Master presentation at the North West COPD joint collaborative event on Friday 27 September at Mercure Haydock Hotel. Hilton.

1. 27th September 2019
COPD Discharge Bundle
Northwest Collaborative Event

2. • COPD Discharge Bundle
• National priority for Patient Safety Collaboratives – part of the Adoption and
Spread workstream commissioned by NHS Improvement
• Evidence demonstrates improved patient care through reduced exacerbation
and hospital readmission (if all bundle elements used)
• Support available for implementation and improvement
• Event:
• Collaboration between 2 Northwest Patient Safety Collaboratives (Innovation
Agency and Health Innovation Manchester) and AQuA
• Background, Data, Improvement Support
• Celebrate success!

4. Adoption & Spread:
COPD Discharge Bundle
Ellie Wells, Programme Manager, KSS AHSN
Tom Myers, Senior Analyst, KSS AHSN

5. Kent, Surrey and Sussex: key facts
Population
• 4.5 million, expected to reach 5 million by
2029
• High commuter levels to London
• High levels of social deprivation in many
coastal towns
• Dispersed population in smaller towns and
villages
NHS
• 11 acute trusts
• 3 STPs
• 7 community providers
• 3 mental health trusts
• 20 CCGs

6. Improving the quality, availability and
accessibility of respiratory services,
and reducing unwarranted variation in
the management of pathways
KSS Respiratory Programme aim
_

7. Why…
The scale of Chronic Obstructive Pulmonary Disease in KSS
KSS: 2014/15
• There were 8,648 unscheduled hospital admissions with
AECOPD in the KSS region
• 4.9% of patients admitted to hospital with AECOPD died in
that admission
• COPD admissions accounted for 49,475 bed days in KSS
• Variation in key metrics
Source: KSS Respiratory Dashboard, HES data

8. What…
COPD Discharge Bundle Overview
• 2014: it was recognised that there was room for improvement in the care of hospitalised
COPD patients
• KSS Respiratory Network agreed to deliver the BTS discharge bundle to reduce variation
and improve care on discharge, 9 of 11 acute trusts currently fully participate
• 2017 Best practice tariff (BPT) for COPD introduced
• BPT is paid bundle when 60% of patients:
• Receive specialist care within 24 hours
• Receive a COPD discharge bundle
• Data on BPT is collected by the RCP National Asthma & COPD Audit Programme (NACAP)

9. What…
COPD Discharge Bundle Overview
COPD Discharge Bundle Measures
1. Inhaler Technique assessed and corrected
2a. Patient or carer has written information &
understands their self management plan
2b. Provision of rescue packs
3. Smokers referred for smoking cessation
4. Assessment for enrolment in Pulmonary
Rehabilitation (PR)
5. Appropriate follow-up arranged

10. How.. Methodology for
Spread & Adoption
How…
Methodology

11. • Defining COPD Leads
• Engaging clinical teams
• Commissioner input

12. • COPD bundle measures
• Outcomes: LOS, Mortality,
30/60/90 day re-admissions
• ACS/CQS

13. • Build a network
• Creating a safe space for
collaboration - encourage
network to share tips,
learning & examples of
best practice
• Peer support
• Use of data to drive
improvement

14. • Site visits, webex’s etc.
• Clinical Leadership
• Support & guidance
• Sharing key news &
updates

15. Data, data, data…
• Regional trends
• Clinical commentary
• Support & guidance

16. • Sustainable QI & peer support
• Continued focus on better care bundle
delivery for better care

17. ACS = Appropriate Care
Score
The total number of
patients who receive all
elements of the
discharge bundle
Increasing compliance with full COPD discharge bundle delivery

18. Headline results: KSS
• Reduced variation in outcomes: length of stay
Down from a difference of 3.81 days in 2014/15 to 1.93 days as of 2018/19 Q3
• Reduced variation in outcomes: 30 day readmission rate (same cause)
Down from a difference of 8.3% in 2014/15 to a difference of 4.9%
• Regional downward trend in length of stay
5.58 (14/15) to 4.62 days, p <0.0001 for trend
• Regional downward trend in inpatient mortality
4.9% (15/15) to 3.6% P<0.0001 for trend
Impact

19. Making a difference
KSS: 2017/18 – 2018/19
• There were 9,459 unscheduled hospital admissions with
AECOPD (acute exacerbation of COPD) in the KSS region - 2017/18
Q4 – 2018/19 Q3
• 3.6% of patients admitted to hospital with AECOPD died in that
admission - 2017/18 Q4 – 2018/19 Q3
• COPD admissions accounted for 45,464 bed days in KSS - 2017/18 Q4
– 2018/19 Q3
Source: KSS Respiratory Dashboard, HES data
KSS: 2014/15
• There were 8,648
unscheduled hospital
admissions with AECOPD in
the KSS region
• 4.9% of patients admitted to
hospital with AECOPD died
in that admission
• COPD admissions
accounted for 49,475 bed
days in KSS
Source: KSS Respiratory Dashboard, HES
data

20. Case study: improvement across all measures
Key points
• Engaged clinical
team
• Strong clinical
leadership
• Structured
approach to
discharge bundle
delivery

21. Case study: a challenging journey
Key points
• Staff / resource
issues
• Changing clinical
leadership
• Inconsistent
bundle delivery

22. • Collaboration is key
• Ensure sustainability – continued focus
and maintaining enthusiasm through
building a network, Quality Improvement
awards, respiratory dashboard & regular
talks at collaborative events
Create a safe space:
• Build a community – encourage network
to share tips & examples of best practice
• Discuss challenges openly & celebrate
success
• Use of data to drive improvement
Learning

23. There are 15 regional Patient Safety Collaboratives (PSC) in England, hosted by the
Academic Health Science Network (AHSNs).
PSCs are in a unique position to be able to support and facilitate improvement across the NHS:
• Focus on quality improvement
• Work directly with local teams, supporting with resources to implement successful
improvement
• Focus on people-centred care, across all care settings
• Share good practice
• Identify local priorities for quality improvements that will make a difference to our local
health care systems
• Link and build relationships with frontline staff, businesses and academia helping to
stimulate innovation and improvement
COPD is currently 1 of 4 Adoption & Spread Programmes, your local PSC will be
supporting you to improve adherence to the COPD Discharge Bundle, supporting
increased implementation and sustainability.
National Patient Safety Improvement Programme

