NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

NHS Improvement - Lung: NationalImprovement Projects

Transforming acute care inchronic obstructive pulmonarydisease (COPD): testing thecase for change

People with COPD should receive specialist respiratory reviewwhen acute episodes have required referral to hospital.

They should be assessed for management by early dischargeschemes, or by a structured hospital admission, to ensure thatlength of stay and subsequent readmission are minimised.

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Introduction

• Case for change: the current position for chronicobstructive pulmonary disease in the UK

• Improvement approach

• Common challenges and solutions

• Project outcomes: Emerging success principlesfrom project learning

• Future ‘prototyping’ work

Project case studies

Acknowledgements

References

Contents

Transforming acute care in chronic obstructive pulmonarydisease (COPD): testing the case for change

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Introduction4

Case for change: the current positionfor chronic obstructive pulmonarydisease in the UK

Three million people in the UKhave chronic obstructive pulmonarydisease (COPD).When a patient has anexacerbation of COPD, it is importantthat the right treatment is given as earlyas possible in order to minimise the acuteand long term deterioration of thecondition, and speed recovery. COPD isone of the most common reasons foradmission to hospital, with 107,000admissions in 2009/10.

Exacerbations of COPD are inevitable forsome patients, particularly those withmore severe disease. During the first yearof project work, NHS Improvement –Lung through the ‘Transforming AcuteCare’ national workstream has focussedon developing services that deliverefficient, high quality care and supportfor patients with acute exacerbation ofCOPD both in the community andsecondary care settings. This focusreflects objectives three and five from therecently published Outcomes Strategy forPeople with Chronic ObstructivePulmonary Disease (COPD) and Asthmai:to reduce premature mortality from COPDthrough proactive care and managementand to ensure people with COPD receivesafe and effective care.

The aim of the national workstream wasto ensure that patients admitted tohospital with COPD receive timelyspecialist care and assessment so thatthey are optimally managed along astreamlined inpatient pathway mostappropriate to their clinical needs. Workalso included opportunities to identifypathways that avoid admissions wherepossible. A common objective of thework was to reduce length of stay forperiods of hospitalisation and to reducesubsequent re-admissions with a view

Introduction

to release resources, both in terms ofcapacity release and cost avoidance, butalso support the NHS to achieve theQuality, Innovation, Productivity andPrevention (QIPP) challenge.

Further evidence for the need for thiswork can be found in the Royal Collegeof Physicians 2008 NCROP studyii. Itshowed that access to early supporteddischarge schemes was limited with only18% of patients being discharged withsuch schemes, despite evidence thataround 25% of patients having anadmission for acute exacerbation ofCOPD would be suitable for thisapproach to care.

The audit also demonstrated that morethan one in five patients admitted foracute exacerbation of COPD did notreceive care from a respiratory specialistduring their hospital stay. A more recentreport by the King’s Fundiii has suggestedthat early specialist review can bebeneficial in reducing emergency andunplanned hospital admissions, so it isimportant to address this deficit in care toraise quality and improve outcomes.

Many healthcare systems lack robustprocesses to ensure that patients arefollowed up after their exacerbation ofCOPD. A 2010 survey by the British LungFoundation and British Thoracic Society[i]demonstrated that, whilst there is goodevidence for the use of discharge plans,their introduction as a routine part ofpatient care has been limited with lessthan one in three hospitals adoptingthem. In addition, the 2008 COPD auditshowed that only 53% of patients weredischarged from hospital under the careof a respiratory physician. Improvingthese aspects of patient care during anacute exacerbation will improveoutcomes, reduce re-admissions and leadto a better patient experience of care.

This publication, which is aimed athealthcare professionals, commissionersand other key stakeholders involved inrespiratory health, draws together theevidence and learning from the past 12months and highlights the workundertaken by the project sites in the‘Transforming Acute Care’ nationalworkstream.

Improvement approach

In July 2010, NHS Improvement – Lunginvited NHS organisations to work inpartnership on projects dedicated toimproving the COPD patient pathway andto help address the geographical variationin care that patients receive. Projectsplans were submitted from a number ofsites including acute trusts, primary caretrusts (PCTs) and communityorganisations.

The primary aims of the project workwere to:

• Define the patients pathway• Test the components of care that led toan effective acute care model

• Identify the success principles thatother organisations and teams couldlearn from and adopt

• Inform future ‘prototyping’ work.

Focus was also given to improving thepatient’s experience and outcomes and tothe removal of duplication and wastefrom the pathway and specific processesthrough different ways of working andservice redesign. Productivity gainsachieved by sites were measured toidentify the impact of the work in termsof reductions in bed days, avoidablehospital admissions and re-admissions.

