1. Respiratory Care Bundles Professor Thida Win Lister Hospital Thida.win@nhs.net

2.  November 2012 - December 2013  21 NHS Trusts in England and Wales  a care bundles-based approach to quality improvement in the care of patients admitted to hospital with an acute exacerbation of COPD (AECOPD) and Community Acquired Pneumonia (CAP) BTS (British Thoracic Society) Care Bundle Project

3.  High level data  11,748 patients admitted with AECOPD  14,451 patients admitted with CAP  Patient level data on processes and outcomes of care  3,266 COPD admissions  2,563 CAP admissions 1,438 bundles were used

4.  use of a care bundle was associated with a reduction in 30 day in-patient mortality from CAP from 13.6% to 8.8%.  The presence of an oxygen prescription was also associated with a reduction in length of stay for those with COPD Benefits

5.  COPD admission bundle with outcomes of care demonstrated a statistically significant reduction in mortality from AECOPD in patients  in whom oxygen was prescribed at admission (OR 0.22 95%CI 0.05-0.88)  and in patients in whom care was delivered within 4 hours of admission (OR 0.60 95% CI 0.42-0.87)  This is the first time that use of a COPD bundle has been associated with a reduction in in-hospital mortality! Mortality

6.  COPD Care Bundle (Acronym: DARTS)  Diagnosis  Assessment (for oxygen)  Recognition (of acidosis)  Timely medications  Specialist review Care Bundle Components

7.  COPD Discharge Care Bundle (Acronym: TAPSS)  Technique (inhalers)  Action plan  Pulmonary rehabilitation  Smoking Cessation  Specialist follow-up Care Bundle Components cont..

8.  Pneumonia Care Bundle (Acronym: COST)  Chest x-ray (CXR)  Oxygen (assessment)  Severity (Scoring)  Timely & appropriate treatment Care Bundle Components cont..

9.  14/15 Trust replied  4 Trusts not using Care Bundles at time of survey, but 1 was implementing  Majority (9) use a COPD discharge-bundle  1 uses admission and Pneumonia bundle (KL)  3 use asthma bundle addition to discharge bundle (Add/ Ip/South)  1 use pneumonia and admission bundle addition to discharge bundle (JP)  2 on Respiratory wards, 2 at MAU and 10 at All EoE Care Bundle Survey

10.  L&D  Princess Alexandra (Harlow)  Peterborough Trusts not using Care Bundles

11.  3 Trusts achieved >90% use of discharge bundle  Southend  West Herts  E&N Herts Success

12.  Help readmissions  25% reduction in readmission (Ipswich)  Some found difficult to say specific benefit due to partial effects- pathway, specialist review, education, staff change over etc Benefit

13.  CCGs  Staffing  Support  Evidence  CQUIN will ensure delivery of care bundle Barriers to implementation

14.  Care Bundles effective in improving reliability and reducing unwarranted variation in care  Wide implementation of Care Bundles is feasible  Evidence suggested CAP, and COPD admission bundle shows mortality benefit  Emergency Oxygen prescribing & timely care essential components  Value of Clinical Specialist Leadership to ensure success  Most EoE Trusts use care bundles, but uncertainty of their components and outcomes Conclusions