24. The NHS Long Term Plan – Respiratory focus
Respiratory disease has been identified as a clinical priority, with
improving outcomes for respiratory disease and reducing
variation featuring as distinct themes in the plan.
Key points in the respiratory focus include:
 Earlier detection and diagnosis of respiratory problems
 Increased access to pulmonary rehabilitation (including
those with mild COPD rather than a focus on severe COPD) –
recognising the improvement in exercise capacity and quality
of life
 Medicines optimisation: supporting respiratory patients to
receive and use the right medications
 Improved response to pneumonia – relieving the pressure,
particularly during winter

25. This dashboard aims to support effective
delivery of the COPD Discharge Care
Bundle. Supporting improvement in the
care of hospitalised COPD patients,
reducing variation and ultimately
improving patient safety and care on
discharge.
COPD Dashboard

27. COPD Dashboard – What is ACS?
Discharge Status Measure 1 Measure 2 Measure 3 Measure 4 Measure 5 Measure 6 ACS Score
Patient 1 A 1 1 1 1 1 1 1
Patient 2 A 0 0 0 0 0 1 0
Patient 3 A 1 1 1 1 1 1 1
Patient 4 A 1 1 0 Excluded 1 1 0
Patient 5 A 1 0 1 0 1 0 0
Patient 6 A 1 1 1 1 1 1 1
Patient 7 D 0 0 0 0 0 0 Excluded
Patient 8 A 0 0 1 1 0 1 0
Patient 9 A 1 1 0 0 1 1 0
Patient 10 A 1 1 1 Excluded 1 1 1
Patient 11 A 1 1 1 1 1 0 0
Total 4
𝐴𝐶𝑆 % =
𝐴𝐶𝑆 𝑆𝑐𝑜𝑟𝑒
𝐿𝑖𝑣𝑒 𝐷𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠
=
4
10
= 40%

28. COPD Dashboard – What is CQS?
CQS % =
𝐶𝑄𝑆 𝑆𝑐𝑜𝑟𝑒
𝐴𝑙𝑙 𝑚𝑒𝑎𝑠𝑢𝑟𝑒𝑠 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑒𝑙𝑒𝑔𝑖𝑏𝑙𝑒 𝑓𝑜𝑟 (𝑙𝑖𝑣𝑒 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠)
=
43
58
= 74%
Discharge Status Measure 1 Measure 2 Measure 3 Measure 4 Measure 5 Measure 6 CQS Score
Patient 1 A 1 1 1 1 1 1 6
Patient 2 A 0 0 0 0 0 1 1
Patient 3 A 1 1 1 1 1 1 6
Patient 4 A 1 1 0 Excluded 1 1 4
Patient 5 A 1 0 1 0 1 0 3
Patient 6 A 1 1 1 1 1 1 6
Patient 7 D 0 0 0 0 0 0 Excluded
Patient 8 A 0 0 1 1 0 1 3
Patient 9 A 1 1 0 0 1 1 4
Patient 10 A 1 1 1 Excluded 1 1 5
Patient 11 A 1 1 1 1 1 0 5
Total 43

33. Additional features – coming shortly:
• Score card infographic
• COPD case ascertainment
• Outcomes
• Detailed user-guide (brief instructions can currently be found on each tab)
• Ability to access via mobile or tablet device
COPD Dashboard – What is next?

34. Ellie Wells, Programme Manager
Tom Myers, Senior Analyst
Peter Carpenter, Service Delivery Director
Clinical Leads:
Dr Jo Congleton, Respiratory Clinical Lead, KSS AHSN &
Integrated Respiratory Care Consultant, Brighton & Sussex University
Hospitals NHS Trust
Julia Bott, Respiratory Clinical Lead & Consultant Physiotherapist, KSS
AHSN
Patient Safety Lead:
Ursula Clarke, Senior Programme Manager
Our Team
Contact
Ellie Wells, Programme Manager: ellie.wells@nhs.net
Kent Surrey Sussex Academic Health Science Network Phone: 0300 303 8660 Website: www.kssahsn.netnet

35. NACAP COPD Audit:
National context, discharge bundle and BPT
Liam Shanahan
Project Manager
National Asthma and COPD Audit Programme

36. NACAP background
• Commissioned by the Healthcare Quality Improvement
Partnership (HQIP). Part of the National Clinical Audit
and Patient Outcomes Programme (NCAPOP).
• Deliver secondary care audits across England and
Scotland and primary and secondary care audits in
Wales.
• National Asthma and COPD Audit Programme (NACAP)
covers 6 workstreams.
• Overarching aim of NACAP is to improve the quality of
care, services and clinical outcomes for patients with
asthma and COPD.

38. COPD reporting
• A suite of reports are produced as part of the
COPD audit, including:
– Annual national clinical and outcomes reports
(including site level and patient friendly versions)
– Six-monthly regional reports (STP level)
– Six-monthly case ascertainment reports
– Quarterly Best Practice Tariff (BPT) reports
• National, regional and BPT reports are published
on the audit website. Case ascertainment is
published on the NACAP COPD website.

39. COPD reporting
• National reports are
published in May
each year.
• Most recent report
published in May
2019, covering
patients discharged
between September
2017 and 2018.
• Data cutoff for next
national report is 8
November

40. Key findings
• 21% of patients
that received NIV
did so within 2
hours of arrival
• 64% of admissions
were reviewed by a
member of the
respiratory team
within 24 hours
• 67% of admissions
were recorded as
having a discharge
bundle

41. National context
• The audit contributes to a series of national
programmes aimed at improving patient
safety and reducing unwarranted variation:
– Best Practice Tariff (BPT)
– Care Quality Commission (CQC) visits
– Getting It Right First Time (GIRFT)
– Patient Safety Collaboratives

42. Best Practice Tariff (BPT)
• The BPT is a payment designed to incentivise
and reimburse best practice care
• It is based on audit performance against two
metrics:
– Respiratory review within 24 hours
– Completion of a discharge bundle
• 60% of patients entered into the audit need to
have both elements completed for Trusts to
be eligible for a BPT payment

43. Best Practice Tariff (BPT)
• Payment is split into two components:
– A base price paid regardless of whether the
patient meets the BPT criteria
– A BPT price (top-up payment) payable if all
requirements are met
• More information is available on the NHS
Improvement website or by contacting the
Pricing team at pricing@improvement.nhs.uk

44. • Audit run charts are available through the ‘Reports’ link at the top
of the audit web page.
• Show your hospital’s performance compared to national averages
for BPT, NIV, oxygen, readmissions, smoking and spirometry
• Updated every 15 minutes

45. COPD Discharge Bundle
• A series of high-impact actions to ensure the
best clinical outcome for patients admitted
with an acute exacerbation of COPD.
• Aim is to reduce readmissions after patients
are discharged.
• British Thoracic Society COPD Discharge Care
Bundle includes five items that should be
addressed when a patient is discharged.

