsNHS Improvement - Lung would like to Prof Martyn Partridge, Professor of Respiratory Medicine Imperial Collegethank all national improvement project London, Senior Vice Dean, Lee Kong Chian School of Medicine Singapore andsites for their hard work and Chairman DH Asthma Steering Groupdedication to improve quality and carefor people with asthma, and for their Professor Sue Hill, National Clinical Director for Respiratory Servicescontributions to this document.In addition, the following people have Dr Robert Winter, National Clinical Director for Respiratory Servicesprovided a source of expertise and Members of the Asthma Clinical Project Steering Group: Dr Bernard Higgins,support and their help is gratefully Jan Gould, Dr Dermot Ryan, Dr Mike Thomas and Simon Selo (Asthma UK)acknowledged: Kevin Holton, Department of Health Head of Policy for Respiratory, Kidney, Diabetes and Liver Bronwen Thompson, Department of Health Policy Lead for Asthma For more information please contact Hannah Wall, National Improvement Lead Email: hannah.wall@improvement.nhs.uk
  28. 28. NHSCANCER NHS ImprovementDIAGNOSTICS NHS ImprovementHEART NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improved patient experience and outcomes.LUNG Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements with over 250 sites across the country as well as providingSTROKE an improvement tool to over 2,000 GP practices.NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NBTelephone: 0116 222 5184 | Fax: 0116 222 5101www.improvement.nhs.uk Publication Ref: IMP/LUNG0001 - August 2012 ©NHS Improvement 2012 | All Rights ReservedDelivering tomorrow’simprovement agendafor the NHS