5Introduction

During the ‘testing’ phase of theprogramme the project teams haveexplored the reality of making thishappen by taking stock of currentpractice and understanding the processof implementation towards ensuringpatients receive optimal care in achallenging environment. The projectsites adopted a systematic approach toquality improvement to ensure that anychanges implemented were thoroughlytested and measured. Prior tocommencing the work the project siteswere required to establish their servicebaseline through analysis of local dataand to understand the variation inservices.

Once the project teams were established,a period of ‘diagnosis’ followed to allowteams to understand the patient pathwayand dispel a number of assumptionsabout the processes, its challenges andthe solutions. Potential solutions weretested using the model for improvementand Plan-Do-Study-Act (PDSA) cycles withongoing measurement to evaluate theimpact of the interventions and refinewhere appropriate.

The project sites worked for a 12 monthperiod and one of these sites, NHS WestSussex and Western Sussex Hospital NHSTrust, will continue into the second yearof project work. For most of theseprojects this represented a starting pointon the improvement journey for COPDpatients. This publication contains anumber of case studies produced fromthe final ‘testing phase’ COPD projectreports, demonstrating the key learningfrom the work that project sites haveundertaken.

Common challenges and solutions

Clinical teams at all sites have beenfocussed on specific aims which haveincluded:

• Increasing the number of patients withacute exacerbation of COPD who canbe safely and effectively managed inthe community through admissionsavoidance schemes

• Ensuring patients admitted to hospitalwith acute exacerbation of COPD areseen by a respiratory specialist

• Streamlining the inpatient stay foracute exacerbation of COPD so thatpatients receive optimal care and canbe discharged into the community assoon as clinically ready

• Ensuring patients who have an acuteexacerbation of COPD receive timelyand appropriate follow up care.

Whilst each project site has worked on adifferent part of the acute pathway, anumber of themes have emerged acrossall sites:

• Implementing co-ordinated casemanagement for cohorts of patientswith frequent hospital presentations isan effective way to reduce admissions.Several sites have demonstrated thatthis intervention has directly improvedthe quality of care delivered

• A lack of clear and effective referralmechanisms for specialist care leads toincreased variation in the quality of careand potential waste of resources asclinical time is spent ‘searching’ forappropriate patients

• Early access to specialist respiratory carehas been demonstrated as an effectivemeans in reducing length of stay.Colchester University Hospitals NHSFoundation Trust demonstrated a meanreduction in length of stay of 0.4 daysand St George’s Healthcare NHS Trustachieved a reduction of 1.5 days byinstigating early specialist review

• Within and between organisationsthere is a lack of awareness by someclinicians of all available services forCOPD patients and so reducedopportunities for the provision of highquality care. Improving communicationis important in raising awareness ofthese services

• Improving communication and serviceintegration is effective in reducingadmissions. South Tyneside FoundationHospital Trust prevented 66 admissionsthrough closer working between GPand Hospital at Home services.

• Discharge plans which have beeninstigated at several project sites havebeen proven as an effective way ofimproving the quality of care in COPDby helping the patient to be moreeffective in self management and alsofacilitating a more integrated approachacross primary and secondary care

• Care bundles improve the quality ofcare by ensuring key components ofcare are implemented and that there isconsistency in the care being delivered.Several sites such as NHS West Sussexand Western Sussex Hospital Trust havesuccessfully implemented COPD carebundles into their COPD patientmanagement

• Developing an integrated acute carepathway for COPD is an important stepin improving the patient care process,increasing the quality of clinical careand transforming the patient’sexperience of care during anexacerbation of COPD.

Introduction6

Through problem solving and asystematic approach to improvement,all teams worked through a number ofchallenges in order to achieve theirproject aims. Across the sites, anumber of success principles havebeen identified that representsimprovement opportunities towardseffective service provision in managingthe acute exacerbation of COPD:

• Defining and gaining a goodunderstanding of the whole pathwayof care supported by robust data todemonstrate current processes,performance and variation isessential when embarking onimprovement work. This allowedorganisations to identify priorities forchange and also to benchmarkthemselves against others locally andnationally

• Issues and challenges viewed inisolation without due considerationto the whole patient pathway wereless likely to lead to sustainableimprovements in care provision

• Effective working relied on thecommitment of teams in primary,secondary and community care toimprove communication across thepatient pathway. Integrated workinghelped to build positive relationshipswith health care professionals,departments and organisations, andimprove the critical interfacebetween these organisations

• Access to and effective use of datathrough collaboration betweenclinical and managerial staff enabledthe project teams to betterunderstand the patient pathway anddemonstrate the impact of anychange.

