NHS CANCER NHS Improvement Lung DIAGNOSTICS HEART LUNG STROKE NHS Improvement - Lung: National Improvement Projects Transforming acute care in chronic obstructive pulmonary disease (COPD): testing the case for change
People with COPD should receive specialist respiratory review when acute episodes have required referral to hospital. They should be assessed for management by early discharge schemes, or by a structured hospital admission, to ensure that length of stay and subsequent readmission are minimised.
3 Transforming acute care in chronic obstructive pulmonary disease (COPD): testing the case for change Contents Introduction Case for change: the current position for chronic obstructive pulmonary disease in the UK Improvement approach Common challenges and solutions Project outcomes: Emerging success principles from project learning Future prototyping work Project case studies Acknowledgements References 4 4 4 5 6 6 8 17 18
4 Introduction Introduction Case for change: the current position for chronic obstructive pulmonary disease in the UK Three million people in the UK have chronic obstructive pulmonary disease (COPD). When a patient has an exacerbation of COPD, it is important that the right treatment is given as early as possible in order to minimise the acute and long term deterioration of the condition, and speed recovery. COPD is one of the most common reasons for admission to hospital, with 107,000 admissions in 2009/10. Exacerbations of COPD are inevitable for some patients, particularly those with more severe disease. During the first year of project work, NHS Improvement Lung through the Transforming Acute Care national workstream has focussed on developing services that deliver efficient, high quality care and support for patients with acute exacerbation of COPD both in the community and secondary care settings. This focus reflects objectives three and five from the recently published Outcomes Strategy for People with Chronic Obstructive Pulmonary Disease (COPD) and Asthma i : to reduce premature mortality from COPD through proactive care and management and to ensure people with COPD receive safe and effective care. The aim of the national workstream was to ensure that patients admitted to hospital with COPD receive timely specialist care and assessment so that they are optimally managed along a streamlined inpatient pathway most appropriate to their clinical needs. Work also included opportunities to identify pathways that avoid admissions where possible. A common objective of the work was to reduce length of stay for periods of hospitalisation and to reduce subsequent re-admissions with a view to release resources, both in terms of capacity release and cost avoidance, but also support the NHS to achieve the Quality, Innovation, Productivity and Prevention (QIPP) challenge. Further evidence for the need for this work can be found in the Royal College of Physicians 2008 NCROP study ii. It showed that access to early supported discharge schemes was limited with only 18% of patients being discharged with such schemes, despite evidence that around 25% of patients having an admission for acute exacerbation of COPD would be suitable for this approach to care. The audit also demonstrated that more than one in five patients admitted for acute exacerbation of COPD did not receive care from a respiratory specialist during their hospital stay. A more recent report by the King s Fund iii has suggested that early specialist review can be beneficial in reducing emergency and unplanned hospital admissions, so it is important to address this deficit in care to raise quality and improve outcomes. Many healthcare systems lack robust processes to ensure that patients are followed up after their exacerbation of COPD. A 2010 survey by the British Lung Foundation and British Thoracic Society[i] demonstrated that, whilst there is good evidence for the use of discharge plans, their introduction as a routine part of patient care has been limited with less than one in three hospitals adopting them. In addition, the 2008 COPD audit showed that only 53% of patients were discharged from hospital under the care of a respiratory physician. Improving these aspects of patient care during an acute exacerbation will improve outcomes, reduce re-admissions and lead to a better patient experience of care. This publication, which is aimed at healthcare professionals, commissioners and other key stakeholders involved in respiratory health, draws together the evidence and learning from the past 12 months and highlights the work undertaken by the project sites in the Transforming Acute Care national workstream. Improvement approach In July 2010, NHS Improvement Lung invited NHS organisations to work in partnership on projects dedicated to improving the COPD patient pathway and to help address the geographical variation in care that patients receive. Projects plans were submitted from a number of sites including acute trusts, primary care trusts (PCTs) and community organisations. The primary aims of the project work were to: Define the patients pathway Test the components of care that led to an effective acute care model Identify the success principles that other organisations and teams could learn from and adopt Inform future prototyping work. Focus was also given to improving the patient s experience and outcomes and to the removal of duplication and waste from the pathway and specific processes through different ways of working and service redesign. Productivity gains achieved by sites were measured to identify the impact of the work in terms of reductions in bed days, avoidable hospital admissions and re-admissions.
