managing exacerbations in chronic obstructive pulmonary disease (copd): a secondary care toolkit the...

NHSNHS Improvement

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Managing exacerbations in chronicobstructive pulmonary disease (COPD):A secondary care toolkitThe ingredients for success

ContentsBackground

How to use the toolkit

Available resources

Non-invasive ventilation (NIV)PrinciplesCheck listCase studyResources

Access to specialist and clinical decision makingPrinciplesCheck listCase studyResources

Care bundlesPrinciplesCheck listCase studyResources

Pulmonary rehabilitationPrinciplesCheck listCase studyResources

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

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In 2011, the Department of Health published an Outcomes Strategy for ChronicObstructive Pulmonary Disease (COPD) and Asthma and this was followed bythe NHS Companion Document which helped to translate policy into practice.

The Outcomes Strategy identified that all people with COPD, across all socialgroups, should receive safe and effective care, which minimises progression,enhances recovery and promotes independence. During acute exacerbation ofCOPD the Outcomes Strategy advocated a structured approach to hospitaladmission, with specialist care and proactive post-exacerbation follow up.

The NHS Companion Document highlighted three key approaches which couldbe adopted to help people with COPD recover from their acute exacerbation:

i. Provide the right care in the right place at the right time: agreeing locally a pathway of care for acute exacerbation, including timing and location of initial assessment and delivery of care (hospital, GP surgery/community care, or in the individual’s own home).

ii. Ensure structured hospital admission: ensuring people with COPD are seen by a respiratory specialist on admission to hospital and receive key interventions – like non-invasive ventilation (NIV) – promptly.

iii. Support post-discharge: ensuring people who have been admitted to hospital with a COPD exacerbation are supported back into the community to prevent readmissions.

BackgroundThe Outcomes Strategy for COPD and Asthma was published during a periodof financial ‘belt tightening’ for the NHS, with an expectation that £20bnsavings would be generated over a five year timescale. COPD is the secondmost common cause of emergency admission to hospital, with about 100,000admissions for acute exacerbation every year at a cost of £236.6m. There issignificant national variation in the nature of these admissions which maysuggest inefficiency and waste in processes and services:• There is four fold variation in admission rate between the highest and

lowest PCT areas in England.• Mean length of stay was 6.6 days (2011/12), but there is two-fold

variation between best and worst PCT areas.

By reducing unwarranted variation in performance against these nationalmeasures the NHS in England could release capacity and resources,simultaneously improving the quality of care for patients:• If the length of stay for PCTs with an average length of stay above the mean

was reduced to the mean, 65,000 bed days would be freed, which would be a reduction of 10% of bed days, with a financial saving of approximately £14 million.

• If all PCTs could reduce their average length of stay to the level of the PCTs in the top quartile, 146,000 bed days would be saved, a 21% saving, with financial saving of £32 million.

NHS Improvement – Lung worked with a number of sites to develop alternativeapproaches and models of care to improve the services available to patients.This toolkit has been designed to share the learning and show how to makechange happen.


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Where What they did Impact

• 13 patients seen by Early Supported Discharge (ESD) per month• Patients discharged home on average 1.43 days earlier• Access to respiratory specialist improved from 1.27 days to 0.97 days• 100% of patients seen by specialist, 80% being seen within one day• Estimated savings of £40,000 from bed day reduction

• Increase in COPD admissions by 33%• Mean length of stay decreased from 8.56 to 7.07 days (median remained at 4 days)• 50% of Hot Clinic appointments avoided admission, approximately 48 patients a year• Estimate 48 avoided admissions. £106,000 per annum.

• Increase in proportion receiving specialist care• 69% of patients received care bundle• Improved quality of care without increased cost. Trust on target to achieve £960,000 CQUIN.

• Readmissions rate has decreased by 22 to 19%• The length of stay has reduced by 1.6 days• Total admissions have increased from 651 to 727• Reduction in length of stay estimated savings saving £150,000.

• 39% increase in number of patients seen by the respiratory nurse specialist team• 48% of current smokers given nicotine replacement therapy and 50% referred to smoking

cessation services during the inpatient stay for exacerbation of COPD• 92% of patients received rescue medications on discharge - this was associated with a

reduction in readmissions of 50% in some patient groups• Reductions in mean length of stay and readmissions at 30 and 90 days for acute exacerbation

of COPD on all wards where the care bundle was introduced• Mean non-invasive ventilation door to mask time <3 hours.

• Implemented a new Early Supported Discharge (ESD) Team• Implement a COPD discharge care bundle• Increased access to specialist care.

• Introduced respiratory ‘in-reach’ team to admissions ward• Implemented a respiratory HOT clinic• Moving toward seven day respiratory physician cover.

• Implemented a COPD discharge care bundle• Redeployed supported discharge team to increase 'front of

house' contact and access to respiratory specialist.

• Worked across the whole health economy to improve integration of services

• Introduced new ways of working in the respiratory team to increase access to specialist care and clinical decision making

• Improved the discharge process.

• Implemented a COPD discharge care bundle• Redeployed supported discharge team to increase 'front of

house' contact and access to respiratory specialist.

York

Wolverhampton

Leicester –Glenfield

Worthing –Eastbrook Ward

North Tyneside/Northumbria


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Each section will cover:

• The key principles - what the service should look like.• A check list designed to make you think about your existing service and

suggested actions with space for you to write notes as you work through the toolkit.• Case study examples have been provided to show what the outcomes have

been from sites that have implemented change in their service and other resources that you may find helpful.• The management of COPD should be integrated across primary and

secondary care and we would strongly advise you to also refer to the Primary Care Toolkit.

How to use the toolkitThis toolkit will provide additional help for those specifically wanting to improvetheir inpatient services for people with an acute exacerbation in chronicobstructive pulmonary disease (COPD).

This toolkit will focus on:

• Non-invasive ventilation (NIV)• Access to specialist and clinical decision making• Care bundles• Pulmonary rehabilitation.