The routine collection and review ofdata was important in implementingsustainable improvements andunderstanding outcomes of anyservice improvements

• Identifying the key levers and driversin the system by integrating localand national priorities into the worksuch as Quality, Innovation,Productivity and Prevention (QIPP)raised the profile and priority of theproject work with decision makersand helped to achieve improvedengagement from seniormanagement teams.

• There was a need to identify andunderstand the gaps, duplicationand waste in the patient pathway inorder to make best use of availableresources. It was essential to workand communicate with colleagues,commissioners and otherstakeholders in service provision inorder to maximise these resourcesand to ensure a consistent andco-ordinated approach to care.

Many of the issues and challenges metby the project teams were similar tothose faced in other specialities andseveral of the success principles havebeen demonstrated to be effective inother disciplines e.g. the daily decisionmaking ward round that wasintroduced through the NHSImprovement - Cancer inpatient workv.It was important for sites to recogniseareas where common principles andpractice meant that learning could betransferred across specialities.

Future ‘prototyping’ work

In the forthcoming year of project worksites will be building on the learning fromthe ‘testing’ phase of work. Sites will berefining the components attributed to theemerging care models and successprinciples that demonstrated the greatestimpact on the patient pathway during thepast year. The prototyping work willdefine the structured admission forpatients with COPD, representing anefficient and high quality care model thatreflects not only best practice, but alsodemonstrates examples of practicalapproaches towards sustainableimplementation. This will include workthat focuses on:

• Individualised patient managementplans (including a discharge plan onadmission)

• Daily decision making ward round andongoing access to a respiratoryspecialist

• Incorporation of care-bundles intopatient management

• ‘Early exercise’ and ongoing referral topulmonary rehabilitation services.

The past year’s work demonstrated that,despite the findings from the NCROPreports in 2003 and 2008ii, theproportion of patients who receive non-invasive ventilation within three hours ofadmission remains low and many acutetrusts do not have the necessaryprocesses in place to ensure rapidassessment for and access to thisintervention. There is clearly more thatcan be done to improve this position andwork will be undertaken to address thedesign and implementation of sustainablepathways to ensure early assessment ofrespiratory failure and initiation ofnon-invasive ventilation.

Project outcomes: Emerging success principles from project learning

7Introduction

Building on the findings from the King’sFundiii, the projects will also work toimplement emergency department triageby a respiratory specialist as this stepof the patient pathway in acuteexacerbation was not actively addressedthrough work in the ‘testing’ phase.

Despite existing evidence for the clinicalsafety and cost effectiveness of earlysupported discharge in COPD many areasdo not currently offer this service. Thenational workstream will be working withorganisations that are developing theseservices by drawing on the publishedevidence to date and practical examplesfound in respiratory services and otherspecialities.

Several of the ‘testing’ sites implementedstrategies to facilitate collaborativeworking with ambulance services andprimary / community care services, mostcommonly by instigating crossorganisational multidisciplinary working.The impact of this still requires evaluationand ‘prototyping’ sites will assess theeffect such interventions have on highimpact service users and subsequentre-admission rates.

Catherine ThompsonNational Improvement Lead,NHS Improvement – Lung

Phil DuncanDirector,NHS Improvement -Lung

It is the aspiration of the nationalworkstream to deliver a QIPP reduction inemergency admissions by 20%, areduced length of stay by 20% and areduction in readmissions at 30 days by20% by building on work undertaken byproject teams in the ‘testing phase’ andcontinuing to transform acute careservices for patients with COPD. Inaddition, the workstream will continue toidentify the key components of care thatimprove the overall patients’ experienceand outcomes, and further develop thelearning and key success principles thatsupport effective commissioning of acuterespiratory services in England.

Catherine Thompson, NationalImprovement Lead,NHS Improvement - Lung

Phil Duncan, Director,NHS Improvement – Lung

• NHS West Sussex and Western Sussex Hospitals NHSTrust: Improving the acute respiratory service in WestSussex

• North East London, North Central London and EssexHealth Innovation and Education Cluster (HIEC):Improving access to non-invasive ventilation for COPD

• Norfolk and Norwich University Hospital NHS FoundationTrust: An integrated care model for patients withexacerbation of chronic obstructive pulmonarydisease (COPD)

• St George’s Healthcare NHS Trust: Process redesignimproves services for acute exacerbation of chronicobstructive pulmonary disease (COPD) by reducinglength of stay and readmission rates

• South Tyneside NHS Foundation Trust: Improving theacute respiratory assessment service

• South Tyneside NHS Foundation Trust urgent care team:Admissions avoidance through the urgent care team

• Colchester Hospitals University NHS Foundation Trust:Access to specialist care for patients with acuteexacerbation of chronic obstructive pulmonarydisease requiring hospital admission

Project case studies

Case studies8

Case studies 9

What was the problem?The project team at NHS West Sussex andWestern Sussex Hospitals NHS Trust,(Worthing Site) wanted to improve thequality of care for people with COPDadmitted with an acute exacerbation toWorthing Hospital.