Introduction 5 During the testing phase of the programme the project teams have explored the reality of making this happen by taking stock of current practice and understanding the process of implementation towards ensuring patients receive optimal care in a challenging environment. The project sites adopted a systematic approach to quality improvement to ensure that any changes implemented were thoroughly tested and measured. Prior to commencing the work the project sites were required to establish their service baseline through analysis of local data and to understand the variation in services. Once the project teams were established, a period of diagnosis followed to allow teams to understand the patient pathway and dispel a number of assumptions about the processes, its challenges and the solutions. Potential solutions were tested using the model for improvement and Plan-Do-Study-Act (PDSA) cycles with ongoing measurement to evaluate the impact of the interventions and refine where appropriate. The project sites worked for a 12 month period and one of these sites, NHS West Sussex and Western Sussex Hospital NHS Trust, will continue into the second year of project work. For most of these projects this represented a starting point on the improvement journey for COPD patients. This publication contains a number of case studies produced from the final testing phase COPD project reports, demonstrating the key learning from the work that project sites have undertaken. Common challenges and solutions Clinical teams at all sites have been focussed on specific aims which have included: Increasing the number of patients with acute exacerbation of COPD who can be safely and effectively managed in the community through admissions avoidance schemes Ensuring patients admitted to hospital with acute exacerbation of COPD are seen by a respiratory specialist Streamlining the inpatient stay for acute exacerbation of COPD so that patients receive optimal care and can be discharged into the community as soon as clinically ready Ensuring patients who have an acute exacerbation of COPD receive timely and appropriate follow up care. Whilst each project site has worked on a different part of the acute pathway, a number of themes have emerged across all sites: Implementing co-ordinated case management for cohorts of patients with frequent hospital presentations is an effective way to reduce admissions. Several sites have demonstrated that this intervention has directly improved the quality of care delivered A lack of clear and effective referral mechanisms for specialist care leads to increased variation in the quality of care and potential waste of resources as clinical time is spent searching for appropriate patients Early access to specialist respiratory care has been demonstrated as an effective means in reducing length of stay. Colchester University Hospitals NHS Foundation Trust demonstrated a mean reduction in length of stay of 0.4 days and St George s Healthcare NHS Trust achieved a reduction of 1.5 days by instigating early specialist review Within and between organisations there is a lack of awareness by some clinicians of all available services for COPD patients and so reduced opportunities for the provision of high quality care. Improving communication is important in raising awareness of these services Improving communication and service integration is effective in reducing admissions. South Tyneside Foundation Hospital Trust prevented 66 admissions through closer working between GP and Hospital at Home services. Discharge plans which have been instigated at several project sites have been proven as an effective way of improving the quality of care in COPD by helping the patient to be more effective in self management and also facilitating a more integrated approach across primary and secondary care Care bundles improve the quality of care by ensuring key components of care are implemented and that there is consistency in the care being delivered. Several sites such as NHS West Sussex and Western Sussex Hospital Trust have successfully implemented COPD care bundles into their COPD patient management Developing an integrated acute care pathway for COPD is an important step in improving the patient care process, increasing the quality of clinical care and transforming the patient s experience of care during an exacerbation of COPD.
