Transforming acute care in chronic obstructive pulmonary disease (COPD): Testing the case for change

1. 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

2. “
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. 3
Transforming acute care in chronic obstructive pulmonary
disease (COPD): testing the case for change
Contents
Introduction 4
• Case for change: the current position for chronic 4
obstructive pulmonary disease in the UK
• Improvement approach 4
• Common challenges and solutions 5
• Project outcomes: Emerging success principles 6
from project learning
• Future ‘prototyping’ work 6
Project case studies 8
Acknowledgements 17
References 18

4. 4 Introduction
Introduction
Case for change: the current position to release resources, both in terms of This publication, which is aimed at
for chronic obstructive pulmonary capacity release and cost avoidance, but healthcare professionals, commissioners
disease in the UK also support the NHS to achieve the and other key stakeholders involved in
Quality, Innovation, Productivity and respiratory health, draws together the
Three million people in the UK Prevention (QIPP) challenge. evidence and learning from the past 12
have chronic obstructive pulmonary months and highlights the work
disease (COPD). When a patient has an Further evidence for the need for this undertaken by the project sites in the
exacerbation of COPD, it is important work can be found in the Royal College ‘Transforming Acute Care’ national
that the right treatment is given as early of Physicians 2008 NCROP studyii. It workstream.
as possible in order to minimise the acute showed that access to early supported
and long term deterioration of the discharge schemes was limited with only Improvement approach
condition, and speed recovery. COPD is 18% of patients being discharged with
one of the most common reasons for such schemes, despite evidence that In July 2010, NHS Improvement – Lung
admission to hospital, with 107,000 around 25% of patients having an invited NHS organisations to work in
admissions in 2009/10. admission for acute exacerbation of partnership on projects dedicated to
COPD would be suitable for this improving the COPD patient pathway and
Exacerbations of COPD are inevitable for approach to care. to help address the geographical variation
some patients, particularly those with in care that patients receive. Projects
more severe disease. During the first year The audit also demonstrated that more plans were submitted from a number of
of project work, NHS Improvement – than one in five patients admitted for sites including acute trusts, primary care
Lung through the ‘Transforming Acute acute exacerbation of COPD did not trusts (PCTs) and community
Care’ national workstream has focussed receive care from a respiratory specialist organisations.
on developing services that deliver during their hospital stay. A more recent
efficient, high quality care and support report by the King’s Fundiii has suggested The primary aims of the project work
for patients with acute exacerbation of that early specialist review can be were to:
COPD both in the community and beneficial in reducing emergency and
secondary care settings. This focus unplanned hospital admissions, so it is • Define the patients pathway
reflects objectives three and five from the important to address this deficit in care to • Test the components of care that led to
recently published Outcomes Strategy for raise quality and improve outcomes. an effective acute care model
People with Chronic Obstructive • Identify the success principles that
Pulmonary Disease (COPD) and Asthmai: Many healthcare systems lack robust other organisations and teams could
to reduce premature mortality from COPD processes to ensure that patients are learn from and adopt
through proactive care and management followed up after their exacerbation of • Inform future ‘prototyping’ work.
and to ensure people with COPD receive COPD. A 2010 survey by the British Lung
safe and effective care. Foundation and British Thoracic Society[i] Focus was also given to improving the
demonstrated that, whilst there is good patient’s experience and outcomes and to
The aim of the national workstream was evidence for the use of discharge plans, the removal of duplication and waste
to ensure that patients admitted to their introduction as a routine part of from the pathway and specific processes
hospital with COPD receive timely patient care has been limited with less through different ways of working and
specialist care and assessment so that than one in three hospitals adopting service redesign. Productivity gains
they are optimally managed along a them. In addition, the 2008 COPD audit achieved by sites were measured to
streamlined inpatient pathway most showed that only 53% of patients were identify the impact of the work in terms
appropriate to their clinical needs. Work discharged from hospital under the care of reductions in bed days, avoidable
also included opportunities to identify of a respiratory physician. Improving hospital admissions and re-admissions.
pathways that avoid admissions where these aspects of patient care during an
possible. A common objective of the acute exacerbation will improve
work was to reduce length of stay for outcomes, reduce re-admissions and lead
periods of hospitalisation and to reduce to a better patient experience of care.
subsequent re-admissions with a view