Getting started

Before implementing a solution and changing your service, it is essential tounderstand your current system by mapping the process, collecting andanalysing the service data, along with asking patients and staff for theirviews:

• The toolkit also includes tips on how to organise your projects


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Download First steps towardsservice improvement: a simpleguide to improving services at:www.improvement.nhs.uk/documents/ServiceImprovementGuide.pdf

FIRST STEPS INCARE DVD

DATA FOR CHRONIC

SUCCESS PRINCIPLES:

MANAGING COPD

PRIMARY CARE

DISEASE AND ASTHMA:MAKING A REAL DIFFERENCE

MANAGING COPD

HOW TO MAKE A REALDIFFERENCE TO COPDAND ASTHMA SERVICES

INTERACTIVE PATHWAY

SECONDARY CARE

TOOLKITS

INTEGRATED

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Available resources

NHS Improvement has worked with teams around the country over the lastthree years to provide tried and tested examples of improvement formanaging chronic obstructive pulmonary disease as a long term condition.We have developed a suite of resources to help you improve your serviceswhich can all be found at:

www.improvement.nhs.uk/lung/Toolkits.aspx

www.improvement.nhs.uk/lung/toolkits/additionalresources.aspx

Action - It is recommended that you look at theresources available starting with the First steps towardsquality Improvement - A simple guide to improvingservices. This guide will give you a step by step guide to undertaking your own improvement project. It will

provide you with the framework for developing, testing andimplementing change following a five step improvement approach to provide a systematic framework which includes:

• Preparation - define your project aims and objectives and collecting baseline data.• Launch - Developing project and communication plans and

identify an executive sponser.• Diagnosis - understand the current process and define the real

problem.• Implementation - test and measure - Plan, Do, Study, Act (PDSA).• Evaluation - Capture the learning.

Understand ther methodology and toolsavailable for service improvement.

The Model for ImprovementThis model for improvementprovides a framework fordeveloping, testing andimplementing change that leadsto improvements.

First steps to improvingchronic obstructive pulmonary disease (COPD) care This publication comprisespotentially the most significantquality factors along the COPDpathway, but which are frequentlymissed. They are a basic guide tothe key principles every areashould be adopting to providegood COPD care – if you donothing else, start with these ten things andmake sure they are in place for all yourpatients. The publication offers hands onadvice to health professionals who providecare and services for COPD patients as well asproviding a helpful starting point for thosenew to commissioning COPD services, or for astocktake of a local respiratory service.

Case studies from all the sites can be found at: www.improvement.nhs.uk/lung

LIVING WITH...

FINDING OUT

LIVING WITH...

TOWARDS THE END

IDENTIFY RIGHT PATIENTS AND INTERVENE EARLY

DIAGNOSE PATIENTS EARLY AND ACCURATELY

SUPPORT SELF MANAGEMENT

PROVIDE CLINICAL AND COST EFFECTIVE TREATMENT

REVIEW AND SUPPORTPATIENTS

PROGNOSTIC INDICATORS

MANAGE EXACERBATIONSIN PRIMARY CARE

MANAGE EXACERBATIONSIN HOSPITAL

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MANAGING CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AS A LONG TERM CONDITION

SUCCESS PRINCIPLES

RESOURCESPATIENT

INFORMATION

DATA

KEY CHALLENGESCHECKLIST

CASE STUDIES

SEVEN DAYSERVICES

PATIENTSAFETY

ADVANCE CARE PLANNING

ACTION PLANS

PULMONARYREHABILITATION

CO-MORBIDITIES

MEDICINES MANAGEMENTEMERGENCY

OXYGEN

HOME OXYGEN

SERVICEIMPROVEMENTTOOLS

INTEGRATED

CARE DVD


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Success Principles: How to make a realdifference to COPD and asthma services A series of mix and match cards providing practicalexamples of changes you can make and how toimplement them to improve care and quality atevery step of the pathway for patients with COPD and asthma.

Model for Improvement

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What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that willresult in the improvements that we seek?

Action - It is recommended thatyou also look Managing COPD asa Long Term Condition interactivepathway.

Preparation - Find out where to start by asking the right questions

Why might you want to improve things?Do you have:• Higher than average length of stay for acute exacerbation of COPD?• High numbers of emergency admissions?• High readmission rates?• High cost, poor outcomes for COPD in your area?• Complaints about care?• Long waiting times to access pulmonary rehabilitation?

Where should you start?Start with the problem, not the solution: do not assume that the reason is clear or that there is an obvious answer.

For every complex problemthere is an answer that is clear,simple - and wrong.‘

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What is the problem?Make sure you have understood what is really going on and identified thecause, rather than the symptoms, of the problem

What does the data tell you?You need to know how well are you doing things now; and how much bettercan you get, rather than have you met a target for performance management.Data helps you to target your improvement, helps you identify where it willhave the most impact (pareto charts) and also shows you what is happeningover time (statistical process control (SPC) charts).

Data can help you answer these questions:• How does what you are doing now compare with;

• last year? • what others are doing?

• What do patients think of the service being provided?• What do staff think of the service they provide?• Who gets the best results e.g. which speciality or consultant team has the

lowest mortality, length of stay or readmission rates?• Where are you spending most? Achieving most? Wasting most?• How good could you be?

For more information about using data forimprovement download the data guide at: www.improvement.nhs.uk/documents/managingcopd/Data_Guide.pdf

H.L. Mencken


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Understand your current processes to identify your potential for improvement

• Do you know what really happens every day, at every point? How?

In any system, what people should do, think they do, or say they do, may notbe the same as what they actually do most of the time.

To improve things, you need to find out:• what happens?• why it happens?• how long it takes?• where it goes wrong?• what would make it work better?

Map the process with those who know it best to understand whatreally happens, 80% of the time.

When you have mapped the system, identify what the sticking points are• Where is there waste of time, resources, effort? Duplication? Risk?• Who does what? Who else could/should do it?• What gets in the way?• How long do steps take? Why? • Can you eliminate, combine, simplify or change the order of steps to make

things flow better? For more information on process mapping download First steps towardsservice improvement: a simple guide to improving services at:www.improvement.nhs.uk/documents/ServiceImprovementGuide.pdf

YOU NEED TO PROCESS MAP YOURCURRENT SERVICE


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Define what improvement will beBased on what the data has told you and what your process map has revealeddecide what your improvement aim is. What will you achieve? How much? By when? Compared to what? And why?

