Breakout 3.3 Achieving Excellence Across Primary & Secondary Care - Sarah Kearney BLF Respiratory Nurse - Isle of Wight Respiratory Clinical Network Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Isle of Wight
Respiratory Clinical Network
Achieving Excellence Across Primary &
Secondary Care
Sarah Kearney
BLF Respiratory Nurse
IOW LIP project
Achieving excellence in COPD care by:
– Maintaining low admissions
– Optimising prescribing
– Optimising treatment including smoking cessation
and referral to pulmonary rehabilitation
– To minimise frequency and severity of
exacerbations and ensure that patients can live as
well as possible with their condition
1

2. What did we do?
One practice reviewed 20 patients with a history of 2
or more exacerbations in the last year, optimised their
medicines and initiated a self management plan..
NICE Clinical Algorithm for COPD Low CAT SCORE = 0- 9
Smoking cessation
Consider Mucolytic Isle of Wight Have you used INCHECK
Influenza vaccine
if productive cough for over 12/52 Pneumonia vaccine
Device?
IN LAST 2 YEARS Reduce exposure to risk
‘
Consider Spacer device to
Carbocisteine Capsules 750mg TDS Use optmise therapy? Write on
factors
for 4/52 (£25.67) CATS SCORE Nutrition
Oral Liquid 750mg TDS 250mg/5ml PRESCRIPTION – SPACER
NNT=6
to DEVICE Medium CAT SCORE =
Maintenance Dose if effective assess your 10-19
Carbocisteine 750mg BD Capsules patient
NNT=6 (£17.92)PM Refer Pulmonary Rehab
Liquid 250mg/5ml 750mg BD 3x NNT=3 admission
300ml (£18.30) prevention
NNT= 6 mortality
SABA = Salbutamol 100mcg 2 puffs prn £1.50 Dose 200 or SAMA = Ipatropium 20mcg 2 puffs qds £5. 05
Breathlessness and/or exercise limitation Dose 200 Is Patient still smoking?
Or trial both together if monotherapy not optimal in reducing symptoms Passive Smoking?
Review maintenance
FEV1 ≥50% FEV1< 50% therapy
Exacerbations or persistent breathlessness Self management plan
LABA & ICS (combihaler)
LAMA STOP SAMA High CAT SCORE = 20-29
LABA LAMA STOP SAMA Tiotropium 18mcg od Handihaler Symbicort Turbohaler Refer Pulmonary Rehab
Formoterol Easihaler Tiotropium 18mcg od Handihaler (£31.89 refill) Dose 30 400/12 1 puff bd
12mcg 1 puff bd (£23.75) (£33.50) refill) Doses 30 Combopack (£34.8) (£33.00)Dose 60 Review maintenance
Dose 120 Combopack (£34.87 Doses 30 therapy
Tiotropium Respimat 2.5 mcg 2 puffs Tiotropium Respimat 2.5 mcg 2 puffs Seretide 500 Accuhaler 1
Salmeterol 50mcg 1 puff bd daily –only if cannot use handihaler daily –only if cannot use handihaler puff bd (£40.92) Dose 60 Consider Additional
(Accuhaler) (£29.26) (£35.50) Dose 60 (£35.50) Dose 60 NNT=13 Pharmacological
Dose 60 NNT 21 NNT= 21 NNT= 21 Consider LABA & LAMA if Treatments
NNT=21 All patients should be advised not All patients should be advised not ICS not tolerated
exceed stated dose. exceed stated dose. Self management plan
with rescue medicines
Consider Theophylline 3rd line: Uniphyllin 200mg BD (£2.94) care with elderly & concomitant medications. NNT=33 Very High CAT Score =
Recurrent exacerbations or persistent breathlessness 30-40
As HIGH CAT Score +
Check SP02 at Referral to specialist care
LABA & ICS each visit and if you are primary care
(combihaler) LAMA & LABA & ICS (combihaler) STOP SAMA
consider Oxygen professional)
Symbicort Turbohaler Symbicort Turbohaler 400/12 1 puff bd (£33.00) Dose 120 Assessment if
ONLY USE TRIPLE
400/12 1 puff bd (£33.00) Tiotropium 18mcg od Handihaler (£31.89 refill) Dose 60 SATS below 92% THERAPY IN SEVERE
Dose 120 Combopack (device & refill) (£34.87 = TOTAL (£69.89)Dose 60
DISEASE WITH
PERSITIENT
Seretide 500 Accuhaler Seretide 500 Accuhaler 1 puff bd (£40 .92) Dose 60 - Tiotropium 18mcg od Handihaler
EXACERBATIONS
1 puff bd (£40.92) Dose (£33.50 refill) Combopack (£34.87) Dose 60
60 TOTAL (£75.79) NNT=13
NNT=13 = Consider
Consider LABA & LAMA if Tiotropium Respimat 2.5 mcg 2 puffs daily –only if cannot use handihaler NNT = 13 NNT = The NNT is the
ICS not Check Inhaler technique Check BMI
tolerated average number of