5. Introduction 5
During the ‘testing’ phase of the Common challenges and solutions • Early access to specialist respiratory care
programme the project teams have has been demonstrated as an effective
explored the reality of making this Clinical teams at all sites have been means in reducing length of stay.
happen by taking stock of current focussed on specific aims which have Colchester University Hospitals NHS
practice and understanding the process included: Foundation Trust demonstrated a mean
of implementation towards ensuring reduction in length of stay of 0.4 days
patients receive optimal care in a • Increasing the number of patients with and St George’s Healthcare NHS Trust
challenging environment. The project acute exacerbation of COPD who can achieved a reduction of 1.5 days by
sites adopted a systematic approach to be safely and effectively managed in instigating early specialist review
quality improvement to ensure that any the community through admissions • Within and between organisations
changes implemented were thoroughly avoidance schemes there is a lack of awareness by some
tested and measured. Prior to • Ensuring patients admitted to hospital clinicians of all available services for
commencing the work the project sites with acute exacerbation of COPD are COPD patients and so reduced
were required to establish their service seen by a respiratory specialist opportunities for the provision of high
baseline through analysis of local data • Streamlining the inpatient stay for quality care. Improving communication
and to understand the variation in acute exacerbation of COPD so that is important in raising awareness of
services. patients receive optimal care and can these services
be discharged into the community as • Improving communication and service
Once the project teams were established, soon as clinically ready integration is effective in reducing
a period of ‘diagnosis’ followed to allow • Ensuring patients who have an acute admissions. South Tyneside Foundation
teams to understand the patient pathway exacerbation of COPD receive timely Hospital Trust prevented 66 admissions
and dispel a number of assumptions and appropriate follow up care. through closer working between GP
about the processes, its challenges and and Hospital at Home services.
the solutions. Potential solutions were Whilst each project site has worked on a • Discharge plans which have been
tested using the model for improvement different part of the acute pathway, a instigated at several project sites have
and Plan-Do-Study-Act (PDSA) cycles with number of themes have emerged across been proven as an effective way of
ongoing measurement to evaluate the all sites: improving the quality of care in COPD
impact of the interventions and refine by helping the patient to be more
where appropriate. • Implementing co-ordinated case effective in self management and also
management for cohorts of patients facilitating a more integrated approach
The project sites worked for a 12 month with frequent hospital presentations is across primary and secondary care
period and one of these sites, NHS West an effective way to reduce admissions. • Care bundles improve the quality of
Sussex and Western Sussex Hospital NHS Several sites have demonstrated that care by ensuring key components of
Trust, will continue into the second year this intervention has directly improved care are implemented and that there is
of project work. For most of these the quality of care delivered consistency in the care being delivered.
projects this represented a starting point • A lack of clear and effective referral Several sites such as NHS West Sussex
on the improvement journey for COPD mechanisms for specialist care leads to and Western Sussex Hospital Trust have
patients. This publication contains a increased variation in the quality of care successfully implemented COPD care
number of case studies produced from and potential waste of resources as bundles into their COPD patient
the final ‘testing phase’ COPD project clinical time is spent ‘searching’ for management
reports, demonstrating the key learning appropriate patients • Developing an integrated acute care
from the work that project sites have pathway for COPD is an important step
undertaken. 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. 6 Introduction
Future ‘prototyping’ work
Project outcomes: Emerging success principles from project learning
In the forthcoming year of project work
Through problem solving and a The routine collection and review of sites will be building on the learning from
systematic approach to improvement, data was important in implementing the ‘testing’ phase of work. Sites will be
all teams worked through a number of sustainable improvements and refining the components attributed to the
challenges in order to achieve their understanding outcomes of any emerging care models and success
project aims. Across the sites, a service improvements principles that demonstrated the greatest
number of success principles have • Identifying the key levers and drivers impact on the patient pathway during the
been identified that represents in the system by integrating local past year. The prototyping work will
improvement opportunities towards and national priorities into the work define the structured admission for
effective service provision in managing such as Quality, Innovation, patients with COPD, representing an
the acute exacerbation of COPD: Productivity and Prevention (QIPP) efficient and high quality care model that
raised the profile and priority of the reflects not only best practice, but also
• Defining and gaining a good project work with decision makers demonstrates examples of practical
understanding of the whole pathway and helped to achieve improved approaches towards sustainable
of care supported by robust data to engagement from senior implementation. This will include work
demonstrate current processes, management teams. that focuses on:
performance and variation is • There was a need to identify and
essential when embarking on understand the gaps, duplication • Individualised patient management
improvement work. This allowed and waste in the patient pathway in plans (including a discharge plan on
organisations to identify priorities for order to make best use of available admission)
change and also to benchmark resources. It was essential to work • Daily decision making ward round and
themselves against others locally and and communicate with colleagues, ongoing access to a respiratory
nationally commissioners and other specialist
• Issues and challenges viewed in stakeholders in service provision in • Incorporation of care-bundles into
isolation without due consideration order to maximise these resources patient management
to the whole patient pathway were and to ensure a consistent and • ‘Early exercise’ and ongoing referral to
less likely to lead to sustainable co-ordinated approach to care. pulmonary rehabilitation services.
improvements in care provision
• Effective working relied on the Many of the issues and challenges met The past year’s work demonstrated that,
commitment of teams in primary, by the project teams were similar to despite the findings from the NCROP
secondary and community care to those faced in other specialities and reports in 2003 and 2008ii, the
improve communication across the several of the success principles have proportion of patients who receive non-
patient pathway. Integrated working been demonstrated to be effective in invasive ventilation within three hours of
helped to build positive relationships other disciplines e.g. the daily decision admission remains low and many acute
with health care professionals, making ward round that was trusts do not have the necessary
departments and organisations, and introduced through the NHS processes in place to ensure rapid
improve the critical interface Improvement - Cancer inpatient workv. assessment for and access to this
between these organisations It was important for sites to recognise intervention. There is clearly more that
• Access to and effective use of data areas where common principles and can be done to improve this position and
through collaboration between practice meant that learning could be work will be undertaken to address the
clinical and managerial staff enabled transferred across specialities. design and implementation of sustainable
the project teams to better pathways to ensure early assessment of
understand the patient pathway and respiratory failure and initiation of
demonstrate the impact of any non-invasive ventilation.
change.