Understand what is underlying the problemUse a tool that can help you to analyse the problem. In York, patients werebeing discharged late in the day meaning that new admissions were waiting toaccess beds on the specialist ward. The fishbone/cause effect diagram was usedto explore some of the reasons for this.

Bed space notcleaned quickly enoughtherefore not available

Transport arriveson ward before TTOdrugs with patient

EDNs a nursing prioritynot a doctor priority

No senior medical staffroutinely available Wednesday and Thursday

Transport not reliable -comes to early/late/not at all

Discharge loungestaffed 8-6 only

Travelling consultantsgenerate ad-hoc work

Ward round onMonday and Friday

Discharge time on ITsystem not accurate

Patients moved from ward priorto discharge (e.g. day before)

Pharmacists have twohours to see 30 patients

Every rehab unit has differentreferral and transfer process

02 in taxis for homevisits a problem

PLANT PROCEDURES MEASUREMENT

POLICIES PEOPLE

Key services not seven days

OT not on every ward

Bloods not done until 11.30am

Junior doctors jobs take about 4 hourswork after ward round finished

Pharmacy closes at 5.15pm

Junior doctors start at 9am and not before


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Manage your projectTo succeed you will need to actively manage your project. Key elements include:• Align your project with local, corporate and / or national objectives• Identify a project manager• Engage stakeholders who are key to delivery and those who are

interested• Have a plan and actively monitor and report progress.

Sustain the improvement• Share learning and feedback with your stakeholders to generate momentum.• Support them to maintain the improvement with ongoing review, training,

measurement and feedback.• Your initial improvement may be focussed on tackling a backlog of work

errors, but you also need to consider what to put in place to prevent the same problem emerging again over time.

Where do I start?Managing exacerbations of COPD well to optimise outcomes, experience anduse of resources is a complex process dependent on many different factors. All the elements in this toolkit will be relevant to your work to a greater orlesser extent.

We worked with five sites who covered a range of interventions. The broadlearning from the projects have been included in the Success Principles,however, this tool kit provides a step by step guide to implementation for four key areas.

VERY HIGH

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Use a tool such as this prioritisation grid to help identifywhich of the ideas (PDSA cycles) should be tried first.

Decide what to tackle firstTools such as the prioritisation grid can help determine where to start, byidentifying what you can achieve quickly and what may take longer to planand implement.


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• Non-invasive ventilation (NIV) should be delivered within three hours of admission for those patients who require it (An Outcomes Strategy for COPD and Asthma, Department of Health, 2011).

• NIV services should have a pathway that is consistent 24 hours, seven days a week.

• One of the most significant delays in initiating non invasive ventilation (NIV) is inaccurate or slow clinical decision making. Rapid and correct identification of patients who are appropriate for NIV is essential; availability and location of equipment rarely contribute to significant delays in therapy, but this should not be presumed to be the case in every organisation.

Non-invasiveventilation (NIV)

PRINCIPLESNon-Invasive Ventilation (NIV) is an effective treatment for the management ofacute hypercapnic respiratory failure in COPD and has been shown to reducemortality and improve patient outcomes.

Acute NIV services are widely available in acute hospitals throughout thecountry, however data from the ERS COPD audit in 2012 suggest that patientoutcomes for COPD patients receiving NIV in the UK in routine clinical practicemay not be as good as those initially demonstrated in clinical trials. There maybe a multitude of reasons contributing to this, however, data from one NHSImprovement Lung multi-centre project team in 2011 suggested that meandoor to mask times for NIV were in excess of five hours.

Timely access to NIV is important during an acute exacerbation of COPD and itis important that clear pathways and processes exist to enable this to happen.


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CHECK LIST

Review your existing pathway

Prospectively recorded data will be more accurate andreliable than retrospective time-point data.

Process map the pathway. The process map may start as part ofa higher level COPD pathway mapping, but to implementeffective improvement work on the NIV pathway a much lowerlevel of mapping will be required

It is important to understand who is involved in every step ofthe process and what each of the steps in the pathway involvesto allow accurate identification of the bottlenecks and delays.

After mapping it is important to collect data on each step ofthe pathway for analysis.

Measure the time from the patient arriving in the emergencydeparment or admissions unit (whichever is the first accesspoint and you may need to do both) until the NIV is appliedand record timings for the following stages:

Time of admission

Time of medical assessment

Time of arterial blood gas measurement

Time of chest xray

Time of decision for NIV (this may be the time that the NIV nurse/physio is called)

Time of NIV team assessment

Time NIV mask applied.

Identify the key bottlenecks and delays

A tool such as statistical process control (SPC) or a patient pathway analyser (available FREE onlineat: www.improvement.nhs.uk/improvementsystem- registration required) can be used to identifywhere in the pathway the problems arise. SPC

allows the user to see which elements of the pathway alwayshappen in a regular, timely manner (SPC refers to this as aprocess that is ‘in control’) and which elements display largeamounts of variation.


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NOTES

CHECK LIST

From the time points, identify which steps take the longesttime, the main delays in accessing NIV, and where there ispotential to change.

Undertake some root cause analysis to determine why ithappens. This might take the form of notes review for eachoutlier on the charts or in-depth scrutiny of a particularpathway step that causes concern or delays.

Use Plan Do Study Act (PDSA) cycles to try changes to addressthe delays, measuring continuously to determine whetherthere has been any improvement.

Ensure any steps that are changed apply to the pathway in away that is achievable out of hours as well as during normalworking hours, so that further variation is not being introduced into the pathway.

Problem solve bottlenecks and delays

Implement new 24/7 pathways

Ensure all people involved in the pathway are aware of thechanges and engaged with the process of implementing them.

Continue to monitor the pathway to ensure the standardsremain high.