What was the aim?The project aim is to reduce length ofstay, reduce admissions by ‘high impactservice users’, reduce re-admissionswithin 30 days, and to increase theproportion of patients assessed by arespiratory clinician during their stay andthe timeliness of this assessment..What has been achieved?A monthly COPD multidisciplinarymeeting (MDM) was instigated, attendedby acute and community clinicians. Thishas improved communication betweenclinical teams and led to more prompt,better integrated and more proactivecare. For example:

• Community COPD nurses can accessadvice, ensuring the patient receivesthe right care and without the need foran outpatient appointment

• Patients who have been admitted morethan once are now discussedsystematically at the MDM and actionsformulated aiming to prevent furtheravoidable admissions.

What are the key learning points?• Improved communication and jointworking across primary and secondarycare has allowed patients promptaccess to a secondary care opinion. Theprimary and secondary care teams nowfeel that they are working as one teamfor the benefit of the patient

• Having a patient representative on theproject group has been invaluable,providing a different perspective andchallenging the clinicians and managersperceptions of what is ‘good’ or ‘right’about how care is delivered and tellingus what the priorities are for patients

• Finding a data/information analystwithin the trust who is able to supportthe project work has made the retrievaland analysis of data, and monitoring ofprogress much easier

• There is a wealth of dedicated skilledpeople available whose energy can beharnessed to work together to makesignificant changes.

ContactDr Jo CongletonRespiratory Physician, Worthing HospitalEmail: jo.congleton@wsht.nhs.uk

A simple one page ‘COPD Checklist’ wasdesigned for use by the communitymatrons as an aide memoire to helpensure that COPD patients get the correctassessments and treatments.

A discharge proforma was introducedwhich is completed by the RespiratoryNurse Specialist and sent promptly to therelevant community and primary careservices.

A COPD exacerbation care bundle wasintroduced for use in hospital to ensurebest practice in line with clinicalguidelines and improve patient care.

A referral process is being developed toensure that patients who have a firstpresentation for COPD receive anaccurate diagnosis and appropriatefollow up.

By improving communication within theacute hospital the percentage of patientsunder care of a respiratory consultant hasincreased from 38% to 57%.

Improving the acute respiratoryservice in West Sussex

NHS West Sussex and Western Sussex Hospitals NHS Trust

Case studies10

What was the problem?Chronic obstructive pulmonary disease(COPD) is a leading cause of mortalityand exacerbations of COPD areassociated with reduced quality of lifeand increased mortality. Mortality acrossthe UK for acidotic COPD patientsmanaged with non-invasive ventilation(NIV) is 26%. This is much higher thanthe randomised controlled trial evidencewhere the expected mortality isapproximately 10%. Furthermore, about30% of patients who fit the criteria forNIV do not receive it and of those that doreceive NIV only 49% do so within threehours.

What was the aim?Seven acute trusts across the HIEC regionagreed to audit their performance ofdelivering NIV against a series ofstandards including:

• Door to mask time• The presence of an escalation of careplan and resuscitation decisions

• Appropriate monitoring of therapy witharterial blood gas analysis

• Other medical therapy.

The aim was to evaluate whetherprospective monitoring and audit of NIVcould improve practice in delivering NIVthrough the use of a treatment proformawith educational prompts.

ContactSwapna MandalRespiratory RegistrarEmail: swapnamandal22@yahoo.co.uk

What has been achieved?• Three of the seven trusts had a meandoor to mask time of less that threehours and only 44% of patients acrossall seven sites received NIV within theoptimal time frame of three hours

• There was some variation in thepresence of an escalation plan (3 –33% of patients did not have adocumented plan) and resuscitationdecisions (0 – 25% of patients did nothave a documented decision)

• There was a monthly improvement inthe number of ABGs taken at 4-6hours. The proforma may have aidedthis improvement as there was aprompt on the proforma for ABGs tobe taken

• Trusts with a 9-5 respiratory on-callsystem had the shortest door-to-masktime

What are the key learning points?• Prospective audit alone is not enoughto effect change in practice in thedelivery of NIV

• Acute trusts with a 9-5 respiratoryon-call system had the shortestdoor-to-mask time although furtherinvestigation is required to ascertainwhy

• When NIV was started in theemergency department thedoor-to-mask time was shorter than fortherapy commenced elsewhere

Improving access to non-invasive ventilation forchronic obstructive pulmonary disease (COPD)

North East London, North Central London and EssexHealth, Innovation and Education Cluster (HIEC)

Swapna Mandal

Case studies 11

What was the problem?Developing an integrated care model forpatients admitted with an acuteexacerbation of COPD is important fordelivering high quality, holistic, patientcentred care that is closer to the patient’shome. The development of a localnetwork of clinicians involved in thepatients’ care was seen as an essential,underpinning element of this approach tocare. The advent of the OutcomesStrategy for COPD and Asthma providedthe impetus to redesign the way COPDservices were delivered at Norfolk andNorwich University Hospital.