7. Introduction 7
Building on the findings from the King’s It is the aspiration of the national
Fundiii, the projects will also work to workstream to deliver a QIPP reduction in
implement emergency department triage emergency admissions by 20%, a
by a respiratory specialist as this step reduced length of stay by 20% and a
of the patient pathway in acute reduction in readmissions at 30 days by
exacerbation was not actively addressed 20% by building on work undertaken by
through work in the ‘testing’ phase. project teams in the ‘testing phase’ and
continuing to transform acute care
Despite existing evidence for the clinical services for patients with COPD. In
safety and cost effectiveness of early addition, the workstream will continue to Phil Duncan
supported discharge in COPD many areas identify the key components of care that Director,
NHS Improvement -Lung
do not currently offer this service. The improve the overall patients’ experience
national workstream will be working with and outcomes, and further develop the
organisations that are developing these learning and key success principles that
services by drawing on the published support effective commissioning of acute
evidence to date and practical examples respiratory services in England.
found in respiratory services and other
specialities.
Catherine Thompson, National
Several of the ‘testing’ sites implemented Improvement Lead,
strategies to facilitate collaborative NHS Improvement - Lung
working with ambulance services and
primary / community care services, most Phil Duncan, Director,
commonly by instigating cross NHS Improvement – Lung Catherine Thompson
organisational multidisciplinary working. National Improvement Lead,
NHS Improvement – Lung
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.

8. 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

9. Case studies 9
NHS West Sussex and Western Sussex Hospitals NHS Trust
Improving the acute respiratory
service in West Sussex
What was the problem? A simple one page ‘COPD Checklist’ was What are the key learning points?
The project team at NHS West Sussex and designed for use by the community • Improved communication and joint
Western Sussex Hospitals NHS Trust, matrons as an aide memoire to help working across primary and secondary
(Worthing Site) wanted to improve the ensure that COPD patients get the correct care has allowed patients prompt
quality of care for people with COPD assessments and treatments. access to a secondary care opinion. The
admitted with an acute exacerbation to primary and secondary care teams now
Worthing Hospital. A discharge proforma was introduced feel that they are working as one team
which is completed by the Respiratory for the benefit of the patient
What was the aim? Nurse Specialist and sent promptly to the • Having a patient representative on the
The project aim is to reduce length of relevant community and primary care project group has been invaluable,
stay, reduce admissions by ‘high impact services. providing a different perspective and
service users’, reduce re-admissions challenging the clinicians and managers
within 30 days, and to increase the A COPD exacerbation care bundle was perceptions of what is ‘good’ or ‘right’
proportion of patients assessed by a introduced for use in hospital to ensure about how care is delivered and telling
respiratory clinician during their stay and best practice in line with clinical us what the priorities are for patients
the timeliness of this assessment. guidelines and improve patient care. • Finding a data/information analyst
. within the trust who is able to support
What has been achieved? A referral process is being developed to the project work has made the retrieval
A monthly COPD multidisciplinary ensure that patients who have a first and analysis of data, and monitoring of
meeting (MDM) was instigated, attended presentation for COPD receive an progress much easier
by acute and community clinicians. This accurate diagnosis and appropriate • There is a wealth of dedicated skilled
has improved communication between follow up. people available whose energy can be
clinical teams and led to more prompt, harnessed to work together to make
better integrated and more proactive By improving communication within the significant changes.
care. For example: acute hospital the percentage of patients
under care of a respiratory consultant has Contact
• Community COPD nurses can access increased from 38% to 57%. Dr Jo Congleton
advice, ensuring the patient receives Respiratory Physician, Worthing Hospital
the right care and without the need for Email: jo.congleton@wsht.nhs.uk
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.