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Chart 2: The first time step recorded was the time taken from thepatient’s admission to being assessed by a doctor. The mean time is 26minutes but there is significant variation in the process.

Admission to assessment chart

Chart 1: Time from admission to application of NIV for consecutivepatients. The mean time is 144 minutes, but with significant variation.

Non-invasive ventilation (NIV) door to mask chart

EXAMPLES OF SPCCHARTS

The charts 1 to 6 represent the information for 54 consecutivepatients for door to mask time, and then the data broken downinto the pathway steps.

Chart 3: Time from medical assessment to the arterial blood gas beinganalysed. The mean time is 18 minutes, but with significant variation.

Medical assessment to ABG chart


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Chart 4: Time from medical assessment to the patient having the chestxray completed (essential prior to the commencement of NIV, and as anaid to clinical decision making). The mean time is 37 minutes and whilstthere is some variation in this pathway step it is less than for other steps.

Medical assessment to CXR chart

Chart 5: Time from the arterial blood gas analysis to the request for NIVbeing placed with the NIV service. The mean time is 54 minutes andrepresented the longest step in the pathway in this example.

ABG to non-invasive ventilation chart

Chart 6: Time from referral for NIV to application of the mask andcommencement of therapy. The mean time is 43 minutes, withsignificant variation.

NIV service contact to NIV mask application chart


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Northumbria Healthcare NHS Foundation Trustconducted a piece of improvement work on theiracute non-invasive ventilation (NIV) service as part ofa wider improvement project for acute exacerbationof COPD.

Data was collected (see SPC charts on page16 and 17)for each step of the pathway in order to identifyproblems and bottlenecks which caused delays in thepatient receiving timely NIV. To facilitate thecollection of data the recording of the time for eachpathway step was integrated into the patientdocumentation for NIV, resulting in 51 out of 54complete sets of data.

Analysis of their data indicated a mean door to masktime of 144 minutes, which is well within the targettimescale of three hours. However there wassignificant variation within the process and 12 out of 54 patients waited in excess of three hours to receive NIV.

CASE STUDY

Analysis of each pathway step indicated that thelongest step in the patient’s pathway was the timefrom the arterial blood gas (ABG) being taken andanalysed, to the decision being made to use NIV andthe NIV referral being made. The mean time for thisstep was 55 minutes, with significant variation andwith 12 patients waiting longer than an hour for areferral to be made for NIV after the ABG had beenanalysed. Notes audit demonstrated that these delayswere due to delays in clinical decision making or toincorrect interpretation of ABG findings.

The respiratory team addressed errors in clinical decision making through a programme ofone-to-one educational sessions. Individual feedbackwas provided, delivered in a productive andsupportive manner, and led to improvements inclinical care.


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Resources

For more details read the in-depth case studies which are available at:www.improvement.nhs.uk/lung/toolkits/additionalresources.aspx

There is also information about the Respiratory Atlas of Variation whichdemonstrates unwarranted variation in the use of NIV during exacerbation ofCOPD, web links to some published evidence about NIV service delivery andlinks to improvement tools and techniques in the NHS Improvement System.

Decisions are made by using a number of factors e.g diagnosis, intervention,interaction and evaluation not forgetting patient’s choice and evidence basedliterature. The Outcomes Strategy clearly identifies the importance of:

Helping people to recover from episodes of ill health or following injury

• Provide the right care in the right place at the right time • Ensure structured hospital admission• Support post-discharge

Specialist care is more likely to result in the patient receiving the right treatmentby having early interventions and a clear management plan.

Specialist care during the inpatient stay will help identify the mostappropriate follow up care post discharge e.g. referral for pulmonaryrehabilitation or follow up with the community respiratory team and can alsoensure the patient has had confirmation of their diagnosis and a review of the long term management of their condition.

Outcomes have been shown to be improved in hospitals where specialistrespiratory physicians are present, however a recent audit showed that only50% of people admitted with an acute episode of COPD were under arespiratory team at the time of discharge from hospital (National COPD audit 2008).

Access to specialist andclinical decision making

There is also evidence that increasing the frequency of consultant ward rounds,for example changing from twice weekly to twice daily, reduces average lengthof stay by half a day with no increase in mortality or readmissions.

• Early discharge schemes or hospital at home can prevent hospital readmissions (COPD Commissioning Toolkit).

• Make sure every patient admitted for exacerbation of COPD is seen by a respiratory specialist within 24 hoursof admission.

• Get patients better so they can go home safely and at the right time.

• Deliver the right care at the right time in the right place.• Clinical decision making should be made on a daily basis to promote proactive case management.

• Have clear and effective referral mechanisms in place. Agree clinical protocols or guidelines to support decision making in the patient’s pathway.

• Ensure consistency in care being delivered.• Share local data to identify problems and improve patient’s outcomes.

• Ensure clinical decision making is a collaborative process between teams of health care professionals and with the patient.

PRINCIPLES


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CHECK LIST

Access to specialist to ensure a structured hospital admission: early access to specialist respiratory care, prompt management of COPD and co-morbidities in line with the NICE guidelines

Do you have a structured approach to ‘finding’ or referringpatients admitted with exacerbation of COPD?

Are all your patients reviewed by a specialist within 24 hours?

Have you process mapped?

Have you followed a patient on admission?

Consider daily ‘in-reach’ by a respiratory physician or othermember of the respiratory team into the medical admissions unit or emergency department.

Consider patients alerts e.g via electronic PAS system/phone alerts.

Do you have a checklist or care bundle in place?

What is your process to ensure prompt assessment onadmission to hospital, including blood gas analysis andprovision of NIV within one hour of decision to treat beingmade, where clinically indicated. Arterial blood gas and acidbase balance analysis can contribute significantly tomanaging patients who are in respiratory failure and theeffectiveness of any treatment?

Patient assessment: more than 25% of patients admitted withexacerbation of COPD have not been diagnosed with COPD

Do you check every patient has had a quality assured diagnosis – spirometry test?

Do all patients have pulse oximetry within an agreed time frame on admission?