47. COPD Discharge Bundle
• In October 2018,
the discharge
question was
changed to
include elements
of best practice
care that had
been delivered.
• Patients should be
provided with as
many elements as
is relevant to
them, which
should be
recorded as part
of the audit

48. Exporting data
• The BPT looks at whether a discharge bundle
was provided, but it doesn’t look at individual
elements.
• You can export your audit data to look at your
completion of each element of good practice.
• The export function is available in the top
ribbon on the audit web page.

49. • Dataset v2 includes the elements of good practice
• Only choose custom fields if you have set this up
previously
• Select by date – decide whether you want to choose
patients based on admission date, arrival date or
discharge date

50. • Click on the data export to open the file
• Individual elements of the discharge bundle are
listed in columns AY to BI
• REMEMBER – these files contain patient
identifiable information

51. Future developments
• A discharge bundle run chart to look at
completion of individual elements has been
proposed.
– Suggested to only look at the five BTS discharge
bundle elements
• Pivot tables are being developed to allow
more in-depth manipulation of the data.

52. Rolling it all into quality improvement
Local
Sites
NACAP Audit QI
2018-21
External
resources
Workshops
and training
Internal
resources
QI support
to teams
BPT
CQC
Use of
high-level
change
levers
GIRFT
BPT
Reporting
Lobbying
Workshops
Bespoke
support to
devolved
nations
Streamlined
reporting
Real-time
feedback
Dissemination
Support to
enter data
Data
collection
and
feedback
In audit
development
Outputs
Dissemination
Empowerment
Patient and
public
engagement

53. Questions?
copd@rcplondon.ac.uk
020 3075 1526
www.rcplondon.ac.uk/nacap
@NACAPaudit

54. Living with COPD
Ian Kenworthy

55. Smoky/Sneezy/Wheezy/Phlegmy/Snotty/Chesty and Grumpy
The Seven Bronchitic Dwarfs

57. ‘O.K. Ian take a few deep breaths’

58. Creative Doctor / Nurse to Patient
Consult
Review
Educate
Assess
Team
Encourage

60. Being inhospitable
Being in hospital…
Inhospitable ‘ A harsh and difficult place to be in’

62. The Gastroenterologist
I know it is a debilitating disease and at times difficult but my philosophy on life is there is no
cure so live with it and get on with life

63. Discharged with a new inhaler
????

64. The Theophylline Incident

65. Taking Inhalers Correctly

66. Self Management Plan

68. Pulmonary Rehabilitation

69. We all need some inspiration in life, my Granddaughter provides more than enough of this and
certainly keeps me on my toes. I used to look after her every Monday but in September she
started school.

70. Breathe Easy Tameside

71. You only get
out of life
what you put
into it
It is easy to sit back and just take what comes but do you really get any satisfaction from that?

72. ‘You must have
nothing better
to do with
your time’
I was at a BLF user event, probably about 18 months ago, I had just told everyone what I
was involved in and a lady said this sentence to me… I was a bit upset and disappointed at
the time, but then having thought about; this sentence is perfect. Because is cannot think
of a better way to spend my time, than working and helping to improve the care and
service that patients with lung disease deserve and should ultimately get!

74. W’S
Has anyone ever seen this guy smile?
The controversial white paper, soft, strong and very long. But what is it currently
doing for patients?

75. Cutting existing services and delaying any decisions for new or improved
ones.
Our primary care trusts were growing, adding cost implications, but not
improving services so I can see the reasoning for changes.
When I first became involved, the people in managerial roles were ex
GP’s, Nurses or had been involved in NHS roles.
Over the last 6 or 7 years this has changed. We now have new graduates,
with no idea about the intricacies of the NHS or medical qualifications.
They may be good at producing statistics, but does this really help
patients?

76. ‘I have a dream’
Early diagnosisSelf Management plans
Quality spirometry Quality P.R.programmes
O2 Assessment service
Care by Respiratory team in hospital
Please help me to realise my dream

77. Thank you for your time and for listening
Any questions?
‘Sweet Dreams’
Have a great day

78. MyCOPD – digitally
enhancing the COPD Bundle
Dr Binita Kane
27th Sept 2019

79. DISCLAIMER
• These are largely not my slides
• I am not an expert in the MyCOPD evidence base
• I will be calling on Jane Stokes to help me out

80. What is MyCOPD?
myCOPD a complete self-management solution with
wide range of resources including inhaler technique,
delivering education and a complete online pulmonary
rehabilitation class
Clinician developed

81. myCOPD -The Story so Far
• First app on NHS app store and only app to be nationally
endorsed & NHS funded
• National roll out with over 100 separate commissioning bodies
in the UK
• Rapid expansion of patient users 12,000 + and growing monthly
1000+
• Overall patient activation rates 43% (up to 90% with engaged
clinical teams)
• App use data at 3months from activation – median use x 5 per
week
• Dramatic impacts where services have reconfigured to use
digital effectively (PR capacity increased by 129% Essex UK)

82. The Sceptics
• Where’s the evidence?
• How much has the NHS paid for this?
• My patients won’t use it
• We should we paying for pulmonary
rehab instead
• It a deal with a big corporate firm