10. 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? What has been achieved? Contact
Chronic obstructive pulmonary disease • Three of the seven trusts had a mean Swapna Mandal
(COPD) is a leading cause of mortality door to mask time of less that three Respiratory Registrar
and exacerbations of COPD are hours and only 44% of patients across Email: swapnamandal22@yahoo.co.uk
associated with reduced quality of life all seven sites received NIV within the
and increased mortality. Mortality across optimal time frame of three hours
the UK for acidotic COPD patients • There was some variation in the
managed with non-invasive ventilation presence of an escalation plan (3 –
(NIV) is 26%. This is much higher than 33% of patients did not have a
the randomised controlled trial evidence documented plan) and resuscitation
where the expected mortality is decisions (0 – 25% of patients did not
approximately 10%. Furthermore, about have a documented decision)
30% of patients who fit the criteria for • There was a monthly improvement in
NIV do not receive it and of those that do the number of ABGs taken at 4-6
receive NIV only 49% do so within three hours. The proforma may have aided
hours. this improvement as there was a
prompt on the proforma for ABGs to
What was the aim? be taken
Seven acute trusts across the HIEC region • Trusts with a 9-5 respiratory on-call
agreed to audit their performance of system had the shortest door-to-mask Swapna Mandal
delivering NIV against a series of time
standards including:
What are the key learning points?
• Door to mask time • Prospective audit alone is not enough
• The presence of an escalation of care to effect change in practice in the
plan and resuscitation decisions delivery of NIV
• Appropriate monitoring of therapy with • Acute trusts with a 9-5 respiratory
arterial blood gas analysis on-call system had the shortest
• Other medical therapy. door-to-mask time although further
investigation is required to ascertain
The aim was to evaluate whether why
prospective monitoring and audit of NIV • When NIV was started in the
could improve practice in delivering NIV emergency department the
through the use of a treatment proforma door-to-mask time was shorter than for
with educational prompts. therapy commenced elsewhere

