DDES CCG COPD Project 01/05/15 Dr Dilys Waller Respiratory Nurses - Susan Evison Caroline Blackburn Nichola Lowe Karen Beedle

Background The Spend and Outcome Tool (SPOT – Public Health England) gives organisations in England an overview of spend and outcomes across Long Term Conditions. COPD is in Highest Spend, Worse Outcome area DDES GP COPD admission rates vary /100 DDES COPD annual review data varies across the CCG

DDES COPD AUDIT

COPD Wheel

Aims Community respiratory nurse specialist to engage with Practices to: Improve annual COPD review to NICE standard Reduce COPD admissions Ensure all spirometry performed correctly, community nurses to assist with interpretation

Plan 1/3 respiratory nurse for each of 3 localities Arranged practice visits with practice manager and practice nurse Education and support for annual review and spirometry Data entry onto COPD template Reviewed COPD wheel, admission data and work to do lists 6 weekly meetings of project group Project details disseminated by , at DDES wide meetings and in locality groups Practical spirometry and inhaler training for clinicians

Respiratory Nurses 1. Improve COPD Annual Reviews ChallengesSuccesses Inconsistencies in annual review content due to variations in individual practices Improved standardised DDES template Standardise review Education & Upskilling Time for annual review

2. Reduce COPD Admissions ChallengesSuccesses Lack of patient communication regarding patient admission/discharge practice nurses unaware Advocated all COPD discharge letters received in practice are forwarded to practice nurse to arrange follow up within 2 weeks Follow up minimal = increased re- admission rate ANPs/VAWAS follow up 3 days post discharge Data review of ‘At Risk Patients’Reviewed RAIDR COPD non-elective admissions to establish reason for admission & events leading up to admission

ChallengesSuccesses Lack of patient support/education RE self management in relation to disease and admission avoidance. SMP/Rescue Packs IT/Compliance Treatment optimisation Education to nurses RE self management and completion of Self Management Plans. Advocate appropriate rescue packs Education in house RE inhaler devices, regimes and new treatment guidelines Advised patients to be added to admission avoidance registers PN monthly telephone review Recommendations of actions required i.e. treatment optimisation, diagnosis confirmation, added to appropriate register, due review

3. Quality Assured Spirometry ChallengesSuccesses Varied nursing knowledge/trainingExternal education provided Maintenance/cleaning Not correct cleaning methods Not using appropriate agents Not regularly cleaning Lack of equipment In house training/education offered Equipment sourced Calibration Not all 3L syringes Minimal biological checks Lack of understanding when to calibrate Inconsistencies in records 1:1 education provided in practice

ChallengesSuccesses Technique Contraindications Inconsistencies in VCs/FVCs Validity i.e. correct height and demographics Reliability Education in practices Interpretation Unable to interpret poor quality Varied understanding of results On going development of a community spirometry protocol Varied equipment used including FEV1, handheld monitors Advocating full spirometry or no spirometry

Results- early days Overall recording of annual review codes increased from % (Dec 2014 – Dec 15) Small reduction in COPD admissions in period May-October 15 v. same period previous year

Lessons learnt Burden of LTC reviews for practice nurses. Requirement for education and support. Time Organisation and processes within practices to ensure audit and review of patients and performance Include practice nurse leads and practice managers to disseminate good practice and processes Update the COPD template to be a resource as well as means of data entry. Links included for score assessments, self-management plans, COPD guideline, inhaler choices, steroid cards

COPD Template

Next Steps Review commissioning intentions for COPD, with a view to embedding General Practice support in the community respiratory nurse specialist role Ongoing in-house training Work with Meds Ops and community pharmacists to consider controlled cost effective inhaler switches 5YFV and MSCP Work with high admitting practices to develop an action plan to reduce admissions Include spirometry and inhaler updates as part of DDES practice nurse annual training Diagnosis review of new and existing cases, aided by improved spirometry and understanding