83. My personal view

84. What is the evidence base?
How does this fit with the COPD bundle?

85. MyPR

86. Challenges with Delivery of PR
• Face to Face Pulmonary rehabilitation not accessible to all
• Service Factors
• Geography
• Timings - working patients
• Resources
• Staff
• Venues
• Costs
• Patient factors
• Housebound
• Social Anxiety
• CostsAttendance rates and Completion rates are sub optimal
Fischer MJ, Scharloo M, Abbink JJ, ‘t HulAlexJ., van Ranst D, Rudolphus A, Weinman J, Rabe KF, Kaptein AA. Drop-out and attendance in pulmonary rehabilitation: The role of clinical and psychosocial variables. Respiratory Medicine. 2009 Oct;103(10):1564–71
Arnold E, Bruton A, Ellis-Hill C. Adherence to pulmonary rehabilitation: A qualitative study. Respiratory Medicine. 2006 Oct;100(10):1716–23

87. Online Versus Face to Face Pulmonary Rehabilitation
for Patients with COPD: A Randomised Controlled
Trial
• A two-arm parallel single-blind, randomised controlled trial. 2:1
randomisation.
• The online arm carried out pulmonary rehabilitation in their
own homes
• Face-to-face arm carried out PR in a local rehabilitation facility
• Inclusion – anyone eligible for PR

88. Results: Patient Flow

89. Patient Selection and Characteristics
Baseline variables Face-to-face PR (n=26) Online PR(n=64)
Age (years), mean (SD) 71.4 (8.6) 69.1 (7.9)
Gender (male), n (%) 18 (69) 41 (62)
Smoking, n (%)
Current smoker 6 (23) 9 (14)
Ex-smoker 20 (76.9) 55 (85.9)
COPD severity, n (%)
Mild 5 (19) 15 (23)
Moderate 13 (50) 26 (41)
Severe 7 (27) 17 (27)
Very severe 1 (4) 6 (9)
FEV1, mean (SD) 1.66 (0.67) 1.63 (0.71)
FEV1 predicted, mean (SD) 60.5 (20.1) 58.0 (23.6)
FVC, mean (SD)
FVC predicted, mean (SD) 83.2 (21.2) 88.4 (22.0)
comorbidities F2F n (%) Online n(%)
Hypertension 7 (26.9%) 23 (35.9%)
Cardiovascular Disease 13 (50%) 22 (34.3%)
Cerebrovascular Disease 1 (3.8%) 5 (7.8%)
Dermatological 0 7 (10.9%)
Diabetes and endocrine 6 (23.1%) 14 (21.9%)
Gastroenterological 5 (19.2%) 21 (32.8%)
Haematological 1 (3.8%) 1 (1.6%)
Neurological and Psychiatric 3 (11.5%) 11 (17.2%)
History of Malignancy 3 (11.5%) 4 (6.3%)
Musculoskeletal 7 (25.9%) 9 (14.1%)
Renal 2 (7.7%) 2 (3.1%)
Other Respiratory 1 (3.8%) 3 (4.7%)
None 3 (11.5%) 4 (6.3%)

90. Summary of results
• Results: Non- Inferiority of all end points –
6MWTD and CAT with difference between
intervention arms in favour of on-line arm for
all measures.
• Conclusion A six week programme of online
supported PR was not-inferior to a
conventional model delivered in face-to-face
sessions in terms of effects on six minute
walk test distance, and symptom scores and
was safe and well tolerated.
360
370
380
390
400
410
420
430
440
450
6MWTD
(m)
Pre Post

91. Admission and Readmission
• Rising readmission rates for AE
COPD
• 43% of patients readmitted within
3 months
• Risen from 33% in 2008 despite
improved provision of PR and
integrated care services
Role for MyCOPD?

93. Study Conduct
Patient
Identified by
Hospital by
Hospital
Team
Patient given
PIS
Research Team
Contact patient
and arrange Visit
1
Study team carry out
Visit 1 at patients home
Wrtten Consent
Pre Intervention
Questionnaires
Inhaler technique
Randomised
to Study
1:1 Ratio to
receive
written or
myCOPD
myCOPD
demonstrated
to patient
Written plan
demonstrated
to patient
3 month
access to plan
monthly
phone calls to
record CAT
3 month
access to
myCOPD
monthly
phone calls to
record CAT
Blinded team carry out Visit 2 at patients home
Confirm Consent, Post Intervention questionnaires,
Inhaler technique

94. Population
124
Patients
given PIS
41
Randomise
d
1:1
Written
Self
Managem
ent
21
myCOPD
20
3
Withdrew
3
Withdrew
17
Complete
d
18
Complete
d
• Aged 45-80
• COPD Diagnosis
• Admitted with
AECOPD
• Currently taking
inhaled therapies
• Current or E
smokers with a
pack year history of
>10
• Access to the
internet
• Ability to operate a
web based platform
or use a written
SMP.
905 Respiratory
Patients Reviewed
on Ward
Inclusion Exclusion
• Other respiratory
conditions as a main
complaint
• Patient unable to read or
use the internet
• Patient with other
uncontrolled medical
conditions which would
confound the impact od
a COPD directed support
tool

95. GROUP A – WRITTEN GROUP B - MYCOPD
0
1
0
2 2
1
4
2
1
2 3
2
10
02468
<55 55-59 60-64 65-69 70-74 75-79 80+
Age band
Male
Female
10
2
1
1
4 5
2
20 20
02468
<55 55-59 60-64 65-69 70-74 75-79
Age band

