1. COPD, OPIOIDs, DMARDs

2. COPD -Aim: 100% of all COPD patients to receive optimal care in a safe standardised process
An up-to-date smoking history
Has cessation advice recorded yearly in non-smokers and at every visit in smokers
Is there documented spirometry and chest x-ray for all patients with diagnosed COPD
Has the patient’s ability to use an inhaler device has been assessed by a nurse or doctor in the past six months
Documented evidence of advice on physical activity including pulmonary rehabilitation and self-management education where appropriate
Documentation of vaccination status pneumococcal and influenza) status with appropriate recalls
Overall compliance

3. Discuss your Experience So Far
What did your data show?
What changes have you made?
What have been you key successes?
What have been the challenges?
What are you going to do next?

5. COPD- Key Change Ideas Information leaflets to patients
In-house spirometry – cost, training
Shared Medical Appointments
COPD register
COPD nurse lead clinic
COPD patients being enrolled onto Planned Proactive Care
COPD template for every visit
COPD book created in-house for target audience
Refer patients to Better Breathing courses
Routine and opportunistic screening – smokers, over 42 years – spirometry and CXR.

7. Opioids -Aim: 100% of prescribing for Opioid Derived Analgesia will follow a safe standardised process
Is there a clear indication within the clinical record for a moderate to strong opioid derived analgesic to be used/initiated?
Is there evidence that the analgesic ladder has been used prior to the patient being prescribed a moderate to strong opioid derived analgesic?
Is there a clear management plan? (side effects, breakthrough pain, self- management)
If a repeat prescription had been ordered earlier than expected is there evidence of discussion with the patient
Has clinical review occurred effectively prior to the second prescription being issued?
Have all measures been met?

8. Opioid Prescribing

9. Quaymed

10. Apollo

11. Discuss your Experience So Far
What did your data show?
What changes have you made?
What have been you key successes?
What have been the challenges?
What are you going to do next?

12. Opioids- Key Change Ideas
Handouts to patients - Health Navigator has excellent resources
All GPs are prescribing safely according to the analgesic ladder
Opioids prescribing process is streamlined
Management plan clearly documented in notes
Patient given clear instructions about potential side effects and when to report back to GP/nurse
Developed PDSA cycles to inform the team of current tramadol prescribing process
We hypothesised regarding GP prescribing habits, to identify differences between GP’s
Attempt to “socialise” opioid prescribing policy amongst clinicians at the practice
Update of locum / registrar orientation document to this effect
Ensure whole practice team are familiar with CD handling and Rx processes
Controlled drug Rx’s to be scanned into patient notes to ensure audit trail
Elimination of “extra” CD Rx audit record
New CD Rx pads received, continue to be documented in numerical sequence in CD register
Explore possibility of coding for opioid prescribing.

13. DMARDs - Aim and Measures
Aim: 100% of patients on Disease Modifying Anti-Rheumatics Drugs (DMARDs), particularly Methotrexate and Azathioprine, have their drugs safely prescribed and reliably monitored
Has there been a full blood count in the past 12 weeks (AZA) / 8 weeks (MTX) as per local guidance?
If any abnormal results in the previous 12 weeks (WBC <3.5 x 109/L, Neutrophils <2.0 x 109/L, Platelets <150 x 109/L, ALT >x2 upper limit (>60) has action been recorded in the consultation record?
Is there a documented review of blood tests prior to issue of the last prescription?
Has the patient ever had or declined an influenza vaccine in the last 12 months?
Has the patient been asked within the last 3 months about any side effects, e.g. nausea, mouth ulcers, fever, sore throat, shortness of breath, diarrhea?
Has the patient been given written information about the DMARD that they are taking within the last 12 months?
Have all measures been met

15. Discuss your Experience So Far
What did your data show?
What changes have you made?
What have been you key successes?
What have been the challenges?
What are you going to do next?

16. DMARDs- Key Change Ideas
Template to record the monitoring and prescribing of these patients
Recall systems so patient return to have their blood tests taken
Ensuring patients are invited for influenza and pneumococcal vaccines
Using Patient information leaflets from Safe Rx
A variety of ways of ensuring patients have the regular blood tests, i.e. letters texting ing
Training health care assistants to ask about side effects of the drugs.