11. 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? • Patients are being offered a
Developing an integrated care model for comprehensive patient-held record
patients admitted with an acute which enables them to keep a record of
exacerbation of COPD is important for information about diagnoses,
delivering high quality, holistic, patient treatment, medications, previous
centred care that is closer to the patient’s admissions, pulmonary function tests,
home. The development of a local arterial blood gases, appointments and
network of clinicians involved in the health and social care professionals
patients’ care was seen as an essential, involved in their care. Patients are
underpinning element of this approach to encouraged to take these records to all
care. The advent of the Outcomes appointments and hospital attendances
Strategy for COPD and Asthma provided so that attending medical staff can
the impetus to redesign the way COPD make an assessment in the context of
services were delivered at Norfolk and relevant history
Norwich University Hospital. • Closer links with the community
matrons have been established through • Better management of a cohort of
What was the aim? regular meetings. These meetings frequent attendees / high impact
The project aim was to review the provide a framework for regular liaison service users could help to reduce
management of patients admitted with and clinical support; enable sharing of admissions and readmissions in this
acute exacerbation of COPD, identify referral pathways and criteria and an group, however ongoing data
gaps in service provision and improve opportunity for multidisciplinary collection will be required to determine
integration between primary and discussion of complex issues. the impact of changes in service
secondary care services. Through this the Community matrons now have access provision
project would: to electronic discharge summaries • The need for effective communication
• A cohort of patients who are frequent within an organisation should not be
• Reduce COPD admissions attendees and have recurrent underestimated. Open communication
• Reduce length of stay admissions has been identified and plays a key part in successful working
• Reduce rate of readmissions work is ongoing to liaise with relationships
• Establish rapid GP access to COPD clinic community teams to target these • Involve an interested analyst at project
• Establish a local COPD network people for support meetings to assist with obtaining and
• A specialist COPD clinic has been analysing data. Working with a data
What has been achieved? established which has consultant and analyst is essential. It makes the process
• The respiratory nursing team has raised specialist nurse appointments to of data collection and interpretation
their profile within the admissions unit provide prompt specialist post- much simpler
by increasing respiratory nurse presence exacerbation follow-up, rapid access • It is important to establish data and
in the department and encouraging slots for GP / community team referrals analyse the patient pathway before
referral of patients for assessment via and will provide a point of support for deciding what changes to implement in
an electronic referral process the community teams. the service. This will ensure that the
• Accident and Emergency (A&E) and right problems are addressed in the
admissions staff can now access What are the key learning points? best way. This also helps with better
electronic discharge summaries and • It is important to ensure effective understanding of the patient pathway /
clinic letters which has improved access communication between all teams in process.
to relevant clinical information order that appropriate patients are
reviewed in a timely manner by the Contact
respiratory nursing team and referred Sandra Olive
appropriately to community services Respiratory Nurse Specialist
Tel: 01603 289779
Email: sandra.olive@nnuh.nhs.uk

12. 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), The outcomes of this were: Improvement methodologies can identify
geriatrics, and the respiratory ward bottlenecks and through effective service
• Patients are seen by the respiratory • Mean length of stay was reduced from redesign productivity gains can be
nurse earlier in their admission. 4.5 days to 3 days achieved without additional resources.
• Daily e-mails from the acute admissions • Readmission rates within 30 days were The project requires engagement from
ward outlining all patients admitted reduced from 3 per month to 2 per people in all key areas of the patient
and daily attendance of respiratory month suggesting an improvement in journey / process map to eliminate
nurse specialist at MDT meeting quality of care patient blockages.
• Systems developed and implemented • Proportion patients seen by respiratory
for data collection both manually and nurse 47.7% It is important to develop a system to
electronically • Percentage of patients with 4-7 day capture and record data accurately.
• Patients are reviewed, assessed, and length of stay reduced from 40% - Getting the process of data collection
issued with a COPD discharge pack 22%. right early in the project will save a lot of
with includes, a discharge checklist, time later on.
action plan and information about their What is the key learning?
condition Reductions in length of stay and re-
• All patients on discharge are referred to admissions rates can be achieved through Contact
the community respiratory team for integration of services and working across Samantha Prigmore
follow up within 24 hours. organisational boundaries. Specialist care Respiratory Nurse Consultant
delivered earlier in the patient’s inpatient Tel: 020 8725 1275
stay may reduce length of stay and Email:
reduce length of stay for acute samantha.prigmore@stgeorges.nhs.uk
exacerbation of COPD. Effective
communication across the acute trust into
the community is essential.

13. 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 non-
urgent 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 are the key learning points? team has improved which has led to
Effective working relies not only on the improvements in the quality of care
What has been achieved? service provided in secondary care but offered to people with acute exacerbation
• Monthly reflective practice meetings also on the committment from our of COPD.
were arranged with ARAS, community community based health professional
matrons and Intermediate care to teams. Regular meetings with The use of a structured approach has
discuss frequent users/admissions and stakeholders and full involvement in the given all involved a clear direction and
how best to manage these change process by all staff will help to staff within the team have a clear focus,
• In future, the staff member responsible reduce uncertainty and maintain focus . feel valued and have been given a greater
for the urgent care referrals will work opportunity to develop their skills and
across the emergency department and The development of a standardised knowledge base whilst contributing to
the community to maximise the impact clinical pathway of care and the use of service development.
on admission avoidance reflective practice meetings with primary
• By targetting GP practices the team has care colleagues have helped to increase Contact
increased the numbers of direct GP their knowledge of a wider range of Pauline Milner
referrals, resulting in further avoided treatment and referral pathways for Respiratory Nurse Specialist
admissions. From April 2010 to July patients with COPD. Tel: 0191 404 1062
2011, this accounts for 66 admissions Email: pauline.milner@stft.nhs.uk
avoided and a total of 462 hospital bed Integrated working helps to build positive
days relationships with other health care
• By moving to a 7-day service 106 professionals, departments and
weekend assisted discharges occurred organisations. Communication between
between April 2010 and March 2011, primary care services such as the
saving 206 bed days. community matrons and urgent care