6 Introduction Project outcomes: Emerging success principles from project learning Through problem solving and a systematic approach to improvement, all teams worked through a number of challenges in order to achieve their project aims. Across the sites, a number of success principles have been identified that represents improvement opportunities towards effective service provision in managing the acute exacerbation of COPD: Defining and gaining a good understanding of the whole pathway of care supported by robust data to demonstrate current processes, performance and variation is essential when embarking on improvement work. This allowed organisations to identify priorities for change and also to benchmark themselves against others locally and nationally Issues and challenges viewed in isolation without due consideration to the whole patient pathway were less likely to lead to sustainable improvements in care provision Effective working relied on the commitment of teams in primary, secondary and community care to improve communication across the patient pathway. Integrated working helped to build positive relationships with health care professionals, departments and organisations, and improve the critical interface between these organisations Access to and effective use of data through collaboration between clinical and managerial staff enabled the project teams to better understand the patient pathway and demonstrate the impact of any change. The routine collection and review of data was important in implementing sustainable improvements and understanding outcomes of any service improvements Identifying the key levers and drivers in the system by integrating local and national priorities into the work such as Quality, Innovation, Productivity and Prevention (QIPP) raised the profile and priority of the project work with decision makers and helped to achieve improved engagement from senior management teams. There was a need to identify and understand the gaps, duplication and waste in the patient pathway in order to make best use of available resources. It was essential to work and communicate with colleagues, commissioners and other stakeholders in service provision in order to maximise these resources and to ensure a consistent and co-ordinated approach to care. Many of the issues and challenges met by the project teams were similar to those faced in other specialities and several of the success principles have been demonstrated to be effective in other disciplines e.g. the daily decision making ward round that was introduced through the NHS Improvement - Cancer inpatient work v. It was important for sites to recognise areas where common principles and practice meant that learning could be transferred across specialities. Future prototyping work In the forthcoming year of project work sites will be building on the learning from the testing phase of work. Sites will be refining the components attributed to the emerging care models and success principles that demonstrated the greatest impact on the patient pathway during the past year. The prototyping work will define the structured admission for patients with COPD, representing an efficient and high quality care model that reflects not only best practice, but also demonstrates examples of practical approaches towards sustainable implementation. This will include work that focuses on: Individualised patient management plans (including a discharge plan on admission) Daily decision making ward round and ongoing access to a respiratory specialist Incorporation of care-bundles into patient management Early exercise and ongoing referral to pulmonary rehabilitation services. The past year s work demonstrated that, despite the findings from the NCROP reports in 2003 and 2008 ii, the proportion of patients who receive noninvasive ventilation within three hours of admission remains low and many acute trusts do not have the necessary processes in place to ensure rapid assessment for and access to this intervention. There is clearly more that can be done to improve this position and work will be undertaken to address the design and implementation of sustainable pathways to ensure early assessment of respiratory failure and initiation of non-invasive ventilation.
Introduction 7 Building on the findings from the King s Fund iii, the projects will also work to implement emergency department triage by a respiratory specialist as this step of the patient pathway in acute exacerbation was not actively addressed through work in the testing phase. Despite existing evidence for the clinical safety and cost effectiveness of early supported discharge in COPD many areas do not currently offer this service. The national workstream will be working with organisations that are developing these services by drawing on the published evidence to date and practical examples found in respiratory services and other specialities. Several of the testing sites implemented strategies to facilitate collaborative working with ambulance services and primary / community care services, most commonly by instigating cross organisational multidisciplinary working. The impact of this still requires evaluation and prototyping sites will assess the effect such interventions have on high impact service users and subsequent re-admission rates. It is the aspiration of the national workstream to deliver a QIPP reduction in emergency admissions by 20%, a reduced length of stay by 20% and a reduction in readmissions at 30 days by 20% by building on work undertaken by project teams in the testing phase and continuing to transform acute care services for patients with COPD. In addition, the workstream will continue to identify the key components of care that improve the overall patients experience and outcomes, and further develop the learning and key success principles that support effective commissioning of acute respiratory services in England. Catherine Thompson, National Improvement Lead, NHS Improvement - Lung Phil Duncan, Director, NHS Improvement Lung Phil Duncan Director, NHS Improvement -Lung Catherine Thompson National Improvement Lead, NHS Improvement Lung