96. Variable
Usual (n=21) myCOPD(n=20)
Cohort
(N=41)
n
%
(col)
n % (col) n
%
(col)
Sex
Male 11 52.4 13 65.0 24 58.5
Female 10 47.6 7 35.0 17 41.5
Age
< 55 1 4.8 1 5.0 2 4.9
55-59 2 9.5 3 15.0 5 12.2
60-64 3 14.3 5 25.0 8 19.5
65-69 6 28.6 7 35.0 13 31.7
70-74 3 14.3 2 10.0 5 12.2
75-79 5 23.8 2 10.0 7 17.1
80+ 1 4.8 0 0.0 1 2.4
COPD severity
Moderate 10 47.6 4 20.0 14 34.2
Severe 6 28.6 11 55.0 17 41.5
Very
severe
5 23.8 5 25.0 10
24.4
Smoking status
Current
smoker
5 23.8 7 35.0 12
29.3
Ex-smoker 16 76.2 13 65.0 29 70.7
Variable Usual (n=21) myCOPD (n=20) Cohort (N=41)
Pack years
Mean (SD) 59.9 (32.5) 52.2 (39.8) 56.1 (36.0)
Median (IQR) 56.0 (44.0, 65.0) 45.0 (27.0, 53.0) 50.0 (40.0, 60.0)
FEV1 % predicted
Mean (SD) 46.5 (17.8) 41.5 (17.5) 44.1 (17.6)
Median (IQR) 48.0 (32.0, 61.0) 37.0 (29.5, 49.5) 42.0 (31.0, 58.0)
FVC % predicted
Mean (SD) 80.1 (21.0) 71.1 (22.3) 75.8 (21.8)
Median (IQR) 84.0 (72.0, 96.0) 69.0 (49.0, 95.0) 74.5 (61.0, 95.5)

97. RESULTS

98. Primary Outcome – CAT score
Group A – Written Group B - MYCOPD
Variable Coefficient 95% CI P-value
Timepoint
1 Reference
2 -3.778 -5.813 -1.742 <0.001
3 -5.406 -7.524 -3.289 <0.001
4 -3.450 -5.484 -1.417 0.001
Study arm
A Reference
B -4.752 -8.797 -0.706 0.021
Variance parameter () = 37.227
Patients in myCOPD arm had a differential of -4.8 points (95% CI: -8.8, -0.7) compared to usual care
group, (p = 0.021),

99. SECONDARY OUTCOME – INHALER TECNIQUE
GROUP A - WRITTEN GROUP B – MYCOPD
01234
TotalNumberofInhalers
0 2 4 6 8 10 12 14 16 18
Total Number of Errors
Arm A
Arm B
01234
0 2 4 6 8 10 12 14 16 18
Total Number of Errors
Patients in MyCOPD arm had a differential of -1.2 errors (95% CI: -2.0, -0.3) compared to usual care, (p=0.008)
Category
Arm A (n=21) Arm B (n=20)
Pre-intervention Post-intervention Pre-intervention Post-intervention
Count of errors 100 72 101 20
Mean (SD) 5.0 (3.3) 4.0 (5.0) 5.1 (3.1) 1.2 (1.7)
Median (IQR) 5.0 (2.5, 6.5) 2.0 (1.0, 4.0) 4.5 (3.0, 7.0) 0.0 (0.0, 2.0)

100. SECONDARY OUTCOME – EXACERBATIONS
The results indicate that, after adjusting for the number of exacerbations at baseline, patients in MyCOPD
arm had a differential of -0.6 exacerbations (95% CI: -1.2, 0.0) compared to usual care, (p = 0.047)
Readmission rates were lower in digital arm 4 vs 13.
Pre Written
68
Post
Written
34
Pre
myCOPD
58
Post
myCOPD
18
Exacerbation Rates
Pre Written
30
Post
Written
13
Pre
myCOPD
29
Post
myCOPD
4
Admission Rates

101. Secondary outcomes - MRC
Category
Arm A (n=21) Arm B (n=20)
Pre-
interventi
on
Post-
interventio
n
Pre-
interventio
n
Post-
interventio
n
n
%
(col
)
n
%
(col)
n
%
(col)
n
%
(col)
0 0 0.0 0 0.0 1 5.0 1 5.0
1 2 9.5 3 14.3 2 10.0 3 15.0
2 5
23.
8
4 19.1 5 25.0 1
5.0
3 3
14.
3
5 23.8 2 10.0 7
35.0
4 11
52.
4
6 28.6 10 50.0 4
20.0
Missing
observatio
n
0 0.0 0 0.0 1 5.0 1
5.0
Patient
withdrawn
0 0.0 3 14.3 0 0.0 3
15.0
Mean (SD) 3.1 (1.1) 2.8 (1.1) 2.9 (1.3) 2.6 (1.3)
Median
(IQR)
4.0 (2.0,
4.0)
3.0 (2.0,
4.0)
4.0 (2.0, 4.0)
3.0 (1.5,
3.5)
Overall both arms of the study showed slight improvement with a
mean reduction of 0.3 although not significant p0.953
Pre Written
3.1
Post Witten
2.8
Pre
myCOPD
2.9
Post
myCOPD
2.6
MRC

102. Secondary outcome – Patient Activation
measurement
Category
Arm A (n=21) Arm B (n=20)
Pre-
intervention
Post-
intervention
Pre-
intervention
Post-
intervention
n
%
(col)
n
%
(col)
n
%
(col)
n
%
(col)
1 7 33.3 7 33.3 3 15.0 1 5.0
2 5 23.8 2 9.5 5 25.0 2 10.0
3 6 28.6 4 19.0 9 45.0 8 40.0
4 3 14.3 3 14.3 3 15.0 5 25.0
Missing
observation
0 0.0 2 9.5 0 0.0 1
5.0
Patient
withdrawn
0 0.0 3 14.3 0 0.0 3
15.0
Mean (SD) 54.0 (11.2) 56.1 (18.5) 59.7 (11.4) 64.7 (13.5)
Median (IQR)
53.2 (47.0,
58.1)
51.1 (43.9,
65.4)
59.4 (52.1,
64.3)
60.6 (55.6,
73.8)
This test indicated that patients in Arm B had a mean differential of +4.3 points (95% CI: -8.0, 16.7)
compared to Arm A, although this was not statistically significant (p = 0.479).
Pre Written
54
Post
Written
56.1
Pre
myCOPD
59.7
Post
myCOPD
64.7
PAMS

103. Secondary Outcome - SGRQ
Category
Arm A (n=21)
Arm B (n=20)
Pre-
intervention
Post-
intervention
Pre-
intervention
Post-
intervention
n
%
(col)
n % (col) n
%
(col)
n
%
(col)
Missing
observation
0 0.0 2 9.5 0 0.0 1
5.0
Patient
withdrawn
0 0.0 3 14.3 0 0.0 3
15.0
Mean (SD) 68.1 (13.7) 64.1 (15.9) 66.4 (16.6) 61.9 (14.9)
Median (IQR)
70.2 (57.2,
77.8)
67.2 (53.2, 74.1)
71.9 (60.6,
77.0)
65.6 (59.3,
71.6)
This test indicated that patients in Arm B had a mean
differential of -0.3 points (95% CI: -6.6, 5.9) compared to Arm
A, although this was not statistically significant (p = 0.911).
Pre Written
68.1
Post Written
64.1
Pre myCOPD
66.4
Post
myCOPD
61.9
SGRQ