Do all patients have an arterial blood gas if necessary? Is this done within an agreed time frame on admission?

Managing the appropriate length of stay

Have you looked at the length of stay by the day of admission.

Does your data show peaks in length of stay on certain days?

Have you identified what is different about these days?

Who makes the decision that patients are able to go home?

Do you have an agreed discharge criteria?

Do you consider planning for discharge on admission?

Do you have nurse led discharge?

Can patients be discharged at the weekend? Have you audited your current practice?

CHECK LIST

Clinical decision making - what is your process?

Do you have daily ward rounds? If not why not? Have you tried virtual ward rounds /paper ward rounds/boardrounds?

How do you record outcomes of your ward round. eg.sticker/stamp in notes?

Do your ward rounds include members of the multidisciplinaryteam?

How long does it take for the outcome of the decision to beimplemented. Have you process mapped the time it really takesto see how things could be done differently?

Ensure the respiratory ‘specialist’ (e.g. physician, nurse orphysiotherapist) has the level of competency, to know whatrange of interventions is required)

Do you have agreed clinical guidelines or protocols to supportclinical decision making in the patient pathway?

Do you have agreed clinical guidelines or protocols for pathwaysfor people with complex needs and comorbidities?

Do you have agreed clinical guidelines and protocols for socialcare and other community services?

Do you have agreed clinical guidelines and protocols forcare coordination?

Are COPD patients frequently admitted to wards otherthan respiratory wards?

Do you know the reasons for this?

Have you contacted your IT department for your localdata?

Have you involved your bed manager?

Do you have multidisciplinary team meetings?


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CHECK LIST

Seven day working: Ensure that the respiratory service operatesover seven days so that patients can access specialist care wheneverthey are admitted, including weekends and holidays

Do you have seven day working?

Compare numbers of admissions and discharges by day of theweek. Do you discharge as many patients each day at theweekend as you do between Monday and Friday?

Compare the number of admissions by the time of day. Knowwhen your peak admission and discharge times occur. Could yourdischarge time move earlier in the day?

Process map your pharmacy distribution of dischargemedications to fit with your peak discharge times to preventpatients having to wait for tablets.

Have you got good links within the community to ensurepatients are able to go home with support?

How do you communicate with GPs so they know when patientshave gone home?

Do you have a process to contact patients at home to providesupport for early discharge?

Do you have a discharge lounge that you could use?

Do you use your discharge lounge as much as you could?

Do patients know who to contact if they have a problemat home?

Do you have mechanisms in place to support patients athome if they have a problem?

Do all your patients receive follow up within two weeks?

What is your follow up process: who, when and where?

NOTES

NHS Improvement has worked closely with a number siteslooking at ways to improve the respiratory pathway for patientswith COPD. Timely clinical decision making can make asignificant impact on quality improvement, efficiency and theinpatient experience, but often requires a change of mind set,practice, system and behaviour in order to gain the benefits.

Reduction in length of stay• Proactive clinical decision making• Effective use of bed capacity• Valuing patient’s time• Enhance clinical governance and reduce risk.

The Outcomes Strategy for COPD and Asthma clearly identified that:

• People with COPD, across all social groups should receive safe and effective care, which minimises progression, enhances recovery and promotes independence.

• People who are admitted to hospital with an exacerbation of COPD should be cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support.

Notes reviews and continuous monitoring of data are a good wayof identifying how effective your improvements have been. InYork Teaching Hospitals NHS Foundation Trust, 80% of patientswere seen by a specialist within 24 hours and by implementingan early supported discharge programme, mean LOS hasreduced by 1.5 days per patient.

CASE STUDY

Poor clinical decision making due to lack of specialistknowledge was the main delay identified in patients accessingnon-invasive ventilation (NIV). Northumbria Healthcare NHSFoundation Trust improved their access time to less than threehours (see case study on page 18).

Within six months University Hospitals Leicester NHS Trust hasseen an increase from 5% to 100% of patients receiving self-management plans. Providing more respiratory specialist nursesupport whilst the patients are in hospital has reduced thesupport required in the patient’s home following discharge. Thishas released the respiratory nursing team’s time to see evenmore inpatients, with no increase in readmission rates. Patientsare more confident to self- management and know when and howto seek help.

Royal Wolverhampton Hospitals NHS Trust were fundamental inthe development of a Respiratory Action Network (RAINBOW)which has looked at a number of interventions along the patientpathway to improve care for patients. They introducedrespiratory in-reach where respiratory physicians wouldproactively see all respiratory patients on admission, improvingthe clinical decision making process at the earliest opportunity.This resulted in an increase in patients being discharged earlierwith the necessary interventions and support to return homesooner.


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A HOT clinic was also introduced where patients could bereferred to be seen by a respiratory physician. This avoided 46unnecessary admissions. Early data suggests that only 11% ofpatients referred to the HOT clinic required admission. Thisservice is now being extended to seven days a week.

Eastbrook ward in Worthing Hospital (Western Sussex NHS Trust)reduced patient length of stay by one day. Contributing factorsincluded improved clinical decision making. Improved patientflow meant that more patients were admitted to the respiratoryward, allowing more patients to be under the care of a respiratoryphysician. The respiratory nursing team also used an admissionproforma/safety check list to ensure adherence to the NICEguidelines. A new discharge form ensures that GPs are informedof all patients’ admissions to hospital in a timely manner.

By changing the way the team worked the average length of stayreduced from 9.8 days to 9.1 days and readmissions fell fromrespiratory consultants now flex their working to review all newpatients on consultant ward rounds, and to have ward rounds onfour rather than just two days of the week.

Number of COPD admissions by length of stay Percentage patients seen by a specialist on Eastbrook Ward

CASE STUDY

The respiratory nurse specialistsnow cross cover each other andrun a ‘virtual respiratory ward’ fornon-Eastbrook patients. Anelectronic tagging system wasadopted allowing an efficient wayfor the nurse specialists to identifyrespiratory patients who had beenadmitted. They improved theirpatient flow by strengthening thedischarge process, and improvedmulti professional working byincluding consultant presence atward ‘social meetings’. They alsointroduced bi-monthly crossorganisational COPDmultidisciplinary meetings toallow joint protocols to be agreedfor high impact users with phonecalls to patients three days post-discharge resulting in a 6%reduction of readmissions.