8 Case studies Project case studies NHS West Sussex and Western Sussex Hospitals NHS Trust: Improving the acute respiratory service in West Sussex North East London, North Central London and Essex Health Innovation and Education Cluster (HIEC): Improving access to non-invasive ventilation for COPD Norfolk and Norwich University Hospital NHS Foundation Trust: An integrated care model for patients with exacerbation of chronic obstructive pulmonary disease (COPD) St George s Healthcare NHS Trust: Process redesign improves services for acute exacerbation of chronic obstructive pulmonary disease (COPD) by reducing length of stay and readmission rates South Tyneside NHS Foundation Trust: Improving the acute 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 acute exacerbation of chronic obstructive pulmonary disease requiring hospital admission
Case studies 9 NHS West Sussex and Western Sussex Hospitals NHS Trust Improving the acute respiratory service in West Sussex What was the problem? The project team at NHS West Sussex and Western Sussex Hospitals NHS Trust, (Worthing Site) wanted to improve the quality of care for people with COPD admitted with an acute exacerbation to Worthing Hospital. What was the aim? The project aim is to reduce length of stay, reduce admissions by high impact service users, reduce re-admissions within 30 days, and to increase the proportion of patients assessed by a respiratory clinician during their stay and the timeliness of this assessment.. What has been achieved? A monthly COPD multidisciplinary meeting (MDM) was instigated, attended by acute and community clinicians. This has improved communication between clinical teams and led to more prompt, better integrated and more proactive care. For example: Community COPD nurses can access advice, ensuring the patient receives the right care and without the need for an outpatient appointment Patients who have been admitted more than once are now discussed systematically at the MDM and actions formulated aiming to prevent further avoidable admissions. A simple one page COPD Checklist was designed for use by the community matrons as an aide memoire to help ensure that COPD patients get the correct assessments and treatments. A discharge proforma was introduced which is completed by the Respiratory Nurse Specialist and sent promptly to the relevant community and primary care services. A COPD exacerbation care bundle was introduced for use in hospital to ensure best practice in line with clinical guidelines and improve patient care. A referral process is being developed to ensure that patients who have a first presentation for COPD receive an accurate diagnosis and appropriate follow up. By improving communication within the acute hospital the percentage of patients under care of a respiratory consultant has increased from 38% to 57%. What are the key learning points? Improved communication and joint working across primary and secondary care has allowed patients prompt access to a secondary care opinion. The primary and secondary care teams now feel that they are working as one team for the benefit of the patient Having a patient representative on the project group has been invaluable, providing a different perspective and challenging the clinicians and managers perceptions of what is good or right about how care is delivered and telling us what the priorities are for patients Finding a data/information analyst within the trust who is able to support the project work has made the retrieval and analysis of data, and monitoring of progress much easier There is a wealth of dedicated skilled people available whose energy can be harnessed to work together to make significant changes. Contact Dr Jo Congleton Respiratory Physician, Worthing Hospital Email: jo.congleton@wsht.nhs.uk
10 Case studies North East London, North Central London and Essex Health, Innovation and Education Cluster (HIEC) Improving access to non-invasive ventilation for chronic obstructive pulmonary disease (COPD) What was the problem? Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and exacerbations of COPD are associated with reduced quality of life and increased mortality. Mortality across the UK for acidotic COPD patients managed with non-invasive ventilation (NIV) is 26%. This is much higher than the randomised controlled trial evidence where the expected mortality is approximately 10%. Furthermore, about 30% of patients who fit the criteria for NIV do not receive it and of those that do receive NIV only 49% do so within three hours. What was the aim? Seven acute trusts across the HIEC region agreed to audit their performance of delivering NIV against a series of standards including: Door to mask time The presence of an escalation of care plan and resuscitation decisions Appropriate monitoring of therapy with arterial blood gas analysis Other medical therapy. The aim was to evaluate whether prospective monitoring and audit of NIV could improve practice in delivering NIV through the use of a treatment proforma with educational prompts. What has been achieved? Three of the seven trusts had a mean door to mask time of less