What was the aim?The project aim was to review themanagement of patients admitted withacute exacerbation of COPD, identifygaps in service provision and improveintegration between primary andsecondary care services. Through this theproject would:

• Reduce COPD admissions• Reduce length of stay• Reduce rate of readmissions• Establish rapid GP access to COPD clinic• Establish a local COPD network

What has been achieved?• The respiratory nursing team has raisedtheir profile within the admissions unitby increasing respiratory nurse presencein the department and encouragingreferral of patients for assessment viaan electronic referral process

• Accident and Emergency (A&E) andadmissions staff can now accesselectronic discharge summaries andclinic letters which has improved accessto relevant clinical information

• Better management of a cohort offrequent attendees / high impactservice users could help to reduceadmissions and readmissions in thisgroup, however ongoing datacollection will be required to determinethe impact of changes in serviceprovision

• The need for effective communicationwithin an organisation should not beunderestimated. Open communicationplays a key part in successful workingrelationships

• Involve an interested analyst at projectmeetings to assist with obtaining andanalysing data. Working with a dataanalyst is essential. It makes the processof data collection and interpretationmuch simpler

• It is important to establish data andanalyse the patient pathway beforedeciding what changes to implement inthe service. This will ensure that theright problems are addressed in thebest way. This also helps with betterunderstanding of the patient pathway /process.

ContactSandra OliveRespiratory Nurse SpecialistTel: 01603 289779Email: sandra.olive@nnuh.nhs.uk

• Patients are being offered acomprehensive patient-held recordwhich enables them to keep a record ofinformation about diagnoses,treatment, medications, previousadmissions, pulmonary function tests,arterial blood gases, appointments andhealth and social care professionalsinvolved in their care. Patients areencouraged to take these records to allappointments and hospital attendancesso that attending medical staff canmake an assessment in the context ofrelevant history

• Closer links with the communitymatrons have been established throughregular meetings. These meetingsprovide a framework for regular liaisonand clinical support; enable sharing ofreferral pathways and criteria and anopportunity for multidisciplinarydiscussion of complex issues.Community matrons now have accessto electronic discharge summaries

• A cohort of patients who are frequentattendees and have recurrentadmissions has been identified andwork is ongoing to liaise withcommunity teams to target thesepeople for support

• A specialist COPD clinic has beenestablished which has consultant andspecialist nurse appointments toprovide prompt specialist post-exacerbation follow-up, rapid accessslots for GP / community team referralsand will provide a point of support forthe community teams.

What are the key learning points?• It is important to ensure effectivecommunication between all teams inorder that appropriate patients arereviewed in a timely manner by therespiratory nursing team and referredappropriately to community services

An integrated care model for patients with exacerbationof chronic obstructive pulmonary disease (COPD)

Norfolk and Norwich University Hospital NHS Foundation Trust

Case studies12

What was the problem?Data from the 2008 COPD audit for therespiratory service at one NHS trustrevealed the number of patients with alength of stay (LOS) of between 4-7 dayswas higher than the national average.

What was the aim?• To reduce the number of patientsstaying in hospital for four and sevendays and to reduce length of stay

• To improve the patient pathway forpatients with acute exacerbation ofCOPD requiring hospital admissions.

• To identify and resolve reasons fordelayed discharge and improvedischarge planning, providing supportand review post discharge

• To improve the patient experience• To provide integrated care.

What has been achieved?The service was redesigned so that:• Closer working with key areas such asthe medical assessment unit (MAU),geriatrics, and the respiratory ward

• Patients are seen by the respiratorynurse earlier in their admission.

• Daily e-mails from the acute admissionsward outlining all patients admittedand daily attendance of respiratorynurse specialist at MDT meeting

• Systems developed and implementedfor data collection both manually andelectronically

• Patients are reviewed, assessed, andissued with a COPD discharge packwith includes, a discharge checklist,action plan and information about theircondition

• All patients on discharge are referred tothe community respiratory team forfollow up within 24 hours.

Improvement methodologies can identifybottlenecks and through effective serviceredesign productivity gains can beachieved without additional resources.The project requires engagement frompeople in all key areas of the patientjourney / process map to eliminatepatient blockages.

