South London Practice Nurse

Launch Event

3rd November 2011

Matthew Hodson & Kirsty Barnes

HEIC COPD Fellows

A play of 2 half's

• Introduce to ACERs Team

• Integration & Challenges

• Organisation & Wider Picture in COPD

• Resources

• The Shine Project

Introducing ACERS

Acute COPD

Early Response Service Matthew Hodson

Nurse Consultant ACERS

Homerton University Hospital

Setting the scene in Hackney

COPD is projected to be the third

biggest killer by 2020

Murray & Lopez 1997

Ischaemic heart disease

CVD disease

Lower respiratory infection

Diarrhoeal disease

Perinatal disorders

COPD

Tuberculosis

Measles

Road traffic accident

Lung cancer

Stomach cancer

HIV

Suicide

1990 2020

3rd

6th

Diagnosis • Generally over 40 years1

• A smoker or ex-smoker (remember passive

smoking)

• Presentation with:

• cough

• excessive sputum

• dyspnoea (most common)

• Spirometry

• FEV1/FVC < 70%

• FEV1 – As per 2010 Guidelines 1. NICE 2010

No. of patients discharged with a diagnosis of COPD

380

508587

531617

830

0

100

200

300

400

500

600

700

800

900

2000 2001 2002 2003 2004 2005 2006 2007

Year

• Primary Care Support

• Community Based Rapid Response

• Emergency Department Intervention

• Early Supported Discharge

• Community Clinics

• Education

• End of Life Pathway

Service Model

To provide a comprehensive, integrated,

responsive community-focused COPD

service, for acute exacerbations and

ongoing chronic disease management,

which meets the diverse needs of City &

Hackney patients in a sustainable and

timely manner.

Service Philosophy

Who are we?

• 1 wte Nurse Consultant – Matthew Hodson

• 2 wte COPD Specialist Nurses

• 4 wte COPD Senior Staff Nurses

• 2 wte COPD Specialist Physiotherapists

• 1 wte COPD Team Administrator

• Medical Consultant Lead

Base: Respiratory Offices, Homerton Hospital

Patient GP

Practice

nurse

Clinic

Medical

Wards

Emergency

Department

Community

Matron

Other

health

professionals

ACERS

• Opening Hours (7 days, 8 am – 7 pm)

• Response Time (<4 hrs for community referral)

• Length of Care Package for H @ H within the

community (approx< 8 days)

• Focus on 30 and 90 days post exacerbation

• Referral in to PR – ASAP after exacerbation

• Medical Support (Close links with hospital team)

ACERS Core Features

Clinical Responsibility

• ACERS have regular contact with

Respiratory Consultant and SpR

• Easy access to hospital diagnostics

• Regular communication with Practice

Nurse & GP

• GP asked for input with non-respiratory

problems when appropriate

Hospital @ Home

• Admission Avoidance – SOS Calls

• Early & Supportive Discharge

• Links with Other Local Acute Hospitals

• Acute Intervention

• Weekly MDT & Links with Respiratory Team

• Up to 14 days intervention (HV/Telephone)

• Physiotherapy Intervention

• Post exacerbation PR offered

Specialist COPD Case Management

• Level 1 & 2 COPD case management

• Proactive disease management can make a real

difference to patients with a single condition

provided by a specialist team

• COPD main long term condition

• Support generic workforce in managing COPD in

community links with practice nurse

• Focus on 30 and 90 day follow-up – single

pathway

Community Clinics

• Diagnostic and therapeutic support to

practices

• Assist in case detection / diagnosis

• Follow up of exacerbations seen at home

• Advise in the management of “difficult”

problems

• Location Homerton Hospital

Education

• Support LES and Non LES practices in

providing direct education to the practice in

COPD.

• In practice join COPD Clinics with PN

• Named COPD Nurse links with Practice Nurse

• Direct Access to COPD Healthcare

professional – Via fax spirometry / phone

• Email Advice

Education - Challenges

• Key – self management

• Understanding and accepting diagnosis

• New diagnosis – where does it start?

• NICE 2010 Guidelines – update

• Rescue Packs

• Variety of inhaler choices – but why and MDI?

• Annual Reviews – making changes

Multidisciplinary working

– COPD care should be delivered by a multidisciplinary team that

includes respiratory nurse specialists & Specialist Ward Nurses

– Consider referral to specialist departments (not just respiratory

physicians)

[2004]

Specialist department Who might benefit?