that three hours and only 44% of patients across all seven sites received NIV within the optimal time frame of three hours There was some variation in the presence of an escalation plan (3 33% of patients did not have a documented plan) and resuscitation decisions (0 25% of patients did not have a documented decision) There was a monthly improvement in the number of ABGs taken at 4-6 hours. The proforma may have aided this improvement as there was a prompt on the proforma for ABGs to be taken Trusts with a 9-5 respiratory on-call system had the shortest door-to-mask time What are the key learning points? Prospective audit alone is not enough to effect change in practice in the delivery of NIV Acute trusts with a 9-5 respiratory on-call system had the shortest door-to-mask time although further investigation is required to ascertain why When NIV was started in the emergency department the door-to-mask time was shorter than for therapy commenced elsewhere Contact Swapna Mandal Respiratory Registrar Email: swapnamandal22@yahoo.co.uk Swapna Mandal
Case studies 11 Norfolk and Norwich University Hospital NHS Foundation Trust An integrated care model for patients with exacerbation of chronic obstructive pulmonary disease (COPD) What was the problem? Developing an integrated care model for patients admitted with an acute exacerbation of COPD is important for delivering high quality, holistic, patient centred care that is closer to the patient s home. The development of a local network of clinicians involved in the patients care was seen as an essential, underpinning element of this approach to care. The advent of the Outcomes Strategy for COPD and Asthma provided the impetus to redesign the way COPD services were delivered at Norfolk and Norwich University Hospital. What was the aim? The project aim was to review the management of patients admitted with acute exacerbation of COPD, identify gaps in service provision and improve integration between primary and secondary care services. Through this the project 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 raised their profile within the admissions unit by increasing respiratory nurse presence in the department and encouraging referral of patients for assessment via an electronic referral process Accident and Emergency (A&E) and admissions staff can now access electronic discharge summaries and clinic letters which has improved access to relevant clinical information Patients are being offered a comprehensive patient-held record which enables them to keep a record of information about diagnoses, treatment, medications, previous admissions, pulmonary function tests, arterial blood gases, appointments and health and social care professionals involved in their care. Patients are encouraged to take these records to all appointments and hospital attendances so that attending medical staff can make an assessment in the context of relevant history Closer links with the community matrons have been established through regular meetings. These meetings provide a framework for regular liaison and clinical support; enable sharing of referral pathways and criteria and an opportunity for multidisciplinary discussion of complex issues. Community matrons now have access to electronic discharge summaries A cohort of patients who are frequent attendees and have recurrent admissions has been identified and work is ongoing to liaise with community teams to target these people for support A specialist COPD clinic has been established which has consultant and specialist nurse appointments to provide prompt specialist postexacerbation follow-up, rapid access slots for GP / community team referrals and will provide a point of support for the community teams. What are the key learning points? It is important to ensure effective communication between all teams in order that appropriate patients are reviewed in a timely manner by the respiratory nursing team and referred appropriately to community services Better management of a cohort of frequent attendees / high impact service users could help to reduce admissions and readmissions in this group, however ongoing data collection will be required to determine the impact of changes in service provision The need for effective communication within an organisation should not be underestimated. Open communication plays a key part in successful working relationships Involve an interested analyst at project meetings to assist with obtaining and analysing data. Working with a data analyst is essential. It makes the process of data collection and interpretation much simpler It is important to establish data and analyse the patient pathway before deciding what changes to implement in the service. This will ensure that the right problems are addressed in the best way. This also helps with better understanding of the patient pathway / process. Contact Sandra Olive Respiratory Nurse Specialist Tel: 01603 289779 Email: sandra.olive@nnuh.nhs.uk