104. Secondary outcome – Hospital anxiety and
depression scale
Category
Arm A (n=21)
Arm B (n=20)
Pre-
intervention
Post-
intervention
Pre-
intervention
Post-
intervention
Mean (SD) 18.1 (6.1) 18.1 (7.8) 18.9 (10.6) 15.5 (8.9)
Median (IQR)
19.0 (14.0,
22.0)
18.5 (13.0,
21.0)
17.0 (11.5,
27.5)
12.0 (10.0,
21.0)
Arm B had a mean differential of -3.0 points (95% CI: -7.4, 1.3)
compared to Arm A, although this was not statistically
significant (p = 0.166).
Pre Written
18.1
Post Written
18.1
Pre myCOPD
18.9
Post
myCOPD
15.5
HAD

105. Summary
Those patient randomised to myCOPD overall made greater
improvements than those randomised to a written plan though not all
outcomes were clinically significant
Greatest clinically significant improvements were to CAT symptom
score, inhaler technique and a reduction in the number of critical
errors and exacerbation rates.
The cohort is small in size and the intervention period short
Need for larger RCT or RWE Trial – with full Health economic analysis

106. Real World Evidence

107. Real World Evidence
(C) my mhealth limited 2018 - Not for distribution outside agreements

108. 0
2
4
6
8
10
12
Very Easy 41% Easy 45% Adequate 9% Difficult 0% Very Difficult 5%
How easy did you find myCOPD to use?
How Easy did you find
MYCOPD to use?
Very easy: 41%
Easy: 45%
Adequate: 9%
Difficult: 0%
Very Difficult: 5%

109. 0
2
4
6
8
10
12
Extremely helpful
32%
Very helpful 50% Helpful 14% Not helpful 5% Unsatisfactory 0%
Overall, how helpful did you find myCOPD for
looking after you COPD
Overall, how helpful did you
find myCOPD for looking after
your COPD?
Extremely helpful: 32%
Very Helpful: 50%
Helpful: 14%
Not helpful: 5%
Unsatisfactory: 0%

110. 0
2
4
6
8
10
12
14
Extremely helpful
32%
Very helpful 55% Helpful 14% Not helpful 0% Unsatisfactory 0%
How would you rate the 'education' section?
How would you rate the
education section?
Extremely helpful: 32%
Very Helpful: 55%
Helpful: 14%
Not Helpful: 0%
Unsatisfactory: 0%

111. 0
2
4
6
8
10
12
Extremely helpful
45%
Very helpful 31% Helpful 23% Not helpful 0% Unsatisfactory 0%
How would you rate the inhaler videos?
How would you rate the
inhaler videos?
Extremely Helpful: 45%
Very helpful: 31%
Helpful: 23%
Not helpful: 0%
Unsatisfactory: 0%

112. 0
2
4
6
8
10
12
14
Extremely helpful
23%
Very helpful 55% Helpful 13% Not helpful 5% Unsatisfactory 5%
how would you rate the pulmonary rehab section?
How would you rate the
pulmonary rehab section?
Extremely helpful: 23%
Very helpful: 55%
Helpful: 13%
Not helpful: 5%
Unsatisfactory: 5%

113. 0
2
4
6
8
10
12
Extremely
confident 23%
Very Confident
45%
Confident 27% Hardly confident
0%
Not confident at
all 5%
Since using MyCOPD how confident are you that
your symptoms are more controlled?
Since using MyCOPD how
confident do you feel about
looking after your COPD?
Extremely confident: 23%
Very confident: 45%
Confident: 27%
Hardly confident: 0%
Not confident at all: 5%

114. Would you recommend
MyCOPD to friends and family
with COPD?
Definately recommend 50%
Highly recommend 32%
Recommend 13%
Might recommend 5%
Would not recommend 0%
0
2
4
6
8
10
12
Definitely
recommend 50%
Highly
recommend 32%
Recommend 13% Might
recommend 5%
Would not
recommend 0%
Would you reccommend MyCOPD to friends and
family with COPD

115. • I dislike having sore legs after some of
the exercise’s
• I like having more knowledge now
about my condition.
• I liked the COPD assessment test and
pulmonary rehabilitation sections.
• I liked all aspects of the site especially
that it is monitored by a member of
staff available.
• I didn't like the initial log on part as this
was a real issue.
Is there anything your particularly
like/dislike about MYCOPD?
What can be done to improve myCOPD?
• A part about diet and exercise would be
beneficial.
• It would benefit from a diary section
where examples of activities that cause
particular difficulties could be recorded
or times of the day that are more
troublesome. Could also record the
efficiency of medication frequency of use
and when it wears off etc.
• A section on smoke related illnesses and
assistance in stopping smoking.
• Great as it is.
• No improvement required.
• No

116. Southend

117. Southend hybrid model
• In August 2018 Southend introduced a hybrid model of pulmonary
rehabilitation delivery with patients offered the choice of mode of
delivery (further detail provided on the next slide)
• The aims of the new model were
• to increase completion rates
• Increase patients through the service
• To ensure parity of care delivered irrespective of mode of delivery

