BTS Care Bundles Project Webex 28 June 2013

1. BTS Care Bundles ProjectWebex28 June 2013

2. Agenda • Update on progress • Feedback from project participants • Whittington • Morriston • Worcester • Birmingham • George Eliot • Questions

3. COPD • COPD admission bundle: 1271 patient records committed from 18 hospitals (further 247 uncommitted records in progress) • COPD discharge bundle: 824 patient records committed so far from 14 hospitals (further 109 uncommitted records in progress) • 7 hospitals have added LTC6 data (133 so far)

5. Community Pneumonia • CAP bundle: 872 patient records committed from 15 hospitals (further 272 uncommitted records in progress) • CAP High level data: 19 hospitals have committed high level yearly and monthly data

8. Reminders • Reports: • CAP and COPD bundle reports available to download • Reports will change as more data is added (ie records committed); if you have not yet made a start in adding data for your hospital we would encourage you to do so - any queries then please make contact. • COPD high level monthly data report has been amended to remove the misleading charts on pages 8/9 which incorrectly showed number of bundles in relation to A&E admissions/discharges.

9. Whittington HospitalCAP bundle Sarah Crook on behalf of Dr Sara Lock and Whittington Team

10. Update • ED elected to use paper form • Colourful audit box to attract attention • Uptake poor to date, despite engagement of ED consultant and lead nurse • Planning to use sticker for notes with paper form so that other clinicians will know bundle completed

11. Sticker for notes

13. Update continued • Acute medicine and other medical colleagues happy to use electronic bundle on Anglia ICE (our electronic ordering programme) • Better uptake than for paper form, placed with essential admission bundles such as VTE, smoking, dementia • Microbiology trying to reduce unnecessary Pneumococcal antigen testing in non pneumonias – opportunity to increase bundle use if only means of requesting is via the bundle – being explored

15. Conclusions • Early days, but increasing bundle awareness with grand rounds, junior doctor training sessions, audit presentations • High level data highlighted our high readmission rate, which may be related to our deprived urban population, but we are looking at data to see if there are any themes we can address • Separately looking at enhanced recovery in medicine which may have impact.

16. BTS COPD AND CAP CARE BUNDLES BRIEF UPDATE FOR MORRISTON HOSPITAL, ABMU HB JUNE 29TH 2013

17. BACKGROUND • ABMU HB – 4 HOSPITALS • TEACHING HOSPITAL STATUS • MORRISTON HOSPITAL • 800 BEDDED TEACHING HOSPITAL • 2.2 WTE RESPIRATORY CONSULTANTS • DIFFICULT BED MANAGEMENT (>100% BED OCCUPANCY) • RESPIRATORY WARD – MAINLY GEN MED • NO WARD-BASED NIV – ALL ON ITU

18. NOTEABLE ACHIEVEMENTS • CREATION OF BUNDLES STEERING GROUP • TERMS OF REFERENCE • INTEGRATED INTO HB GOVENANCE STRUCTURE • CHAIRED BY DR E EVANS • ATTENDED/ORGANISED BY MRS F HUGHES ASSISTANT HEAD OF OPERATIONS • REGULAR WELL ATTENDED MEETINGS

19. NOTEABLE ACHIEVEMENTS • PILOT OF COPD DISCHARGE BUNDLE ON RESPIRATORY WARD • SOME INITIAL TEETHING PROBLEMS • TO CONSIDER ROLLING OUT TO OTHER MEDICAL WARDS/OTHER HOSPITALS • NOT CONVINCED THAT THIS WILL WORK ON NON-RESPIRATORY WARDS • AGREEMENT ON CAP ADMISSION BUNDLE • TO CONFRIM WITH THE A AND E TEAMS • PLAN TO BEGIN IN NEXT FEW WEEKS

20. NOTEABLE ACHIEVEMENTS • PLAN TO MOVE RESPIRATORY WARD JULY 6TH • 4 FEWER BEDS • INCREASED NURSE/BED RATIO • NIV EQUIPMENT PURCHASE IN PROCCESS • PLAN TO INITIATE WARD-BASED NIV IN THE AUTUMN • WHEN WARD-BASED NIV AVAILABLE WILL BE ABLE TO IMPLEMENT COPD ADMISSION BUNDLE

24. George Eliot Hospital • Monthly audit for COPD and pneumonia • Submitted until March • April nearly done • Adapted the COPD care bundles for local use • Redone on powerpoint and printed • Existing care bundle for pneumonia remains in use • Feedback from users is being collected before making changes • Staff in A&E aware of the bundles • Need to monitor their use and remind staff • Pneumonia care bundle is part of our CQUINS