By looking at the data ondischarges by day of week and time of day, they identified fewerdischarges occurring on Wednesdays and at weekends.Proactively managing patients increased discharges on thesedays. By moving discharge times earlier in the day they havebenefited patients and staff.

Discharges by day of the week

CASE STUDY


26


27

Resources

The Royal College of Physicians has a useful website outlining the questionsthat need to be considered for healthcare delivery over the next 20 years. The site has a section that focusses on ‘People’ and asks questions about the right mix of generalist and specialist care.www.rcplondon.ac.uk/projects/future-hospital-commission

The KIng’s Fund has a a publication called Avoiding Hospital Admissions (2010).The document discusses the benefits of disease specific, multidisciplinary casemanagement and early senior review in A&E.www.kingsfund.org.uk/publications/avoiding-hospital-admissions

A good admission for acute exacerbation of COPD would ensure everypatient receives high quality care that addresses the key components oflong term condition management in COPD. This would typically include:

Care bundles

• Early (within 24 hours) and on-going access to specialist care.

• Timely and appropriate access to non-invasive ventilation. • 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 rehab within two weeks of dischargefrom hospital.

• Advice on how best to manage future exacerbations to avoid secondary care admission.

• Follow up with an appropriate professional within two weeks.

PRINCIPLES

Such an approach can reduce re-attendances and readmissions. Several NHSorganisations have successfully used COPD care bundles to help implementsome of these interventions.

Care bundles and checklists can be valuable tools for improving the quality andsafety of patient care, and ensuring standardisation of care i.e. that all patientsreceive the core interventions that are appropriate for their condition. Manyexamples are already in use in the NHS and have been successful in reducinginfections (e.g. the sepsis care bundle and ventilator care bundle) and reducingmistakes in surgical interventions (e.g. the safe surgery checklist).

What is the difference between a care bundle and a checklist?Care bundles were developed by the Institute for Healthcare Improvement tohelp healthcare providers more reliably deliver quality patient care. Thecomponents within an individual care bundle do not represent advances inpatient care, rather they are accepted best practice and have beendemonstrated to make a difference to patient outcomes. The point of a carebundle is to make sure that these elements of care are delivered uniformly andconsistently for every patient. Each care bundle is usually made up of three tofive evidence based interventions.

A checklist can be a very important and reliable way to improve patient care. Achecklist may contain many items, and they may not all be evidence basedinterventions but they are all important and need to be done reliably, uniformlyand for every patient, every time.

How do care bundles work?They work by ensuring standard work, facilitating ownership and responsibilityfor making sure each element is completed to make sure each element of careis delivered.


28

CHECK LIST

Be clear about what it is you are trying to achieve

Ensure clarity about the aspect of patient care that is to beimproved before starting to develop the care bundle, otherwiseit will be difficult to agree on the right components to include.For example the bundle may address the admissions process orthe discharge process. One bundle cannot address both as itwould become too complex and difficult to administer.

Tools such as driver diagrams / action effect diagrams can help todetermine the core elements that should be included in thebundle or checklist.

Will the outcomes of the care bundle / checklist be linked to alocal CQUIN? This may influence monitoring requirements andhence the design.

Consider how you will measure its implementation andcompletion of each component – these requirements mayinfluence the physical design of the bundle.

Engage the help and support of other people in the trustwho may have implemented care bundles previously e.g.team who introduced venous thrombo-embolism bundle,service improvement/service transformation team.

Does the information in the bundle need to becommunicated to health care professionals outside ofyour organisation? Consider how this will be done.

Identify any elements of the care bundle that are timecritical e.g. access to chest x-ray, arterial blood gasanalysis, non-invasive ventilation, antibiotics for acute/admission bundles, and how the time will be recorded.

Regular communication and project team meetings will aid the development of the care bundle. Severaliterations may need to be tested before reaching a final version.

Develop the bundle: Identify the core elements of care thatmust be delivered

Don’t reinvent the wheel – there may already be a bundle youcould adopt/modify (see examples in the resources section)

Consider what it will physically look like, where it will be placedin the patient’s notes

How simple will it be to complete the care bundle in real time(i.e. not retrospectively)? The key to successful implementation ismaking it easy, and preferably easier than what currentlyhappens.


29

CHECK LIST

Develop an implementation plan: who, what, where, when, how

Consider starting with one ward e.g. the admissions ward or the respiratory ward for the first stage ofimplementation and then spread to other wards, lessonslearned about implementation can shape the futurestages of ‘roll out’.

Define the target patient group. Identify whether thecare bundle will be for all patients who are admittedwith COPD, or for a particular cohort, e.g. for those whohave a primary diagnosis of exacerbation of COPD astheir reason for admission. Consider whether currentstaffing arrangements need to be revised to capturepatients admitted over the weekend or during out ofhours periods.

The best way to start is with a process mapping event. This willengage all the relevant teams and people, and help to identifyproblems and challenges with the patient pathway. It may helpwith stakeholder engagement to do this before the design ofthe care bundle is complete, to allow all those involved to have avoice and feel included.

The care bundle must be completed in ‘real time’, notretrospectively so it is essential that the design andimplementation plan facilitate this to happen.

Who will deliver each element of the care bundle – all therelevant people need to be involved from the beginning

Consider whether all elements will be delivered while thepatient is an inpatient. Consider how completion of all elementswill be ensured/recorded if delivered following discharge.

Engage with all the people / professionals who will be involvedin the delivery of the bundle

Engage with all the people/professionals who will be affected by introduction of the bundle.

Use stakeholder mapping to identify who should be involvedand what format their involvement should take.


30

NOTES

CHECK LISTEmbed into practice, evaluate and monitor impact

Ensure there is a reliable mechanism for monitoringimplementation/adoption of the care bundle on a month bymonth basis.