14. 14 Case studies
South Tyneside NHS Foundation Trust
Admissions avoidance through the
urgent care team
What was the problem? What has been achieved? What are the key learning points?
The nurse-led Sunderland urgent care An innovative approach to delivering • Take opportunities and think out of the
team (UCT), part of South Tyneside NHS acute home oxygen therapy was box. Initially the North East Ambulance
Foundation Trust, provides a 24 established through collaboration with Service had not been considered for
hours/seven days a week service the North East Ambulance Service. oxygen provision and considerable time
delivering acute care to people in their was spent trying to negotiate within
own homes, avoiding hospital admission Near patient testing of capillary blood gas the national oxygen contract which did
wherever possible. To support provision analysis in the community has facilitated not meet the needs or cost resource of
of this rapid response and assessment, a rapid assessment of the patient’s clinical the service. It was a chance
step down facility exists within the status and implementation of appropriate conversation with a director in the
intermediate care structure, which also short term oxygen therapy. ambulance service that led to the
includes physiotherapy and social work. outcome that was secured
Close collaboration with secondary care • Work with the local and national
What was the aim? allowed the team to expand the agenda. Understand and share with
The Urgent Care Team wanted to develop boundaries around which patients can be stakeholders ongoing work such as
a more integrated care pathway for safely managed in a community Quality, Innovation, Productivity and
people with COPD across community environment. Prevention (QIPP) initiatives, practice
services and secondary care. based commissioning group work, and
During the first four months of the pilot strategies to reduce readmission in
The aim was to prevent avoidable 20 patients were initially managed at order to get senior buy in
hospital admissions and reduce re- home, with continuous oxygen therapy to • Have the right people around the table;
admissions for COPD in Sunderland. The correct hypoxaemia associated with their early engagement with stakeholders is
target patient group for this pilot where acute exacerbation of COPD. crucial. Do not underestimate the
those who require continuous oxygen impact and influence of bringing
therapy in the short term to assist the Of these patients, only three together all the stakeholders in one
recovery from an acute exacerbation. subsequently required hospital admission. room to discuss the patient pathway
Previous to the pilot such patients would The team were able to prevent 17 and appropriate health contact points
have always been admitted to secondary patients being admitted. This represents and access. It’s a slow process but well
care. an 85% success rate in admission worth building those relationships in
prevention in the target group. order to enhance patient focused
The project would also involve: quality care delivery.
• Introduction of near patient capillary The service was initiated as a six month
blood gas analysis into the urgent care pilot and work is now in progress to Contact
team as a resource to provide improved consider extending the service in Marie Herring
patient information for safe clinical response to its success. Modern Matron, Urgent Care
decision making Email: marie.herring@sotw.nhs.uk
• 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.

15. 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? What has been achieved?
Over the past few years significant efforts
have been made to improve the care for Baseline data period - June to August 2010 Improvements to date
people with chronic obstructive
pulmonary disease (COPD) in the • Number of admissions with acute exacerbation • 30 and 90 day re-admissions
community in the Colchester locality. It of COPD 132 12.3% and 19.8% respectively
was identified that improvements could • 30 & 90 day readmissions 9.4% and 17.7% • Length of stay 7.2
be made for patients who require a respectively • Deaths (% admissions) 4%
hospital admission for acute exacerbation • Length of stay 10 days • % patients treated on
of COPD in particular around access to • Deaths (% admissions) 7.8% respiratory ward 57%
specialist care as Colchester Hospitals • % patients treated on respiratory ward 47%
University Foundation Trust had not
performed well in this field in the 2008
National COPD Resources and Outcomes • Introduced daily (Monday - Friday) What are the key learning points?
Project (NCROP) study. consultant review of patients with • Early specialist review may impact on
COPD which has reduced length of stay patients’ length of stay for acute
What was the aim? by 0.4 days. This will be continued with exacerbation of COPD
The project aim was to improve the daily ward rounds for COPD in the • An inpatient care bundle for COPD may
proportion of patients with an acute Emergency Admissions Unit and the be an effective way to drive up the
exacerbation of COPD who receive Accident and Emergency department. quality of patient care, reduce length of
specialist care in hospital and within the • Developed and implemented an in- stay and reduce readmissions for
six weeks post discharge, and evaluate patient care bundle, which was exacerbation of COPD
the impact of this service change on adapted from North West London • Data has been a constant challenge.
length of stay, re-admission rate and Hospitals NHS Trust to ensure all Whilst data drives change, accessing
patient mortality. patients with COPD receive high quality the relevant data can be difficult. By
care talking to the organisation's leaders
• A discharge care bundle will be and the information department the
developed as a next step from the project team in Colchester found that
project work much of the data was already being
• Developed a written self management collected, albeit in a different form.
plan in collaboration with community • If it works somewhere else then try to
colleagues, which is given to all focus on implementing it rather than
patients on discharge from the chest changing the innovation e.g. care
ward. This will be extended to include bundles. If it has worked elsewhere ask
patients in Accident and Emergency why it is not being done already rather
(A&E), the emergency assessment unit, than why it can not be done!
on other wards and patients being
managed in the community Contact
• Developed a patient experience Peter Hawkins
questionnaire to help to evaluate the Respiratory Physician
quality of the patient’s experience and Email:
indentify areas for further peter.hawkins@colchesterhospital.nhs.uk
improvement.
Lianne Jongepier
Respiratory Services Manager
Lianne.Jongepier@acecic.nhs.uk