25. BTS Chronic Obstructive Pulmonary Disease (COPD) Admission Care Bundle: 2012 / 13 This care bundle describes 5 high impact actions to ensure the best clinical outcome for patients admitted with an acute exacerbation of COPD (AECOPD). The aim is to ensure patient safety with a timely and accurate diagnosis of COPD, correct assessment of oxygenation, early response to respiratory failure and early specialist review. This bundle applies to all patients admitted to hospital with an acute deterioration of known or suspected COPD. Patients seen and assessed in A&E who are diagnosed with an acute exacerbation of COPD who are discharged without admission to hospital either with or without follow up by a community respiratory team should also be included. Banda Label ENSURE CORRECT DIAGNOSIS OF AN ACUTE EXACERBATION OF COPD The diagnosis of an acute exacerbation of COPD starts with a clinical assessment and is supported by review of an ECG and CXR which should be done within 4 hours of admission. The patient should also have documented evidence of spirometry showing airflow obstruction CXR done within 4 hours of admission: ECG done within 4 hours of admission? Date and time of CXR : Record of spirometry available in medical records? Smoking history: current former never if patient smokes, have you referred to stop smoking service? Signature Remember discharge bundle yes yes yes yes yes yes yes yes no no no no no no no no yes no ASSESS OXYGEN & PRESCRIBE TARGET RANGE FOR OXYGEN Early oxygen assessment is associated with improved prognosis. The provision of oxygen, when needed, follows after appropriate assessment. A target range for the oxygen saturation to be achieved (with supplemental oxygen if necessary) should be prescribed (94–98%, Patients at risk of CO2 retention: 88–92%). (BTS Emergency Oxygen Guideline) Physiological observations made within 1 hour of admission: Oxygen prescribed within 1 hour of admission: Signature Complete within 24 hours of admission yes yes yes yes yes no no no no no RECOGNISE AND RESPOND TO RESPIRATORY ACIDOSIS The patients with highest mortality from COPD following hospital admission are those who are admitted in ventilatory failure. An arterial blood gas for all patients admitted to hospital with oxygen saturations of 94% or less (on air or controlled oxygen) is required. Early assessment for suitability for NIV is required for those with Type 2 respiratory failure and a pH of <7.35 after one hour on optimum medical therapy (controlled oxygen and nebulised therapy). Oxygen saturations ≤94% after one hour of medical therapy: ABG carried out: pH<7.35 on ABG: Patient started on NIV: Signature ADMINISTER STEROIDS & NEBULISERS WITHIN 4 HOURS OF ADMISSION Patients medical therapy should be optimised on admission. This should follow local guidance detailed below. Consideration should be given to use of corticosteroids, nebulised bronchodilators and antibiotics (where the patient reports a deterioration in their respiratory symptoms from their stable state plus the presence of purulent sputum) Nebulisers administered within 4 hours of admission: Steroids administered within 4 hours of admission: Antibiotics administered within 4 hours of admission: Time prescription written: Signature REVIEW BY RESPIRATORY TEAM WITHIN 24 HOURS Results of the National COPD Audit 2003 suggest that deaths in hospital from COPD occur within 72 hours of admission and that death rates were lower in larger centres. Early review by a member of the respiratory specialist team may help improve patient outcomes Respiratory medical or nurse review within 24 hours: Date and time of respiratory review: Signature Instructions for use of bundle: Please complete and file with the admission proforma

26. BTS Chronic Obstructive Pulmonary Disease (COPD) Discharge Care Bundle: 2012 Banda Label This care bundle describes 5 high impact actions to ensure the best clinical outcome for patients admitted with an acute exacerbation of COPD (AECOPD). The aim is to reduce the number of patients who are readmitted following discharge after an AECOPD and to ensure that all aspects of the patients COPD care is considered. Respiratory Early Discharge Service (REDS) – Speed Line 1275 or 1358 REVIEW PATIENT’S MEDICATIONS & DEMONSTRATE USE OF INHALERS Assess during medication rounds. Observe the patient using their inhalers and refer to REDS if technique is inadequate. Ensure medications have been optimised by respiratory specialist team. Inhaler technique checked: Medication reviewed by respiratory team before discharge? Ensure all elements of COPD safe discharge checklist completed Nurse checking completion of discharge checklist Checklist completed Date of admission Date of discharge yes yes yes no no no yes no PROVIDE WRITTEN SELF MANAGEMENT PLAN & EMERGENCY DRUG PACK Prescribe COPD emergency drug pack and provide to patient at discharge. Ensure patient has a completed self management plan describing how and when to use medications provided. Provide oxygen alert card if patient is at risk of CO2 retention (referral to a community team for drug pack and plan is acceptable) Self management plan: Emergency drug pack provided? Oxygen alert card? Referred to community team for pack or plan? Day of Discharge Prior to Discharge NA NA NA given NA yes no yes yes no no Already has yes yes no no ASSESS AND OFFER REFERRAL FOR SMOKING CESSATION Ask every patient whether they are a current smoker and offer referral to smoking cessation service (Speed dial – 1342) Smoking history: current former never (To be classed as an ex-smoker, patients must have abstained for 3 months) Referral made? has smoking cessation been recorded as discussed? ASSESS FOR SUITABILITY FOR PULMONARY REHABILITATION All patients who report walking slower than others on the level or who need to stop due to dyspnoea after a mile or after less than 15 minutes walking should be assessed for and offered pulmonary rehabilitation Already completed pulmonary rehabilitation? Referral made? declined Not applicable yes no declined Not applicable ARRANGE FOLLOW UP CALL WITHIN 72 HOURS OF DISCHARGE Follow up all patients at home within 72 hours in person or by phone. A call for the patient can be booked by calling REDS & completing a discharge bundle. Patient has agreed to be contacted: Date and time of respiratory review: Date of call given to patient: Instructions for use of bundle: Complete all boxes and file in the medical record, REDS need to assess before discharge. yes no

27. Pneumonia Care Bundle

29. Discussion

30. LTC-6As many COPD admissions as possible during February

31. Notes of previous discussions together with presentations and copies of materials provided by participating hospitals available on the BTS website at: http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/BTS-NHSI-Care-Bundle-Project-Documents/Friday-15-March-Webex-Meeting.aspx

32. Dates for Diary • 2pm Friday 20 September: Webex • 2pm Friday 8 November: Webex • Friday 7 March 2014 - final project meeting - venue and other details to be confirmed - 2 participants from each centre to attend to present findings.