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.
9 Success principles Making a real difference NINE: N THING HE Acute inpatients: SW ! GO Structured inpatient stay WRO N G Why? A small number of patients attend the Emergency Department (ED) or are admitted frequently and account for a large amount of secondary care resource. Up to one third of patients admitted for exacerbation of COPD will be readmitted within one month. Managing this group more effectively will improve the patient’s experience of care, reduce avoidable ED attendances and admissions and release wasted capacity in secondary care. How? • Review your hospital’s admissions within the past 12 months to identify which patients have had multiple admissions. Your Trust data analysts will be able to provide this information. • Review the hospitals ED attendances over the past 12 months to identify which patients have had multiple attendances. • Determine and understand the reasons why these patients attended secondary care. • Identify which patients could have been managed appropriately in primary care and what steps can be put in place to avoid this in the future. • Establish a supported self management plan for these patients in collaboration with primary and community care providers. • Identify patients who may become the ‘next generation’ of high impact users and manage the group proactively. • Use multidisciplinary meetings across primary, secondary and community care to discuss patients and plan management approaches. • Ask the question ‘would you be surprised if this patient was readmitted within the month?’ to help identify patients who are at risk of readmission. Proactively manage this group with community and primary care to prevent avoidable admissions. • Ask the question ‘would you be surprised if this patient died within the next year?’ 25% of patients admitted for exacerbation of COPD die within the next year and many of these are at risk of readmission. Work with community providers to establish an end of life pathway where appropriate.
• Consider approaches to commissioning that encourage integration of care between care providers e.g. bundled funding for the admission or shared financial risk between community and secondary care providers for readmissions.Make sure every patient has the key components of care during their admissionWhy?Every admission should ensure every patient receives high quality care that addressesthe key components of long term condition management in COPD. This wouldtypically include:• Ongoing access to specialist care.• Confirmation of diagnosis.• Ensure medication is optimal and appropriate to disease severity.• Advice on stopping smoking and referral for support to do this.• Being shown correct inhaler technique.• Referral for pulmonary rehabilitation within two weeks of discharge from hospital.• Advice on how best to manage future exacerbations to avoid secondary care admission.• Follow up with an appropriate professional within two weeks.Such an approach can reduce re-attendances and readmissions.How?• COPD ‘checklists’ or ‘care bundles’ are a good way to standardise the care delivered and a key tool in ensuring all patients receive high quality care.• Provide simple written advice as a self management action plan.• Ensure all ward staff are able to teach correct inhaler technique or ensure all patients are seen by a professional who is able to teach correct inhaler technique.• Link the use of checklists or care bundles to the audit cycle to monitor progress.Ensure patients whose admission is their first presentation receivea quality assured diagnosisWhy?More than 25% of patients admitted with exacerbation of COPD have not previouslybeen diagnosed with COPD. It is important to ensure that they receive an accuratediagnosis to ensure that they receive the right treatment and support to manage thecondition in the long term.
How?• Ensure all patients with a first presentation of COPD receive follow up and an accurate, quality assured diagnosis.• Consider who might be the most appropriate professional to complete the follow up e.g. GP, community matron, practice nurse, respiratory nurse specialist or physician.• Remember that it takes up to six weeks for baseline spirometry and oximetry to stablise following exacerbation, so assessments of COPD severity and of need for long term oxygen therapy should be at least six weeks post admission.Ensure medicines optimisation during the inpatient stayWhy?COPD and asthma medication costs the NHS £1bn pa. However, suboptimalprescribing or adherence will affect the patient’s ability to self manage, as well as theiruse of primary care, emergency departments, secondary care and the cost ofmedicines. Ensuring that medicines are clinically appropriate, cost effective andacceptable to the patient can reduce waste, save money and improve outcomes forpatients.How?• Remember that smoking cessation is a treatment for COPD.• Ensure patients have an accurate diagnosis and assessment of their disease, and that this information is readily accessible.• Use NICE guidelines to determine clinically appropriate choice of medication.• Engage professional groups such as pharmacists who can be involved in medicines review.• Ensure inhaler technique is checked and corrected.Ensure every patient who has an admission for exacerbation of COPD hasactive follow-up and case managementWhy?A hospital admission for exacerbation is a significant event for someone with COPD.Following the exacerbation it is important to ensure the patient receives supportedself management to ensure they know how to recognise and manage futureexacerbations.
How?• Establish case management that is relative to the patient’s disease severity and social situation e.g. with the community matron, district nurse or practice nurse where specialist management isn’t required, or with the community respiratory team or secondary care respiratory team.• Ensure follow up happens within two weeks of discharge.Ensure every patient admitted for exacerbation of COPD receives pulmonaryrehabilitation following dischargeWhy?A hospital admission for exacerbation of COPD is a significant event for someone withCOPD, and usually results in a significant reduction in exercise tolerance and physicalfunction. Following the exacerbation it is important to ensure the patient receivespulmonary rehabilitation to ensure they are able to regain their previous level offunction. Pulmonary rehabilitation has been shown to reduce readmissions forexacerbation of COPD.How?• Make sure you have a systematic process to identify appropriate patients who may benefit from pulmonary rehabilitation.• Ensure you have a systematic and reliable referral process for referral to pulmonary rehabilitation.• Where supported discharge services exist ensure coordination between supported discharge and pulmonary rehabilitation to facilitate seamless transition of care and increase uptake.• Understand the demand for pulmonary rehabilitation e.g. how many patients will require post-exacerbation rehabilitation.• Explore ways to maximise the capacity of existing rehabilitation programmes.• Consider whether you have the most effective structure for your programme. Rolling programmes can lead to an increase in the number of patients who are able to attend without an adverse impact on attendance and completion rates.• Consider whether you could run two classes ‘back to back’ with the groups joining together for education sessions. This would release one hour of staff time every week (or create 100% more capacity with only 50% more resource).