12 Case studies St George s Healthcare NHS Trust Process redesign improves services for acute exacerbation of chronic obstructive pulmonary disease (COPD) by reducing length of stay and re-admission rates What was the problem? Data from the 2008 COPD audit for the respiratory service at one NHS trust revealed the number of patients with a length of stay (LOS) of between 4-7 days was higher than the national average. What was the aim? To reduce the number of patients staying in hospital for four and seven days and to reduce length of stay To improve the patient pathway for patients with acute exacerbation of COPD requiring hospital admissions. To identify and resolve reasons for delayed discharge and improve discharge planning, providing support and 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 as the medical assessment unit (MAU), geriatrics, and the respiratory ward Patients are seen by the respiratory nurse earlier in their admission. Daily e-mails from the acute admissions ward outlining all patients admitted and daily attendance of respiratory nurse specialist at MDT meeting Systems developed and implemented for data collection both manually and electronically Patients are reviewed, assessed, and issued with a COPD discharge pack with includes, a discharge checklist, action plan and information about their condition All patients on discharge are referred to the community respiratory team for follow up within 24 hours. The outcomes of this were: Mean length of stay was reduced from 4.5 days to 3 days Readmission rates within 30 days were reduced from 3 per month to 2 per month suggesting an improvement in quality of care Proportion patients seen by respiratory nurse 47.7% Percentage of patients with 4-7 day length of stay reduced from 40% - 22%. What is the key learning? Reductions in length of stay and readmissions rates can be achieved through integration of services and working across organisational boundaries. Specialist care delivered earlier in the patient s inpatient stay may reduce length of stay and reduce length of stay for acute exacerbation of COPD. Effective communication across the acute trust into the community is essential. Improvement methodologies can identify bottlenecks and through effective service redesign productivity gains can be achieved without additional resources. The project requires engagement from people in all key areas of the patient journey / process map to eliminate patient blockages. It is important to develop a system to capture and record data accurately. Getting the process of data collection right early in the project will save a lot of time later on. Contact Samantha Prigmore Respiratory Nurse Consultant Tel: 020 8725 1275 Email: samantha.prigmore@stgeorges.nhs.uk
Case studies 13 South Tyneside NHS Foundation Trust Improving the acute respiratory assessment service What was the problem? South Tyneside has a high prevalence of people diagnosed with chronic obstructive pulmonary disease (COPD) and patients in this area are more likely to be admitted to hospital during an exacerbation of their COPD than the UK national average. The acute respiratory assessment service (ARAS) were given the opportunity to extend their care pathways from 1 April 2010 to provide a seven day urgent care service for patients with an exacerbation of COPD. The ARAS team already provided a Monday to Friday nonurgent care service to people with an acute exacerbation of COPD in their home setting working closely with the intermediate care team. What was the aim? The project aim was to reduce admissions for acute exacerbation of COPD at South Tyneside NHS Foundation Trust. What has been achieved? Monthly reflective practice meetings were arranged with ARAS, community matrons and Intermediate care to discuss frequent users/admissions and how best to manage these In future, the staff member responsible for the urgent care referrals will work across the emergency department and the community to maximise the impact on admission avoidance By targetting GP practices the team has increased the numbers of direct GP referrals, resulting in further avoided admissions. From April 2010 to July 2011, this accounts for 66 admissions avoided and a total of 462 hospital bed days By moving to a 7-day service 106 weekend assisted discharges occurred between April 2010 and March 2011, saving 206 bed days. What are the key learning points? Effective working relies not only on the service provided in secondary care but also on the committment from our community based health professional teams. Regular meetings with stakeholders and full involvement in the change process by all staff will help to reduce uncertainty and maintain focus. The development of a standardised clinical pathway of care and the use of reflective practice meetings with primary care colleagues have helped to increase their knowledge of a wider range of treatment and referral pathways for patients with COPD. Integrated working helps to build positive relationships with other health care professionals, departments and organisations. Communication between primary care services such as the community matrons and urgent care team has improved which has led to improvements in the quality of care offered to people with acute exacerbation of COPD. The use of a structured approach has given all involved a clear direction and staff within the team have a clear focus, feel valued and have been given a greater opportunity to develop their skills and knowledge base whilst contributing to service development. Contact Pauline Milner Respiratory Nurse Specialist Tel: 0191 404 1062 Email: pauline.milner@stft.nhs.uk