16. 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? What has been achieved? What are the key learning points?
There are high levels of chronic • Each Trust developed local strategies in Patients felt more ‘empowered’ to take
obstructive pulmonary disease (COPD) order to distribute the self control of their COPD as they where
admissions and re-admissions in the East management plans and rescue given the ‘responsibility’ to manage an
London Acute Hospitals. This has been medications. These included respiratory acute exacerbation and after the self
highlighted as particularly prevalent/high specialist nurses, pharmacists and management advice had more awareness
disease burden across North East London, respiratory outreach staff of the signs and symptoms of an acute
North Central London and Essex. Five • Each Trust was able to continue to use exacerbation.
acute Trusts in the sector agreed to take its own patient information and
part in the project: Homerton University protocols for prescribing in an acute The cultivation and development of a
Hospital Foundation Trust; Barts and the exacerbation. Those Trusts without network of healthcare professionals
London Hospital (The Royal London and existing self management / action plans across the local boroughs enabled the
London Chest); Whipps Cross University were able to learn from others project team in each trust to overcome
Hospital; Basildon and Thurrock Hospital examples barriers and resolve issues relating to
NHS Trust and Newham University • 200 patients received discharge implementation of the self management
Hospital NHS Trust. information and rescue medications in plans in an effective and timely manner.
a six month period
What was the aim? • Through the success of the self
The five hospitals had varied strategies in management plans and effective Contact
place which aimed to avoid admission for engagement with primary care Matt Hodson
acute exacerbation of COPD, but there colleagues, some PCTs have adopted COPD Nurse Consultant,
wasn’t a unified regional strategy in place the self management plans for patients Homerton Hospitals NHS Trust
for the distribution of self management in primary care. As a result, a consistent Email:
plans and rescue medication packs action plan has been developed matthew.hodson@homerton.nhs.uk
(antibiotics and steroids) to all patients between Barts and the London and
discharged with COPD. The project aims Tower Hamlets PCT. Hasanin Khachi
were: Highly Specialist Pharmacist –
Specialist Medicine
• To increase the distribution of self Barts and the London NHS Trust
management plans and rescue packs to Email:
more than 80% of all patients hasanin.khachi@bartsandthelondon.
discharged following a COPD admission nhs.uk
• To reduce re-admission rates within 30
days of discharge
• To assess the effect of self management
plans and rescue medications on re-
admission rates across this patch.

17. 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. 18 References
References
Outcomes Strategy for People with Chronic Obstructive Pulmonary Disease
i
(COPD) and Asthma; London; Department of Health
Royal College of Physicians Clinical Effectiveness & Evaluation Unit (2008) Report of
ii
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.
Purdy S (2010) Avoiding hospital admissions. What does the research evidence say?;
iii
London; The King’s Fund. Available on-line at www.kingsfund.org.uk
British Lung Foundation, British Thoracic Society (2010) Ready for Home?; London;
iv
British Lung Foundation.
vNHS Improvement (2008) Transforming Inpatient Care Programme for Cancer
Patients – The Winning Principles; Leicester; NHS Improvement.

20. NHS
CANCER
NHS Improvement
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement
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