It is important to develop a system tocapture and record data accurately.Getting the process of data collectionright early in the project will save a lot oftime later on.

ContactSamantha PrigmoreRespiratory Nurse ConsultantTel: 020 8725 1275Email:samantha.prigmore@stgeorges.nhs.uk

The outcomes of this were:

• Mean length of stay was reduced from4.5 days to 3 days

• Readmission rates within 30 days werereduced from 3 per month to 2 permonth suggesting an improvement inquality of care

• Proportion patients seen by respiratorynurse 47.7%

• Percentage of patients with 4-7 daylength of stay reduced from 40% -22%.

What is the key learning?Reductions in length of stay and re-admissions rates can be achieved throughintegration of services and working acrossorganisational boundaries. Specialist caredelivered earlier in the patient’s inpatientstay may reduce length of stay andreduce length of stay for acuteexacerbation of COPD. Effectivecommunication across the acute trust intothe community is essential.

Process redesign improves services for acute exacerbationof chronic obstructive pulmonary disease (COPD) byreducing length of stay and re-admission rates

St George’s Healthcare NHS Trust

Case studies 13

What was the problem?South Tyneside has a high prevalence ofpeople diagnosed with chronicobstructive pulmonary disease (COPD)and patients in this area are more likely tobe admitted to hospital during anexacerbation of their COPD than the UKnational average. The acute respiratoryassessment service (ARAS) were given theopportunity to extend their care pathwaysfrom 1 April 2010 to provide a ‘seven dayurgent care service’ for patients with anexacerbation of COPD. The ARAS teamalready provided a Monday to Friday non-urgent care service to people with anacute exacerbation of COPD in theirhome setting working closely with theintermediate care team.

What was the aim?The project aim was to reduce admissionsfor acute exacerbation of COPD at SouthTyneside NHS Foundation Trust.

What has been achieved?• Monthly reflective practice meetingswere arranged with ARAS, communitymatrons and Intermediate care todiscuss frequent users/admissions andhow best to manage these

• In future, the staff member responsiblefor the urgent care referrals will workacross the emergency department andthe community to maximise the impacton admission avoidance

• By targetting GP practices the team hasincreased the numbers of direct GPreferrals, resulting in further avoidedadmissions. From April 2010 to July2011, this accounts for 66 admissionsavoided and a total of 462 hospital beddays

• By moving to a 7-day service 106weekend assisted discharges occurredbetween April 2010 and March 2011,saving 206 bed days.

team has improved which has led toimprovements in the quality of careoffered to people with acute exacerbationof COPD.

The use of a structured approach hasgiven all involved a clear direction andstaff within the team have a clear focus,feel valued and have been given a greateropportunity to develop their skills andknowledge base whilst contributing toservice development.

ContactPauline MilnerRespiratory Nurse SpecialistTel: 0191 404 1062Email: pauline.milner@stft.nhs.uk

What are the key learning points?Effective working relies not only on theservice provided in secondary care butalso on the committment from ourcommunity based health professionalteams. Regular meetings withstakeholders and full involvement in thechange process by all staff will help toreduce uncertainty and maintain focus .

The development of a standardisedclinical pathway of care and the use ofreflective practice meetings with primarycare colleagues have helped to increasetheir knowledge of a wider range oftreatment and referral pathways forpatients with COPD.

Integrated working helps to build positiverelationships with other health careprofessionals, departments andorganisations. Communication betweenprimary care services such as thecommunity matrons and urgent care

Improving the acute respiratoryassessment service

South Tyneside NHS Foundation Trust

Case studies14

What was the problem?The nurse-led Sunderland urgent careteam (UCT), part of South Tyneside NHSFoundation Trust, provides a 24hours/seven days a week servicedelivering acute care to people in theirown homes, avoiding hospital admissionwherever possible. To support provisionof this rapid response and assessment, astep down facility exists within theintermediate care structure, which alsoincludes physiotherapy and social work.

What was the aim?The Urgent Care Team wanted to developa more integrated care pathway forpeople with COPD across communityservices and secondary care.

The aim was to prevent avoidablehospital admissions and reduce re-admissions for COPD in Sunderland. Thetarget patient group for this pilot wherethose who require continuous oxygentherapy in the short term to assist therecovery from an acute exacerbation.Previous to the pilot such patients wouldhave always been admitted to secondarycare.

The project would also involve:• Introduction of near patient capillaryblood gas analysis into the urgent careteam as a resource to provide improvedpatient information for safe clinicaldecision making

• The collaborative development of amedical management plan so thattimely, appropriate, information couldassist decision making in communitycare and also expedite admission tohospital from the urgent care service,where this was necessary.

