Using improvement methodology, a COPD discharge care bundle was implemented by a multidisciplinary team (MDT) on the respiratory ward at West Middlesex hospital (WMUH), and its impact on readmission rates assessed after one year.
This example was originally submitted to demonstrate implementation of NICE guideline CG101. The guideline has now been updated and replaced by NG115. The example has been amended to reflect this and remains consistent with the updated guideline. NG115 should be referred to if seeking to replicate any aspects of this example.
Aims and objectives
To see if implementing a Chronic Obstructive Pulmonary Disease (COPD) discharge care bundle for all patients admitted with COPD to the respiratory ward would improve patient experience and reduce readmission rates. There were 4 main objectives in carrying out this project. Firstly, we wanted to improve the discharge process for patients admitted with an exacerbation of COPD by reducing variation in care. Further, we wanted to improve patient experience, empower self management and achieve earlier community supported discharge and follow up. Finally, we wanted to improve compliance with National COPD guidelines.
Reasons for implementing your project
COPD is a condition characterized by lung tissue damage and progressive airflow obstruction, and is primarily caused by smoking. It can result in shortness of breath, chronic cough, and acute exacerbations with can require hospitalisation. COPD accounts for 30,000 deaths per yr in England and Wales and is the 4th main cause of mortality worldwide. It accounts for 1 in 8 of all hospital admissions in the UK. The 2008 Royal College of Physicians/ British Thoracic Society National COPD audit revealed significant variations in outcomes between different hospitals implying that there is scope to improve outcomes by standardising care.
Hounslow suffers from a lack of community support for COPD patients including lack of pulmonary rehabilitation and community oxygen monitoring services. In addition, there are fewer community matrons in Hounslow to support these patients compared with neighbouring Primary Care Trusts, and there is no intermediate respiratory care team in Hounslow. These factors are important in explaining why WMUH has the highest number of emergency COPD admissions per 100 patients on a COPD register in London. In addition local data showed that the 28 day COPD readmission rate for WMUH was 25% in 2009/2010. As a result, a COPD discharge care bundle was implemented on the respiratory ward at WMUH and supported by North West London CLAHRC (Collaboration for Leadership in Applied Health Research and Care).
The aim was to see if the care bundle approach would improve patient experience and reduce readmission rates, as well as reduce variation in care and achieve compliance with National guidelines. The COPD discharge care bundle is a list of evidence based practices using Royal College of Physicians (RCP), British Thoracic Society (BTS), NICE, and the Global Initiative for chronic Obstructive Lung disease (GOLD) standard guidelines. We also compared our readmission data with our local CQIN readmission targets set by Hounslow commissioners.
How did you implement the project
The COPD discharge care bundle was implemented on the respiratory ward in May 2010. An MDT consisting of doctors, nurses, and other health care workers carried out a process mapping exercise to map the patients' journey following admission. A care bundle was completed for all COPD patients, and this consisted of 4 evidence based interventions known to improve patient outcomes. Elements of the bundle included giving a COPD information booklet to each patient, offering smoking cessation advice, ensuring patients could use their inhalers correctly, and providing a clinic appointment for 4 weeks prior to discharge. In addition, all patients received a telephone call 3 days post discharge, if they gave consent.
Regular MDT meetings were held to assess compliance with the bundle and to overcome any problems, using 'plan-do-study-act' cycles for rapid improvement. To help with sustainability, there were regular teaching sessions on the respiratory ward, as well as drop in inhaler technique and smoking cessation workshops. Education about the bundle was included as part of the nurse induction and appraisal process. Data on compliance with the bundle elements was kept on a bespoke web tool.
A baseline audit of 50 patients was carried out to assess the quality of care given to COPD patients by medical teams across the hospital by retrospective analysis of case notes. An improvement in the primary outcome (reduction in readmissions) was analyzed by the hospital's information and performance team, as part of the local CQIN (commissioning for quality and innovation) data requirements by commissioners. The 28 day COPD readmission rate over the course of 1 year with the bundle in place (May 2010-April 2011) was compared with the previous year's baseline readmission rate. Secondary outcome measures included 90 day reduction in mortality following discharge, length of stay, and resource saving. Ethical approval was obtained from the Hospital's Ethics Committee.
Sixteen months after introduction of the bundle, results showed that sustained improvements in smoking cessation referrals increased from a baseline of 25% to 96%; provision of information booklets increased from 5% to 97%; demonstration of inhaler technique increased from 10% to 98%, and an out-patient appointment given to patients prior to discharge increased from 30% to 97%. Overall compliance with all elements of the bundle was 92% over 16 months.
CQIN data (Commissioning for Quality and Innovation) showed a baseline 28 day COPD readmission rate of 25% in 2009/2010, and a readmission rate of 18.4% in 2010/2011 in the first year after introduction of the bundle (a reduction of 26.4%, p=0.06). This translates into a saving of £31,500 over the course of 1 year. Eighty-five percent of patients who replied said that they found the bundle useful or very useful.
No reduction in length of stay or reduction in 90 day mortality was demonstrated. Ward staff felt that their education and skills around caring for COPD patients had improved and they also felt that the bundle had made their work easier.
Key learning points
Introduction of the COPD discharge care bundle can improve patient and staff experience, and may help to reduce readmissions and thus provide resource savings.
There were no additional staff or resource implications during this project. The bundle did not prove time consuming for nursing or medical staff. In fact, it took about 10 minutes to discuss smoking cessation, give the patient a self management booklet, and demonstrate correct inhaler technique. The 3 day post discharge phone took 20 minutes and was carried out using a set proforma. Implementing the bundle provided on going education for nursing staff who felt this was a beneficial intervention in delivering high quality care.
Problems encountered in implementing the bundle have included recent changes in hospital infrastructure and reduction in nurse and administrative staff numbers in order to save resources. This has meant that roles previously carried out by staff on the respiratory ward which were important in ensuring implementation of the bundle have had to be taken over by existing staff members. Frequent changes in the bed model in the last year at our hospital involving the Medical Admissions Unit (MAU), has meant that the bundle could not be rolled out to the MAU due to changing priorities on this ward and rapid turnover of staff. Recent stability on the MAU however, and the identification of a 'champion' on the ward has meant that we have been able to introduce the bundle on that ward with good compliance.
Regular education, raising awareness campaigns and team meetings are important in sustaining the service improvement, especially at times of resource savings and cutbacks affecting the NHS. Entering data onto a bespoke web tool allows monitoring of compliance with the project, and any issues of non compliance can be addressed by using 'plan-do-study-act' cycles. We would like to acknowledge the support provided by North West London CLAHRC during this project.