118. Centre-based Option
(SUHFT/Hockley/Canvey/St Luke’s Church) -
face to face sessions and tailored exercise.
• Initial centre-based assessment
• 12 sessions, supervised by a
physiotherapist, combining
exercise and education over 6
weeks
• Attendance is twice weekly
• myCOPD licence or BLF materials
• Priority access for current
inpatients with a respiratory-
related exacerbation
• Assessment session on completion
to measure improvement
• Personalised exercise plan on
discharge
Hybrid Option – Get both face to face
sessions & tailored exercises, and
myCOPD
• Initial centre-based assessment
• 6 supervised exercise sessions
over 6 weeks combined with
additional exercise and
education accessed at home via
MyCOPD app (or BLF materials if
no internet access)
• Attendance is once weekly
• Assessment session on
completion to measure
improvement
• Personalised exercise plan on
discharge
Home-based Option – Just exercise
from myCOPD – regular phone calls.
• Initial centre-based
assessment
• Exercise rehabilitation and
education accessed at
home via MyCOPD app (or
BLF materials if no internet
access)
• 6 weeks to complete
programme
• Regular phone call to
monitor progress
• Assessment session on
completion to measure
improvement
• Personalised exercise plan
on discharge
Study: 3 armed study into the use of myCOPD in pulmonary rehabilitation.
They all have an initial centre based assessment

119. 1 year results
Pre – service remodeling – August 2018
• Completion rates 40%
• Patients through the service per year = 181
Post – service remodeling – August 2019
• Completion rates 72%
• Patients through the service per year = 384
• Parity of care delivered with all modes as evaluated through 6MWST

120. Where are we up to in GM?
Locality Licences
Secured
Licences
Distributed
Training
Delivered
Patient
Enrolment
NHS Bolton CCG - - - -
NHS Bury CCG - - - -
NHS Heywood, Middleton & Rochdale CCG 745 67 ● ●
NHS Manchester CCG 1678 - ● -
NHS Oldham CCG 768 - ● -
NHS Salford CCG - - - -
NHS Stockport CCG 942 - ● -
NHS Tameside & Glossop CCG 924 19 ● ●
NHS Trafford CCG 601 - ● -
NHS Wigan Borough CCG 1094 - ● -
● In progress
● Completed

121. What are the known barriers to success?
• Just giving out licenses in isolation and expecting patients to use it
• No integration into clinical pathways
• Internet access
• Access to smart devices
• Digital awareness/ enablement

122. 123
My COPD
Digital Motivators
• Digital Motivators will build
confidence in people living with
COPD to access, use and
understand the different elements
of the app.
• Digital Motivators may or may not
have lived experience of COPD e.g.
parents or relatives living with
COPD. It is envisaged that Digital
Motivators could be identified from
local schools, Breathe Easy groups
and the voluntary sector.

123. Things to think about
• Does your CCG have licenses, has your team been engaged?
• How will this be deployed and by whom?
• What will we measure (depends on context)
• It doesn’t have to be complicated – but measurement is the only way
to prove cost effectiveness!
• If we prevent a few hospital admissions, it has paid for itself
• Can we create some GM-wide measures?

124. Thank you for listening

125. Liberating Structures
1:2:4:All

126. Liberating Structures
Collection of 35 tools
that are:
Simple and easy to use
Involve everyone at all
levels
Encourage lively
participation
Action focussed

127. Engaging everyone in generative conversation
1-2-4-ALL
Silent self-reflection: 1 min.
Generate ideas in pairs, building on ideas
from self-reflection. 2 min.
Share and develop ideas from your pair in
foursomes (notice similarities and
differences). 4 min.
“What is one idea that stood out in your
conversation?” 5 min.
Your question in response to an issue, problem, or proposal

128. Adopt & Spread PSC COPD
Discharge Bundle
Health Innovation Manchester

129. Aim: Improvement in one or more bundle elements by March 2020

130. COPD Discharge elements
1
1a. Review of medication &
1b. inhaler technique
2
2a. Provide written self-management plan/
refer to community team for plan &
2b emergency drug pack
3
Assess and offer referral
for smoking cessation
4
Assess for suitability for
Pulmonary Rehab
5
Appropriate follow-up call
within 72hrs of discharge

131. 30-60-90 day planning
Jo Higgins
AQ Senior Improvement Advisor
Liz Kanwar
AQ Programme Manager

132. Where to start?
10 steps:
1. Think differently
2. Use a simple, systematic approach to plan your improvement
3. Be clear and focused
4. Identify who you will ask to help you
5. Think about how you might involve others
6. Organise your time
7. Make a change and evaluate it to see if it worked
8. Document your project to show what you have learned
9. Consider sustainability
10.Now take that first step and get started – 30/60/90 day plan

133. Why a 30-60-90 day plan?
• A 30-60-90 day plan lays out a clear course of
action for you during the first 30, 60, and 90
days of your project
• Facilitates setting of concrete goals and a
vision for your abilities at each stage of the
plan
• Helps you identify key areas/actions to be
undertaken to promote your project
• Set out in stages it will help focus on specific
tasks/engagement required to progress your
plan

134. 1. Our high impact actions 2. One action that we commit to delivering or testing in the next 90 days:
3. Why is it important? 4. Changes required to help achieve the
action in 90 days
5. Who’s involved and who could be involved: 6.How do we know we’ve made a difference? (measures)
Actions in next 30 days: Actions in next 60 days: Actions in next 90 days: Help required:
Organisation Name
What will we do in
the next 60 days?
Aim What do you want to achieve?
Education
Data
Monitoring
Why is this important – to
patients/ staff
Team - and other stakeholders?
What will we do in
the next 30 days?
What will we do in
the next 90 days?
Who do you need to
help who isn’t
directly involved?
Resources?
What changes will need to
happen to succeed in 90
day plan?
Measures to demonstrate improvement
Improvement/change idea

135. 1. Our high impact actions 2. One action that we commit to delivering or testing in the next 90 days:
3. Why is it important? 4. Changes required to help achieve the
action in 90 days
5. Who’s involved and who could be involved: 6.How do we know we’ve made a difference? (measures)
Actions in next 30 days: Actions in next 60 days: Actions in next 90 days: Help required:
Organisation Name
Additional training as
required
Devise process for
patient identification
and review
Aim Increase the number of patients having their inhaler technique checked from 30% to 60% by March 2020.
Data – patient review
Education – inhaler
technique review
Monitoring - measures
to assess improvement
Correct technique improves
patients’ ability to self-manage
May prevent admissions for acute
exacerbations and reduce
emergency medication use
Respiratory team: specialist nurses, doctors,
pharmacists, HCAs, physiotherapists; BI team
Review baseline data
on patients receiving
review and not
Identification of team
members able to
review technique
Test process on
sample of wards
initially
Measure, review and
roll out
Commitment from
senior staff to support
resource use
Information for patients
on why this is necessary
List of patients admitted with COPD
exacerbation obtained each day
Training additional staff to review
Number of patients with completed inhaler
technique review recorded in bundle
documentation/notes; could measure by ward
Assign dedicated team members to review patients’ technique