Have a clear plan for how the monitoring information will bedisseminated, and to whom. Staff groups implementing the carebundle require this feedback in a timely manner to know howthey are doing.

Determine whether the care bundle helped to achieve the desiredgoals. If not, analyse the reasons why (e.g. the wronginterventions were chosen, implementation is patchy etc.)

Ensure support for implementation continues until use of thebundle becomes standard practice (over 80% of the targetpopulation receive the bundle consistently, month on month).


31

NHS Improvement – Lung worked with a number of sites whoimplemented care bundles for COPD as part of their projectwork.

Designing a bundleRather than starting from scratch, the project teams in Leicesterand York modified existing care bundles to meet their ownneeds. University Hospitals Leicester NHS Trust based theirs onone developed by the North West London CLAHRC which was aCOPD discharge care bundle designed to ensure every patientreceived five key components of care prior to discharge fromhospital. Both bundles included smoking cessation, inhalertechnique, self-management plans, pulmonary rehabilitation andfollow up. However the North West London CLAHRC bundleincluded rescue medications as part of the self-managementplan and this was not included in the Leicester bundle.

York Teaching Hospitals NHS Foundation Trust adapted a bundledeveloped by the team in Northumbria, which addressed coreelements of the inpatient stay, and added in spirometryassessment to ensure each patient had a confirmed diagnosis ofCOPD. Modifying existing bundles saved significant amounts oftime in the planning stages of the project, allowing them to moveswiftly to implementing the care bundles.

The project teams developed a range of approaches for thephysical design of their care bundles. In Wolverhampton a largerubber stamp was developed which was placed directly into thepatient’s notes.

CASE STUDY

In Leicester and York, the care bundle was implemented by therespiratory nursing team and was a separate, coloured sheet thatwas inserted into the patient’s notes.

Other teams have produced care bundle paperwork as stickylabels which could be inserted into admission clerkingdocuments with additional stickers for the front of the patientnotes to alert health care professionals to look for the bundledocument.

Implementing the bundleBy engaging the whole multidisciplinary team in the design andimplementation of their COPD care bundle the project team atNorthumbria Healthcare NHS Trust secured involvement of thepharmacists to deliver several aspects of their care bundle. Thepharmacists issued the patients with their rescue packs andexplained to the patient how and when to use them. They alsocompleted this with a follow-up telephone call two weeks afterdischarge to ensure the patient was confident about theappropriate use of the rescue medications.


32

Embed into practice, monitor and evaluateContinuous monitoring of completion ofthe COPD care bundle in Leicesterdemonstrated improvements in referralsto pulmonary rehabilitation (PR). Initiallyless than 20% of patients were beingconsidered for PR and around 10%referred but by the end of their project allpatients were being considered for PR and over 60% being referred. Similarimprovements were seen in theproportions of patients receiving self-management plans and smoking cessation advice.

Leicester - patients referred for pulmonary rehabilitation

CASE STUDY


33

York demonstrated improvements in the quality of carebeing delivered to patients through continuous monitoring ofthe implementation of their care bundle. Referral of patientsfor PR had been very limited prior to the implementation oftheir care bundle and this increased to 60%. There weresimilar improvements in the numbers of patients who hadtheir diagnosis confirmed by spirometry (80%) and who hadtheir inhaler technique checked and corrected (100%).

Leicester - patients referred for smoking cessation

York - patients referred for pulmonary rehabilitation

N/A patients countes as YES

Notes audit

Monthly audit

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

Mar

12

Feb

12

Jan

12

Dec

11

Ap

r 12

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 12

Dec

12

Jan

13

Feb

13

CASE STUDY


34

York - patients having inhaler technique checkedand corrected

York - patients having diagnosis confirmed byspirometry

Notes audit

Monthly audit

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

Mar

12

Feb

12

Jan

12

Dec

11

Ap

r 12

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 12

Dec

12

Jan

13

Feb

13

Notes audit

Monthly audit

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

Mar

12

Feb

12

Jan

12

Dec

11

Ap

r 12

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 12

Dec

12

Jan

13

Feb

13

CASE STUDY


35

Resources

There are also examples of care bundles, checklists and CQUINS, web links tosome published evidence about care bundles and links to improvement tools on the NHS Improvement System.



36

For patients at all stages of disease, multi professional approachpulmonary rehabilitation is a programme of exercise, advice andsupport for people who experience functional limitation as a result ofbreathlessness arising from a chronic respiratory condition such aschronic obstructive pulmonary disease (COPD).

Pulmonaryrehabilitation

• Multidisciplinary professional approach focusing on individual needs.

• To reduce the symptoms, disability and handicap and to improve the functional independence of people living with lung disease.

• Optimum medical management continues alongside rehabilitation.

• Ensure every patient admitted for exacerbation of COPD who is suitable is offered pulmonary rehabilitation within one month post discharge.

• Increase demand using positive messages.

PRINCIPLES

‘ ’‘ ’Breathe better, feel good, do more.London Respiratory Team Pulmonary Rehabilitation


37

CHECK LIST

Consider pulmonary rehabilitation for all stages of diseaseprogression when symptoms are present. Pulmonaryrehabilitation should be offered to anyone who may benefitfrom it and this is usually people who notice that they arebecoming limited by their breathlessness (MRC grade 3-5) andpeople who have been hospitalised for an exacerbation of theirCOPD (MRC grade 2 and above)

To prevent inappropriate referrals ensure you have clear referralcriteria and that referrers know what the requirements / criteriaare.

Minimise the number of inappropriate referrals youreceive so assessment slots are not wasted and yourservice does not become inefficient. Check if your referralform is clear enough to allow referrers to makeappropriate referrals especially around co-morbidities orpatients choice. Think about getting back to theindividual referrer and giving them feedback on why thepatient was not suitable.

Think about how you deliver the programme e.gCohort/rolling/rolling cohort/back to back programmes-think about combining programmes across diseasegroups to improve patient access/increase flexibility

Ensure the sessions are multi component,multidisciplinary and tailored to suit the patients’ needs.