patients who need to be
 Consider anxiety and reactive depression treated to prevent 1
 Symptomatic benefit is expected within 4 weeks but reduced exacerbations may be longer additional bad outcome
 High dose ICS can increase the risk of pneumonia (NNH=47) i.e fluticasone 1000mcg NNH = The number
 Rescue Medicines held by patient for exacerbations:TREAT with Prednisolone (NOT EC) 30mg 7 days Consider osteoporosis prophylaxis if patients that have needed to harm is an
had 4 courses of steroids within 12 months. Any patients over 65 should be started on prophylaxis without the ne ed for monitoring. epidemiological measure
 Antibiotics only given for purulent exacerbations: TREAT with Amoxicillin 500mg TDS for 5 Days or Doxycycline 200mg stat then 100mg OD for 7 days that indicates how many
 2nd line Clarithromycin 500mg 12hrly (Co-Amoxiclav) 625mg 8hrly5 days. Only 30-50% are bacterial; many viral. Only use 2nd line if failure to respond to patients need to be
1st line agents. Take sputum for culture and treat according to sensitivities if pathogen isolated. Do not use tetracyclines in pregnancy. exposed to a risk-factor
Please turn over for device/month/costs guidance over a specific period to
cause harm in 1 patient
2

3. My usual medication:
Including name, strength, dose, route and frequency.
COPD Action Plan
Taking your chest infections seriously
You can spot a flare-up coming if your usual symptoms get worse for at least
one or two days. It’s very important to know how to recognise the symptoms
because the earlier you spot them the better.
Key points to think about: Name:
Medication if unwell:
Please ring the surgery when you start this medicine and say
“I have started my rescue medicines –
please ask ____________ to call me to see if I need an
appointment or not”
Useful contacts:
• GP and Practice Nurse Telephone:
• Community Respiratory
Team
Telephone (office): 01983 552428
Telephone (mobile): 07826908704
British Lung Foundation Helpline for confidential advice and
support.
Telephone: 08458 50 50 20 (Monday to Friday, 10.00am –
6.00pm)
Website: www.lunguk.org
• 15 patients were already on optimal medication
indicating that there was a lot of good practice already.
• The numbers of urgent, non urgent and t/call contacts
with the surgery, as well as use of antibiotics and
admissions were recorded for the 6 months prior to the
review. The same metrics were then reviewed at 6
months.
• There was a reduction in urgent appointments for 11
patients from 27 in the 6 months pre-use of the plan to
8 in the 8 months afterwards (33%)
3

4. So What?
This can be extrapolated to demonstrate that a
reduction of 30% demand for urgent / routine
appointments on a list size of 100 COPD patients
would amount to a cost benefit of £2800 and saving of
13 hours GP time
Case Study
• 65 year old gentleman who has Severe COPD with co-morbidities
of epilepsy, coronary heart disease, and a past history of TIA.
• He was given a personalised Exacerbation Action Plan as he was
having regular telephone consultations which resulted in
prescriptions for Rescue Medication to manage his COPD.
• He had completed Pulmonary Rehabilitation and was on optimum
inhalers but difficult and challenging to manage.
Case Study
14
12
Number of Contacts
10
8 PRE Exacerbation Action Plan
6 POST Exacerbation Action Plan
4
2
0
Booked : Emergency Telephone Rescue
Appointments Appointments Consultations Medication
Prescriptions
Typer of Contacts
4

5. 5