136. Completing the plan
• Brain dump!
• Understand the current system:
- Use profound knowledge
- Data availability
- Actions you and your team can take to understand the COPD
bundle process within your organisation
• Ideas and actions to support improvement in delivery/compliance

137. Completing the plan
• 1hr 20 mins allocated for discussion and planning including working
coffee break
• Plan within teams across delivery area – hospital team/community
team
• Discussion and sharing
• Completed examples on tables
• Coaches in room to support and advise

138. INDIVIDUAL BUNDLE ELEMENTS RECORDED AND
REPORTED ON FROM OCTOBER 2018 DISCHARGES
OCTOBER
2018
AQuA RECEIVES NACAP DATA SHARED BY
PARTICIPANT TRUSTS
AQuA PRODUCES A REPORT QUARTERLY
WHICH IS CIRCULATED TO TRUSTS
REPORT GIVES OVERVIEW OF TRUST
PERFORMANCE AND PEER COMPARISON

139. 8 TRUSTS PARTICIPATING
AINTREE
LANCASHIRE TEACHING
MANCHESTER FT
MID-CHESHIRE
PENINE ACUTE
ROYAL LIVERPOOL
SALFORD
SOUTHPORT & ORMSKIRK
11 SITES IN TOTAL

140. AQ REPORTS ON…

141. DISCHARGE BUNDLE COMPLETE
OCT 18 – JUN 19 DISCHARGES
2248/4171 ADMISSIONS

142. DISCHARGE BUNDLE COMPLETION RATE BY TRUST
OCT 18 – JUN 19 DISCHARGES

143. BLF PASSPORT
EMERGENCY DRUG PACK
FOLLOW UP
INHALER TECHNIQUE
MEDICATION ISSUED
OXYGEN ALERT CARD
PATIENT DISCUSSED AT MDT
PULMONARY REHABILITATION
SELF-MANAGEMENT
SMOKING CESSATION
DISCHARGE
BUNDLE
NACAP

144. BLF PASSPORT
OCT 18 – JUN 19 DISCHARGES
466/4204 ADMISSIONS

145. BLF PASSPORT
OCT 18 – JUN 19 DISCHARGES
HIGHEST
ROYAL LIVERPOOL
51.6%

146. EMERGENCY DRUG PACK
OCT 18 – JUN 19 DISCHARGES
1013/4204 ADMISSIONS

147. EMERGENCY DRUG PACK
OCT 18 – JUN 19 DISCHARGES
HIGHEST
AINTREE
71.2%

148. FOLLOW UP
OCT 18 – JUN 19 DISCHARGES
1052/4204 ADMISSIONS

149. FOLLOW UP
OCT 18 – JUN 19 DISCHARGES
HIGHEST
SALFORD
59.0%

150. INHALER TECHNIQUE
OCT 18 – JUN 19 DISCHARGES
2129/4204 ADMISSIONS

151. INHALER TECHNIQUE
OCT 18 – JUN 19 DISCHARGES
HIGHEST
AINTREE
86.7%

152. MEDICATION ISSUED
OCT 18 – JUN 19 DISCHARGES
2458/4204 ADMISSIONS

153. MEDICATION ISSUED
OCT 18 – JUN 19 DISCHARGES
HIGHEST
LANCS. TEACHING
97.0%

154. OXYGEN ALERT CARD
OCT 18 – JUN 19 DISCHARGES
227/4204 ADMISSIONS

155. OXYGEN ALERT CARD
OCT 18 – JUN 19 DISCHARGES
HIGHEST
ROYAL LIVERPOOL
27.2%

156. PATIENT DISCUSSED AT MDT
OCT 18 – JUN 19 DISCHARGES
141/4204 ADMISSIONS

157. OCT 18 – JUN 19 DISCHARGES
HIGHEST
WYTHENSHAWE
18.3%
PATIENT DISCUSSED AT MDT

158. PULMONARY REHABILITATION
OCT 18 – JUN 19 DISCHARGES
1557/4204 ADMISSIONS

159. PULMONARY REHABILITATION
OCT 18 – JUN 19 DISCHARGES
HIGHEST
ROYAL LIVERPOOL
72.8%

160. SELF MANAGEMENT
OCT 18 – JUN 19 DISCHARGES
2086/4204 ADMISSIONS

161. SELF MANAGEMENT
OCT 18 – JUN 19 DISCHARGES
HIGHEST
AINTREE
74.2%

162. SMOKING CESSATION
OCT 18 – JUN 19 DISCHARGES
742/1545ADMISSIONS

163. SMOKING CESSATION
OCT 18 – JUN 19 DISCHARGES
HIGHEST
AINTREE
72.9%

164. COMPARISON BY BUNDLE ELEMENT
OCT 18 – JUN 19 DISCHARGES

165. 5 OR MORE BUNDLE ELEMENTS COMPLETED
OCT 18 – JUN 19 DISCHARGES

166. AQuA
CAN MATCH
PATIENTS IN TWO
DATASETS TO GET A
MORE HOLISTIC PICTURE

167. MORTALITY POST-DISCHARGE
AND FURTHER ADMISSIONS
PREVIOUS ADMISSIONS FOR
COPD AND OTHER REASONS
COMBORBIDITIES AND MORTALITY
RISK USING ICD-10 CODES

168. PERFORMANCE VARIES BETWEEN TRUSTS, AS
DOES WHICH ELEMENTS ARE RECORDED
AQuA ANALYSES NACAP DATA AND PRODUCES
QUARTERLY REPORT FOR TRUSTS
10 MEASURES, INCLUDING RECORDING OF
DISCHARGE BUNDLE
DATA ALSO AVAILABLE ON INDIVIDUAL ELEMENTS
OF DISCHARGE BUNDLE
AQuA CAN ALSO LINK TO SUS FOR PRE- AND POST-
DISCHARGE DETAIL AND COMORBIDITY