A series of mix and match cards providing practical examples of changes you can make and how to implement them to improve care and quality at every step of the pathway for patients with COPD and asthma.

1. 9
Success principles
Making a real difference
NINE:
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Acute inpatients:
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Structured inpatient stay
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Why?
A small number of patients attend the Emergency Department (ED) or are admitted
frequently and account for a large amount of secondary care resource. Up to one
third of patients admitted for exacerbation of COPD will be readmitted within one
month. Managing this group more effectively will improve the patient’s experience of
care, reduce avoidable ED attendances and admissions and release wasted capacity in
secondary care.
How?
• Review your hospital’s admissions within the past 12 months to identify which
patients have had multiple admissions. Your Trust data analysts will be able to
provide this information.
• Review the hospitals ED attendances over the past 12 months to identify which
patients have had multiple attendances.
• Determine and understand the reasons why these patients attended secondary care.
• Identify which patients could have been managed appropriately in primary care and
what steps can be put in place to avoid this in the future.
• Establish a supported self management plan for these patients in collaboration with
primary and community care providers.
• Identify patients who may become the ‘next generation’ of high impact users and
manage the group proactively.
• Use multidisciplinary meetings across primary, secondary and community care to
discuss patients and plan management approaches.
• Ask the question ‘would you be surprised if this patient was readmitted within the
month?’ to help identify patients who are at risk of readmission. Proactively manage
this group with community and primary care to prevent avoidable admissions.
• Ask the question ‘would you be surprised if this patient died within the next year?’
25% of patients admitted for exacerbation of COPD die within the next year and
many of these are at risk of readmission. Work with community providers to
establish an end of life pathway where appropriate.

2. • Consider approaches to commissioning that encourage integration of care between
care providers e.g. bundled funding for the admission or shared financial risk
between community and secondary care providers for readmissions.
Make sure every patient has the key components of care during their admission
Why?
Every admission should ensure every patient receives high quality care that addresses
the key components of long term condition management in COPD. This would
typically include:
• Ongoing access to specialist care.
• Confirmation of diagnosis.
• Ensure medication is optimal and appropriate to disease severity.
• Advice on stopping smoking and referral for support to do this.
• Being shown correct inhaler technique.
• Referral for pulmonary rehabilitation within two weeks of discharge from hospital.
• Advice on how best to manage future exacerbations to avoid secondary care admission.
• Follow up with an appropriate professional within two weeks.
Such an approach can reduce re-attendances and readmissions.
How?
• COPD ‘checklists’ or ‘care bundles’ are a good way to standardise the care delivered
and a key tool in ensuring all patients receive high quality care.
• Provide simple written advice as a self management action plan.
• Ensure all ward staff are able to teach correct inhaler technique or ensure all patients
are seen by a professional who is able to teach correct inhaler technique.
• Link the use of checklists or care bundles to the audit cycle to monitor progress.
Ensure patients whose admission is their first presentation receive
a quality assured diagnosis
Why?
More than 25% of patients admitted with exacerbation of COPD have not previously
been diagnosed with COPD. It is important to ensure that they receive an accurate
diagnosis to ensure that they receive the right treatment and support to manage the
condition in the long term.

3. How?
• Ensure all patients with a first presentation of COPD receive follow up and an
accurate, quality assured diagnosis.
• Consider who might be the most appropriate professional to complete the follow
up e.g. GP, community matron, practice nurse, respiratory nurse specialist or
physician.
• Remember that it takes up to six weeks for baseline spirometry and oximetry to
stablise following exacerbation, so assessments of COPD severity and of need for
long term oxygen therapy should be at least six weeks post admission.
Ensure medicines optimisation during the inpatient stay
Why?
COPD and asthma medication costs the NHS £1bn pa. However, suboptimal
prescribing or adherence will affect the patient’s ability to self manage, as well as their
use of primary care, emergency departments, secondary care and the cost of
medicines. Ensuring that medicines are clinically appropriate, cost effective and
acceptable to the patient can reduce waste, save money and improve outcomes for
patients.
How?
• Remember that smoking cessation is a treatment for COPD.
• Ensure patients have an accurate diagnosis and assessment of their disease, and
that this information is readily accessible.
• Use NICE guidelines to determine clinically appropriate choice of medication.
• Engage professional groups such as pharmacists who can be involved in medicines
review.
• Ensure inhaler technique is checked and corrected.
Ensure every patient who has an admission for exacerbation of COPD has
active follow-up and case management
Why?
A hospital admission for exacerbation is a significant event for someone with COPD.
Following the exacerbation it is important to ensure the patient receives supported
self management to ensure they know how to recognise and manage future
exacerbations.

4. How?
• Establish case management that is relative to the patient’s disease severity and social
situation e.g. with the community matron, district nurse or practice nurse where
specialist management isn’t required, or with the community respiratory team or
secondary care respiratory team.
• Ensure follow up happens within two weeks of discharge.
Ensure every patient admitted for exacerbation of COPD receives pulmonary
rehabilitation following discharge
Why?
A hospital admission for exacerbation of COPD is a significant event for someone with
COPD, and usually results in a significant reduction in exercise tolerance and physical
function. Following the exacerbation it is important to ensure the patient receives
pulmonary rehabilitation to ensure they are able to regain their previous level of
function. Pulmonary rehabilitation has been shown to reduce readmissions for
exacerbation of COPD.
How?
• Make sure you have a systematic process to identify appropriate patients who may
benefit from pulmonary rehabilitation.
• Ensure you have a systematic and reliable referral process for referral to pulmonary
rehabilitation.
• Where supported discharge services exist ensure coordination between supported
discharge and pulmonary rehabilitation to facilitate seamless transition of care and
increase uptake.
• Understand the demand for pulmonary rehabilitation e.g. how many patients will
require post-exacerbation rehabilitation.
• Explore ways to maximise the capacity of existing rehabilitation programmes.
• Consider whether you have the most effective structure for your programme.
Rolling programmes can lead to an increase in the number of patients who are able
to attend without an adverse impact on attendance and completion rates.
• Consider whether you could run two classes ‘back to back’ with the groups joining
together for education sessions. This would release one hour of staff time every
week (or create 100% more capacity with only 50% more resource).