What are the key learning points?• Take opportunities and think out of thebox. Initially the North East AmbulanceService had not been considered foroxygen provision and considerable timewas spent trying to negotiate withinthe national oxygen contract which didnot meet the needs or cost resource ofthe service. It was a chanceconversation with a director in theambulance service that led to theoutcome that was secured

• Work with the local and nationalagenda. Understand and share withstakeholders ongoing work such asQuality, Innovation, Productivity andPrevention (QIPP) initiatives, practicebased commissioning group work, andstrategies to reduce readmission inorder to get senior buy in

• Have the right people around the table;early engagement with stakeholders iscrucial. Do not underestimate theimpact and influence of bringingtogether all the stakeholders in oneroom to discuss the patient pathwayand appropriate health contact pointsand access. It’s a slow process but wellworth building those relationships inorder to enhance patient focusedquality care delivery.

ContactMarie HerringModern Matron, Urgent CareEmail: marie.herring@sotw.nhs.uk

What has been achieved?An innovative approach to deliveringacute home oxygen therapy wasestablished through collaboration withthe North East Ambulance Service.

Near patient testing of capillary blood gasanalysis in the community has facilitatedrapid assessment of the patient’s clinicalstatus and implementation of appropriateshort term oxygen therapy.

Close collaboration with secondary careallowed the team to expand theboundaries around which patients can besafely managed in a communityenvironment.

During the first four months of the pilot20 patients were initially managed athome, with continuous oxygen therapy tocorrect hypoxaemia associated with theiracute exacerbation of COPD.

Of these patients, only threesubsequently required hospital admission.The team were able to prevent 17patients being admitted. This representsan 85% success rate in admissionprevention in the target group.

The service was initiated as a six monthpilot and work is now in progress toconsider extending the service inresponse to its success.

Admissions avoidance through theurgent care team

South Tyneside NHS Foundation Trust

Case studies 15

Access to specialist care for patients with acuteexacerbation of chronic obstructive pulmonary diseaserequiring hospital admission

Colchester Hospital University NHS Foundation Trust

What was the problem?Over the past few years significant effortshave been made to improve the care forpeople with chronic obstructivepulmonary disease (COPD) in thecommunity in the Colchester locality. Itwas identified that improvements couldbe made for patients who require ahospital admission for acute exacerbationof COPD in particular around access tospecialist care as Colchester HospitalsUniversity Foundation Trust had notperformed well in this field in the 2008National COPD Resources and OutcomesProject (NCROP) study.

What was the aim?The project aim was to improve theproportion of patients with an acuteexacerbation of COPD who receivespecialist care in hospital and within thesix weeks post discharge, and evaluatethe impact of this service change onlength of stay, re-admission rate andpatient mortality.

• Introduced daily (Monday - Friday)consultant review of patients withCOPD which has reduced length of stayby 0.4 days. This will be continued withdaily ward rounds for COPD in theEmergency Admissions Unit and theAccident and Emergency department.

• Developed and implemented an in-patient care bundle, which wasadapted from North West LondonHospitals NHS Trust to ensure allpatients with COPD receive high qualitycare

• A discharge care bundle will bedeveloped as a next step from theproject work

• Developed a written self managementplan in collaboration with communitycolleagues, which is given to allpatients on discharge from the chestward. This will be extended to includepatients in Accident and Emergency(A&E), the emergency assessment unit,on other wards and patients beingmanaged in the community

• Developed a patient experiencequestionnaire to help to evaluate thequality of the patient’s experience andindentify areas for furtherimprovement.

What has been achieved?

Baseline data period - June to August 2010

• Number of admissions with acute exacerbationof COPD 132

• 30 & 90 day readmissions 9.4% and 17.7%respectively

• Length of stay 10 days• Deaths (% admissions) 7.8%• % patients treated on respiratory ward 47%

Improvements to date

• 30 and 90 day re-admissions12.3% and 19.8% respectively

• Length of stay 7.2• Deaths (% admissions) 4%• % patients treated onrespiratory ward 57%

What are the key learning points?• Early specialist review may impact onpatients’ length of stay for acuteexacerbation of COPD

• An inpatient care bundle for COPD maybe an effective way to drive up thequality of patient care, reduce length ofstay and reduce readmissions forexacerbation of COPD

• Data has been a constant challenge.Whilst data drives change, accessingthe relevant data can be difficult. Bytalking to the organisation's leadersand the information department theproject team in Colchester found thatmuch of the data was already beingcollected, albeit in a different form.

• If it works somewhere else then try tofocus on implementing it rather thanchanging the innovation e.g. carebundles. If it has worked elsewhere askwhy it is not being done already ratherthan why it can not be done!

