1. Centre for Healthcare Improvement and Research NIHR CLAHRC for Northwest London: COPD projects London Health Observatory 20 th July 2011 Cathy Howe Programme Lead for Acute Care NIHR CLAHRC for Northwest London

2. What are CLAHRC’s CLAHRC = Collaboration for Leadership in Applied Health Research & Care Designed to close the second translational gap (Cooksey Report) Evidence Based Medicine / Practice should be supported by Evidence Based Implementation 9 CLAHRC Programmes awarded in England (c.£90m over 5 years) Partnerships between NHS and University

4. Cycle for Improvement Research/Policy Controlled or Remote Research/Policy Controlled or Remote Real World Uncontrolled & Messy Real World Uncontrolled & Messy 1. Patients and Carers Experience and Outcomes 2. Identify needs for improvement 3. Priorities 4. Identify Solutions 5. Implementation Complicated Easy Complicated Easy Simple Hard Simple Hard

5. Overview of the programme

7. Developing Themes & Outputs AreaInnovationsOutputs to date Respiratory COPD Care Bundle Telemonitoring COPD Data base Respiratory CQUIN Thorax publication BTS ? CAP Care Bundle Medicines Management Medication review tool Patient Passport Royal Pharmaceutical Society supporting as basis for a national template. Mental Health Patient involvement Secondary/primary care collaborations Effectively engaging ‘hard to reach groups’ HIV Testing Non traditional settingsPatient engagement, Draft NICE guidance Cardio- vascular CHF Rehabilitation Exercise Programme ICP Vascular Risk Assessment - QOF+ Department of Health award Diabetes Peer led education Foot care bundle Stroke Care Bundle

8. Round 1: Development Site

9. Aim of Development Project “To develop a discharge care bundle to improve experience and outcomes for patients with COPD.” Compliance with RCP, NICE, GOLD, BTS COPD guidelines and RCP audit

10. COPD & Asthma Guidelines Direct connection Shared evidence-base Involvement of same personnel Weblink: http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/docum ents/digitalasset/dh_128428.pdf

11. What is a care bundle? Optimum clinical outcomes require methods of delivering care processes in a consistent manner to reduce unwarranted variation (Fisher 2003). A Care Bundle integrates elements of the latest evidence- based guidelines and provides a means for staff to measure compliance to key clinical procedures (DoH 2007). – usually a distillation of 4-6 priority elements from several published guidelines/articles into a one-page form. – must be completed within a defined timescale. – all elements should be delivered to maximise patient benefit: compliance =‘yes’ if ALL elements are delivered OR = ‘no’ if ANY element is missed. – care bundles do not replace clinical judgement; exceptions should also be evidence based.

12. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) DISCHARGE CARE BUNDLE Summary – This care bundle is a group of evidence based items that should be delivered to all patients being discharged from the hospital following an Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD). The care bundle aims to improve quality of care, patient experience and minimise the risk of re-hospitalisation. To ensure the bundle can apply to all we have prepared a combination of actions and documents to facilitate the discharge process. Inform the COPD CNS of all COPD patients within 24 hours of arrival including patients discharged. Extension 55362 or 58472. 1. If patient is a smoker offer smoking cessation assistance For community referral Fax 020 8962 4135 For C&W clinic referral Fax 020 8746 5684 2. Pulmonary rehabilitation -assessed for suitability First point of contact, either by the CNS Nurses or Physiotherapist, who will assess and refer patient. Nurse to contact if not done prior to discharge (fax referral form) 3. Written COPD patient information given including : British Lung Foundation Self Management Book Oxygen alert WALLET card Information about the Breathe Easy Group An out-patient appointment within 30 days of discharge should be arranged via ward clerk and patient informed. 5. Follow up arrangements after discharge. 4. Satisfactory use of inhalers demonstrated and understood Please assess during medication rounds. Observe the patients using the device's) and document on electronic prescribing record adequate technique demonstrated. (Refer to pharmacist or CNS if extra support is needed). Place the faxed referral form(s) in the plastic sleeve during the patients stay, at discharge place with the COPD Discharge Checklist in the ‘Completed’ COPD Care Bundle Box located; AMU /David Erskine: Nurses Station (Maroon coloured boxes) Care bundle components are based on: NICE COPD guidelines 2004 (1-5) A Patient Experience Survey CLAHRC team April 2009 (6) Systematic Literature Review supported by CLAHRC April 2009 (1-6) The discharging nurse checks that all steps in the care bundle are completed CARE BUNDLE STEPS All required documents are included in package. PRIOR TO DISCHARGE DAY OF DISCHARGE Patient Sticker Date of discharge ___ /___ /___ Nurse (Initials) Completed Not Done Completed Declined N/A Not Done

13. Round 2: Bundle Roll-out Sites

14. High level outputs Spread within NWL NHS London Respiratory CQUIN Thorax article: Hopkinson N, Englebretsen C, Cooley N, Kennie K, Lim M, Woodcock T, Laverty A, Wilson S, Elkin S, Caneja C, Falzon C, Burgess H, Bell D & Lai D (2011) “Designing and implementing a COPD discharge care bundle.” Thorax Interest beyond NWL

15. Chelsea & Westminster

16. Acute Exacerbations of COPD COPD Bundle V.1

18. North West London Hospitals

19. West Mid University Hospital

20. WMUH Readmissions Regional CQUIN data: 39% reduction in readmissions (from baseline data taken from 2009/2010) over 9 months from introduction of the bundle. 2009/2010 Recommended 2010/11 (%readmission rate target 2010/11 (actual- Quarter 3) -baseline) 14 day12% 10.8% 7.3 % 28 day 23.6% 22.4% 14.5%

21. Telemonitoring

22. CLAHRC for Northwest London Aim: Getting evidence into practice COPD bundle: – EBI – Spread – Collaborative working across professions and sites Evidence of improvement in care processes Early indication of impact on outcomes e.g. readmission rates in vulnerable patients