14 Case studies South Tyneside NHS Foundation Trust Admissions avoidance through the urgent care team What was the problem? The nurse-led Sunderland urgent care team (UCT), part of South Tyneside NHS Foundation Trust, provides a 24 hours/seven days a week service delivering acute care to people in their own homes, avoiding hospital admission wherever possible. To support provision of this rapid response and assessment, a step down facility exists within the intermediate care structure, which also includes physiotherapy and social work. What was the aim? The Urgent Care Team wanted to develop a more integrated care pathway for people with COPD across community services and secondary care. The aim was to prevent avoidable hospital admissions and reduce readmissions for COPD in Sunderland. The target patient group for this pilot where those who require continuous oxygen therapy in the short term to assist the recovery from an acute exacerbation. Previous to the pilot such patients would have always been admitted to secondary care. The project would also involve: Introduction of near patient capillary blood gas analysis into the urgent care team as a resource to provide improved patient information for safe clinical decision making The collaborative development of a medical management plan so that timely, appropriate, information could assist decision making in community care and also expedite admission to hospital from the urgent care service, where this was necessary. What has been achieved? An innovative approach to delivering acute home oxygen therapy was established through collaboration with the North East Ambulance Service. Near patient testing of capillary blood gas analysis in the community has facilitated rapid assessment of the patient s clinical status and implementation of appropriate short term oxygen therapy. Close collaboration with secondary care allowed the team to expand the boundaries around which patients can be safely managed in a community environment. During the first four months of the pilot 20 patients were initially managed at home, with continuous oxygen therapy to correct hypoxaemia associated with their acute exacerbation of COPD. Of these patients, only three subsequently required hospital admission. The team were able to prevent 17 patients being admitted. This represents an 85% success rate in admission prevention in the target group. The service was initiated as a six month pilot and work is now in progress to consider extending the service in response to its success. What are the key learning points? Take opportunities and think out of the box. Initially the North East Ambulance Service had not been considered for oxygen provision and considerable time was spent trying to negotiate within the national oxygen contract which did not meet the needs or cost resource of the service. It was a chance conversation with a director in the ambulance service that led to the outcome that was secured Work with the local and national agenda. Understand and share with stakeholders ongoing work such as Quality, Innovation, Productivity and Prevention (QIPP) initiatives, practice based commissioning group work, and strategies to reduce readmission in order to get senior buy in Have the right people around the table; early engagement with stakeholders is crucial. Do not underestimate the impact and influence of bringing together all the stakeholders in one room to discuss the patient pathway and appropriate health contact points and access. It s a slow process but well worth building those relationships in order to enhance patient focused quality care delivery. Contact Marie Herring Modern Matron, Urgent Care Email: marie.herring@sotw.nhs.uk
Case studies 15 Colchester Hospital University NHS Foundation Trust Access to specialist care for patients with acute exacerbation of chronic obstructive pulmonary disease requiring hospital admission What was the problem? Over the past few years significant efforts have been made to improve the care for people with chronic obstructive pulmonary disease (COPD) in the community in the Colchester locality. It was identified that improvements could be made for patients who require a hospital admission for acute exacerbation of COPD in particular around access to specialist care as Colchester Hospitals University Foundation Trust had not performed well in this field in the 2008 National COPD Resources and Outcomes Project (NCROP) study. What was the aim? The project aim was to improve the proportion of patients with an acute exacerbation of COPD who receive specialist care in hospital and within the six weeks post discharge, and evaluate the impact of this service change on length of stay, re-admission rate and patient mortality. What has been achieved? Baseline data period - June to August 2010 Number of admissions with acute exacerbation of 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% Introduced daily (Monday - Friday) consultant review of patients with COPD which has reduced length of stay by 0.4 days. This will be continued with daily ward rounds for COPD in the Emergency Admissions Unit and the Accident and Emergency department. Developed and implemented an inpatient care bundle, which was adapted from North West London Hospitals NHS Trust to ensure all patients with COPD receive high quality care A discharge care bundle will be developed as a next step from the project work Developed a written self management plan in collaboration with community colleagues, which is given to all patients on discharge from the chest ward. This will be extended to include patients in Accident and Emergency (A&E), the emergency assessment unit, on other wards and patients being managed in the community Developed a patient experience questionnaire to help to evaluate the quality of the patient s experience and indentify areas for further improvement. Improvements to date 30 and 90 day re-admissions 12.3% and 19.8% respectively Length of stay 7.2 Deaths (% admissions) 4% % patients treated on respiratory ward 57% What are the key learning points? Early specialist review may impact on patients length of stay for acute exacerbation of COPD An inpatient care bundle for COPD may be an effective way to drive up the quality of patient care, reduce length of stay and reduce readmissions for exacerbation of COPD Data has been a constant challenge. Whilst data drives change, accessing the relevant data can be difficult. By talking to the organisation's leaders and the information department the project team in Colchester found that much of the data was already being collected, albeit in a different form. If it works somewhere else then try to focus on implementing it rather than changing the innovation e.g. care bundles. If it has worked elsewhere ask why it is not being done already rather than why it can not be done! Contact Peter Hawkins Respiratory Physician Email: peter.hawkins@colchesterhospital.nhs.uk Lianne Jongepier Respiratory Services Manager Lianne.Jongepier@acecic.nhs.uk