ContactPeter HawkinsRespiratory PhysicianEmail:peter.hawkins@colchesterhospital.nhs.uk

Lianne JongepierRespiratory Services ManagerLianne.Jongepier@acecic.nhs.uk

Case studies16

What was the problem?There are high levels of chronicobstructive pulmonary disease (COPD)admissions and re-admissions in the EastLondon Acute Hospitals. This has beenhighlighted as particularly prevalent/highdisease burden across North East London,North Central London and Essex. Fiveacute Trusts in the sector agreed to takepart in the project: Homerton UniversityHospital Foundation Trust; Barts and theLondon Hospital (The Royal London andLondon Chest); Whipps Cross UniversityHospital; Basildon and Thurrock HospitalNHS Trust and Newham UniversityHospital NHS Trust.

What was the aim?The five hospitals had varied strategies inplace which aimed to avoid admission foracute exacerbation of COPD, but therewasn’t a unified regional strategy in placefor the distribution of self managementplans and rescue medication packs(antibiotics and steroids) to all patientsdischarged with COPD. The project aimswere:

• To increase the distribution of selfmanagement plans and rescue packs tomore than 80% of all patientsdischarged following a COPD admission

• To reduce re-admission rates within 30days of discharge

• To assess the effect of self managementplans and rescue medications on re-admission rates across this patch.

What are the key learning points?Patients felt more ‘empowered’ to takecontrol of their COPD as they wheregiven the ‘responsibility’ to manage anacute exacerbation and after the selfmanagement advice had more awarenessof the signs and symptoms of an acuteexacerbation.

The cultivation and development of anetwork of healthcare professionalsacross the local boroughs enabled theproject team in each trust to overcomebarriers and resolve issues relating toimplementation of the self managementplans in an effective and timely manner.

ContactMatt HodsonCOPD Nurse Consultant,Homerton Hospitals NHS TrustEmail:matthew.hodson@homerton.nhs.uk

Hasanin KhachiHighly Specialist Pharmacist –Specialist MedicineBarts and the London NHS TrustEmail:hasanin.khachi@bartsandthelondon.nhs.uk

What has been achieved?• Each Trust developed local strategies inorder to distribute the selfmanagement plans and rescuemedications. These included respiratoryspecialist nurses, pharmacists andrespiratory outreach staff

• Each Trust was able to continue to useits own patient information andprotocols for prescribing in an acuteexacerbation. Those Trusts withoutexisting self management / action planswere able to learn from othersexamples

• 200 patients received dischargeinformation and rescue medications ina six month period

• Through the success of the selfmanagement plans and effectiveengagement with primary carecolleagues, some PCTs have adoptedthe self management plans for patientsin primary care. As a result, a consistentaction plan has been developedbetween Barts and the London andTower Hamlets PCT.

Implementing the use of self management plans

North East London, North Central London and EssexHealth, Innovation and Education Cluster (HIEC)

Acknowledgements 17

Acknowledgments

NHS Improvement - Lung would like to thankall national improvement project sites fortheir hard work and dedication to improvequality and care for people with COPD, andfor their contributions to this document.

In addition, the following people haveprovided a source of expertise and supportand their help is gratefully acknowledged:

Phil Duncan, Director,NHS Improvement - Lung

Catherine Blackaby, National ImprovementLead, NHS Improvement - Lung

Ore Okosi, National Improvement Lead,NHS Improvement - Lung

Hannah Wall, National Improvement Lead,NHS Improvement - Lung

Zoë Lord, National Improvement Lead,NHS Improvement - Lung

Alex Porter, Senior Analyst,NHS Improvement - Lung

For more information please contact:Catherine Thompson, NationalImprovement Lead for Transforming AcuteCare in COPDcatherine.thompson@improvement.nhs.uk

18

References

iOutcomes Strategy for People with Chronic Obstructive Pulmonary Disease(COPD) and Asthma; London; Department of Health

iiRoyal College of Physicians Clinical Effectiveness & Evaluation Unit (2008) Report ofThe National Chronic Obstructive Pulmonary Disease Audit 2008: clinical audit of COPDexacerbations admitted to acute NHS units across the UK; London; Royal College ofPhysicians.

iiiPurdy S (2010) Avoiding hospital admissions. What does the research evidence say?;London; The King’s Fund. Available on-line at www.kingsfund.org.uk

ivBritish Lung Foundation, British Thoracic Society (2010) Ready for Home?; London;British Lung Foundation.

vNHS Improvement (2008) Transforming Inpatient Care Programme for CancerPatients – The Winning Principles; Leicester; NHS Improvement.

References

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