Demonstrate improvement by monitoring patientssatisfaction and improvements in physical performance,self-confidence and disease impact on quality of life.

Make sure all patients have had a clear diagnosis , qualityassured spirometry and MRC score with an assessment ofsuitability prior to commencement of the course.

Does your service include cognitive behaviour therapy?

Is the assessment tool being used been validated?

If yes….Does this feed into a prescription forpsychological support if required?

Pulmonary rehabilitation is effective in all settings - hospitalinpatients/hospital outpatients/community or at home

Understand your demand to identify how many pulmonaryrehabilitation places you need. Make sure you have balancedyour capacity for assessment with your capacity for your exerciseprogramme.

Clinical commissioners or localities should be able to assess theextent of MRC recording and using MIQUEST - type queriesestablish the proportion of patients at each MRC level withintheir locality. This should help in estimating the pulmonaryrehabilitation capacity needed. There is a full model described inthe DH England commissioning pack pulmonary rehabilitationsection. There is also commissioning guidance from NICE toestimate numbers of PR places required per capitahttps://mqi.ic.nhs.uk/IndicatorDefaultView.aspx?ref=1.09.03.05


38

CHECK LIST

Smoking cessation is a treatment. Make sure all patients whosmoke are offered help and support to quit.

Monitor referral rates, quit rates and identify the reasons whypatients decline. It may be as simple as the way the offer iscommunicated!

Do you record your patient’s MRC score?

Individual functional exercise capacity should be monitoredusing an exercise test (e.g. the Incremental Shuttle Walking Test).Monitoring of the patient’s perceived exertion with exercise isneeded to judge progress (e.g. the Borg Scale).

Monitoring progress is important but make sure your datacollection gives you the information you require - don’t justcollect information for the sake of it.

Do you know what your completion rate is? Completion meansthat the patient has attended at a minimum number of sessions(this is to be agreed locally; 75% minimum is recommended)

Collect data on numbers of patients offered pulmonary rehaband as a % of the original referrals.

Record patients attendance and drop out rates at all stages• Referral to assessment• Assessments to programme• Within the programme.

Collect data on completion rates especially number ofpatients who decline. Find out the reasons why and acton the results.

Collect data about the patients’ satisfaction with theservice they received for pulmonary rehabilitation.

Do you have a mechanism for educating providers aboutpulmonary rehabilitation? Including motivationalinterviewing skills.

Do you use a patient reported outcome measure(PROM)?


39

NOTES

CASE STUDY

NHS Improvement worked with four acute hospitals sitesintroducing care bundles which allowed clinical teams to focustheir efforts on a small number of measurable strategies aimedat improving specified outcomes. The care bundle elementsincluded referrals to pulmonary rehabilitation.

In Leicester, all patients are now considered for pulmonaryrehabilitation and offered it when appropriate. 60% of patientsaccepted the referral. Pulmonary rehabilitation referral rateincreased significantly from March/April as the team began todeliver the care bundle project. Referrals have then steadied to amean average of around 48 patients per month.

Total inpatient pulmonary rehabilitation referrals

2010/11

70

60

50

40

30

20

10

0

Refe

rral

s (n

)

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2011/12 2012/13

This is a significant increase in the total number of pulmonaryrehabilitation referrals and initial estimates suggest that this maylead to increase of approximately 50% in pulmonaryrehabilitation referrals over the first year of the COPD carebundle project.

At Wolverhampton, there was no increase in the number ofpatients referred to pulmonary rehabilitation but of thosereferred, a high percentage were inappropriate - only 32% werejudged to be appropriate.

Rehabilitation slots were not always fully occupied due to a delayin the initial assessment process. They did not have enough

capacity (slots available) to assess the patient’s suitability.They identified that changing from having a cohort ofpatients to a rolling programme increased the uptake andwas preferred by patients. They also provided a choice ofvenues across the city which seems to be popular withpatients.

York increased their referrals to pulmonary rehabilitationfor patients following exacerbation of COPD byimplementing a care bundle.


40

CASE STUDY

How this message is delivered can make the difference to apatient participating or not. Mechanisms for educating providersabout PR should be included to ensure motivational interviewingskills can be used to reduce drop-out rates and target those whoare at a high risk of admission.

There is a national COPD BTS discharge audit which includesfour questions on pulmonary rehabilitation.

1 April to 31 May 2012 showed that: 31% of patients declined the offer:

• Has the patient been assessed for pulmonary rehabilitation ?• Of patients assessed as suitable for pulmonary rehabilitation, how many have been referred?

• Where is pulmonary rehabilitation provided?• Of patients referred for pulmonary rehabilitation, for how manywas early rehabilitation planned?

Pulmonary rehabilitationThe Improvement work and evidence to date has shown that carebundles provide a small number of measurable strategies aimedat improving specified outcomes. We have shown an increase inthe assessment and referral to pulmonary rehabilitation forpatients admitted with COPD. Although further work needs to bedone to improve referral rates in the general COPD population.

A high proportion of patients offered pulmonary rehabilitationdecline to attend and there needs to be further work inidentifying why this happens. To provide the best service it mustmeet the needs of the participants, Patients need to understandthat interventions offered at Pulmonary rehabilitation have realbenefits .


41

NOTES

Resources


There are also web links to some assessment tools, the forthcoming BritishThoracic Society Pulmonary Rehabilitation Guideline and links to improvementtools and other websites on the NHS Improvement System.


42

NHS Improvement would like to thank:

York Teaching Hospitals Foundation NHS Trust

Royal Wolverhampton Hospitals NHS Trust

University Hospitals Leicester NHS Trust

Western Sussex Hospitals Trust

Northumbria Healthcare NHS Foundation Trust

The British Thoracic Society

Acknowledgements

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NBTelephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade ofexperience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke anddemonstrates some of the most leading edge improvement work in England which supports improvedpatient experience and outcomes.

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 providing an improvement

tool to over 2,400 GP practices.

Delivering tomorrow’simprovement agenda for the NHS

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