16 Case studies North East London, North Central London and Essex Health, Innovation and Education Cluster (HIEC) Implementing the use of self management plans What was the problem? There are high levels of chronic obstructive pulmonary disease (COPD) admissions and re-admissions in the East London Acute Hospitals. This has been highlighted as particularly prevalent/high disease burden across North East London, North Central London and Essex. Five acute Trusts in the sector agreed to take part in the project: Homerton University Hospital Foundation Trust; Barts and the London Hospital (The Royal London and London Chest); Whipps Cross University Hospital; Basildon and Thurrock Hospital NHS Trust and Newham University Hospital NHS Trust. What was the aim? The five hospitals had varied strategies in place which aimed to avoid admission for acute exacerbation of COPD, but there wasn t a unified regional strategy in place for the distribution of self management plans and rescue medication packs (antibiotics and steroids) to all patients discharged with COPD. The project aims were: To increase the distribution of self management plans and rescue packs to more than 80% of all patients discharged following a COPD admission To reduce re-admission rates within 30 days of discharge To assess the effect of self management plans and rescue medications on readmission rates across this patch. What has been achieved? Each Trust developed local strategies in order to distribute the self management plans and rescue medications. These included respiratory specialist nurses, pharmacists and respiratory outreach staff Each Trust was able to continue to use its own patient information and protocols for prescribing in an acute exacerbation. Those Trusts without existing self management / action plans were able to learn from others examples 200 patients received discharge information and rescue medications in a six month period Through the success of the self management plans and effective engagement with primary care colleagues, some PCTs have adopted the self management plans for patients in primary care. As a result, a consistent action plan has been developed between Barts and the London and Tower Hamlets PCT. What are the key learning points? Patients felt more empowered to take control of their COPD as they where given the responsibility to manage an acute exacerbation and after the self management advice had more awareness of the signs and symptoms of an acute exacerbation. The cultivation and development of a network of healthcare professionals across the local boroughs enabled the project team in each trust to overcome barriers and resolve issues relating to implementation of the self management plans in an effective and timely manner. Contact Matt Hodson COPD Nurse Consultant, Homerton Hospitals NHS Trust Email: matthew.hodson@homerton.nhs.uk Hasanin Khachi Highly Specialist Pharmacist Specialist Medicine Barts and the London NHS Trust Email: hasanin.khachi@bartsandthelondon. nhs.uk
Acknowledgements 17 Acknowledgments NHS Improvement - Lung would like to thank all national improvement project sites for their hard work and dedication to improve quality and care for people with COPD, and for their contributions to this document. In addition, the following people have provided a source of expertise and support and their help is gratefully acknowledged: Phil Duncan, Director, NHS Improvement - Lung Catherine Blackaby, National Improvement Lead, 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, National Improvement Lead for Transforming Acute Care in COPD catherine.thompson@improvement.nhs.uk
18 References References i Outcomes Strategy for People with Chronic Obstructive Pulmonary Disease (COPD) and Asthma; London; Department of Health ii Royal College of Physicians Clinical Effectiveness & Evaluation Unit (2008) Report of The National Chronic Obstructive Pulmonary Disease Audit 2008: clinical audit of COPD exacerbations admitted to acute NHS units across the UK; London; Royal College of Physicians. iii Purdy S (2010) Avoiding hospital admissions. What does the research evidence say?; London; The King s Fund. Available on-line at www.kingsfund.org.uk iv British Lung Foundation, British Thoracic Society (2010) Ready for Home?; London; British Lung Foundation. v NHS Improvement (2008) Transforming Inpatient Care Programme for Cancer Patients The Winning Principles; Leicester; NHS Improvement.
NHS CANCER NHS Improvement DIAGNOSTICS HEART LUNG STROKE NHS Improvement NHS Improvement s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improved patient 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 1,000 GP practices. NHS Improvement 3rd Floor St John s House East Street Leicester LE1 6NB Telephone: 0116 222 5184 Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow s improvement agenda for the NHS NHS Improvement 2011 All Rights Reserved Publication Ref: IMP/comms028 - November 2011