Physiotherapy People with excessive sputum

Dietetic advice People with BMI that is high, low or

changing over time

Occupational therapy People needing help with daily living

activities

Social services People disabled by COPD

Multidisciplinary palliative

care teams

People with end-stage COPD (and their

families and carers)

Organisational Aspects

and key messages in

COPD

Focus of COPD Care

Outcomes that matter • Improved Survival

• Earlier and Accurate Diagnosis

• Improved Quality of Life

• Slower disease progression

• Reduced exacerbation rate

• Reduce hospital admission & re-admission rates

• High Quality End of Life care • Patient centred quality care

What does patient centred

COPD care look like

Practice

nurse

Community

Matron GP

Improving Outcomes for Patients

Key Messages to bottle up .. • Earlier Diagnosis

• Smoking as treatment for COPD

• Responsible Prescribing

• Pulmonary Rehabilitation

• Responsible oxygen prescribing

• Living with advanced COPD

…but now what do with them?

• Recognise that there is fantastic

work already happening within

current work places.

• Integration across primary and

secondary care is key in

improving the patient pathway:

- join up working

- reduce repetition

- no silo working

- patient centred care

Quality COPD Service • Proactive and opportunistic case finding to minimise the impact of late

diagnosis on individuals and the healthcare system

• Quality assured, accurate diagnosis and assessment of severity and ongoing monitoring and review of the condition through a proactive chronic disease management model.

• People with COPD are screened, assessed and managed with

pharmacological and non-pharmacological interventions in line with

NICE/quality guidelines

• People with COPD are educated and supported in the management of their

condition so that they can become active partners in care.

• Effective prevention and management of exacerbations and of hospital

Admissions

• Effective palliative, end of life care and bereavement support for people with COPD

Support & Resources Available

Many available..

• Contact your local COPD or Respiratory Specialist within your local hospital or Community Health Services

• Explore the hospital or community website – use COPD as a search term

• Identify your oxygen champion

• Who is leading on Pulmonary Rehabilitation within your local area

National & Resources • National Institute for Clinical Excellence – NICE 2010 Update Guidelines

for the management of COPD in primary and secondary care

• British Lung Foundation

• Primary Care Respiratory Society (PCRS)

• NHS Improvement Programme – Lung Work stream

• NHS London Respiratory Team

• IMPRESS (BTS and PCRS)

• Association of Respiratory Nurse Specialist

NHS London Respiratory Team

www.london.nhs.uk/what-we-do/improving-your-services/better-quality-services/london-respiratory-team

NHS Lung Improvement Programme

• http://www.improvement.nhs.uk/lung/

National COPD Project • Prevent COPD readmissions

• In line with NICE guidance

– Self Management Plans

– Rescue Packs

• Antiobiotic: change in sputum colour

• Corticosteroid: ↑ breathless and/or wheeze

• Admissions 1º Δ of COPD Exacerbation

• NICE: all patients who have had an exacerbation OR are

at risk of an exacerbation should get a self mx plan &

rescue medicines

Department of Health

Primary Care Respiratory Society

http://www.pcrs-uk.org/

And finally…

Even after the

COPD Annual Review

with the Practice Nurse the next

day the patient presents to the

ED department and says…

Acknowledgements

• Nancy Hallett – Chief Executive

• John Coakley – Medical Director

• Dylan Jones – General Manager for Medicine

• Louise Olley – Head of Nursing GEM

• Mervyn Freeze – Assistant GM

Dr A Bhowmik Respiratory Consultant

Jane Osei-Wusu COPD Clinical Nurse Specialist

Ailsa Dann COPD Clinical Physiotherapist

Arthur Tadique COPD SSN

Edmer Sayat COPD SSN

Aminata Gbla COPD SSN

Aziza Zina & Team Team Administrator

Team

Kirsty Barnes HEIC COPD Physiotherapist

NECLES HIEC

Lung Improvement

Projects

• Reducing door to mask time for type 2 respiratory failure

• Reducing readmissions through provision of self management packs

PREMs

• Research to develop the first COPD Patient Reported Experience Measure

• For sub- acute and community dwelling patients

A Year in the Life

• Benchmarking quality and cost of COPD care across 4 boroughs in ONEL

• Providing targeted and free training opportunities for Primary Care Clinicians

A Year in the Life

Dashboards of COPD quality care indicators

circulated:

Co- production of dashboards and

templates

Using data to drive improvements

Training opportunities delivered:

Accredited spirometry training, COPD

masterclasses, Practice nurse mentorship in

COPD management & spirometry clinics,

issuing self management plans

Building sustainable changes through

networks:

Building awareness of quality interventions

Making connections between teams

Facilitating COPD leads to continue improvement

process

Data dashboards

for smoking

status, severity of

disease, annual

reviews

performed

Data

dashboards on

appropriate PR

referrals and

self

management

plans issued

COPD training opportunities • Accredited spirometry training

• Practice Nurse mentorship in COPD

management

• COPD masterclasses

• Performing the COPD annual review

and issuing a self management plan

• Consultant education sessions in

Practice

Questions?

Thank you