Secondary care audit 2017 Good practice repository: case studies and examples from hospitals undertaking the clinical audit (Version 1: August 2017) The National COPD Audit Programme have collated a series of case studies which highlight good practice in audit data collection and entry, and in provision of quality COPD care. This document aims to provide teams with learning to implement locally, and with ideas on how local practice could be improved. It will be regularly updated. If you have any questions about any of the content, or would like more detail about any of the case studies, please contact the audit team on copd@rcplondon.ac.uk or 020 3075 1526 / 1566 / 1565.
Contents To navigate to a section, please hover over the hyperlink and select it. Section 1: Data collection and entry Barnsley Hospital (Barnsley Hospital NHS Foundation Trust) Hull Royal Infirmary (Hull and East Yorkshire Hospitals NHS Trust) Lister Hospital (East and North Hertfordshire NHS Trust) Musgrove Park Hospital (Taunton and Somerset NHS Foundation Trust) Royal Albert Edward Infirmary (Wrightington, Wigan and Leigh NHS Foundation Trust) Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) Royal United Hospital (Royal United Hospitals Bath NHS Foundation Trust) Section 2: Review by a specialist within 24 hours Hull Royal Infirmary (Hull and East Yorkshire Hospitals NHS Trust) Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) Royal United Hospital (Royal United Hospitals Bath NHS Foundation Trust) Section 3: Spirometry Barnsley Hospital (Barnsley Hospital NHS Foundation Trust) Norfolk and Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust) Pinderfields Hospital (Mid Yorkshire Hospitals NHS Trust) Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) Royal Lancaster Infirmary (University Hospitals of Morecambe Bay NHS Foundation Trust) Torbay Hospital (Torbay and South Devon NHS Foundation Trust) York District Hospital (York Teaching Hospital NHS Foundation Trust) Section 4: Discharge bundles Hull Royal Infirmary (Hull and East Yorkshire Hospitals NHS Trust) Lister Hospital (East and North Hertfordshire NHS Trust) Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 2
Section 1: Data collection and entry Barnsley Hospital (Barnsley Hospital NHS Foundation Trust) The team have a dedicated administrator to manage the data input workload, with oversight from clinicians. This has freed up clinical time, and allows the clinicians to focus on the clinical activity of the team. A weekly audit snapshot email is circulated to the team, to remind them of audit standards, to highlight what is going well, and to bring in to focus areas that need improvement or where the team can try harder. The audit process has been integrated with Barnsley Hospital s in-reach service, which identifies all patients admitted with a respiratory problem and ensures that they are reviewed by a specialist nurse and receive a complete discharge bundle. There is a general sense of passion within the team and a commitment to improving the lives of patients with COPD. The team all believe that by focusing the audit that it will help to deliver improvements in the delivery of care for patients with COPD. Hull Royal Infirmary (Hull and East Yorkshire Hospitals NHS Trust) The clinical audit team receive a list of COPD coded patients from the information department on a weekly basis. This is generated for all patients who have been discharged and clinically coded by the central clinical coding department. The audit officer assigned to the COPD audit then requests the notes for these patients, and reads through to extract the necessary data and to ensure they meet the audit eligibility criteria. The clinical audit officer visits the wards daily to check for patients who have been discharged with a primary diagnosis of acute exacerbation of COPD; and linking in with the clinical and administration teams to identify any patients suitable. Audit results [are] reviewed in service level meetings, as well as senior [ ] meetings to [ ] consider options for improvement. Copies of the British Thoracic Society (BTS) discharge bundles are also collected on a weekly basis and notes are requested for these patients if necessary. In order to assess if patients are fully compliant with the RCP COPD audit criteria, the respiratory service has employed a part time auditor to lead this project. Audit results and compliance against the Best Practice Tariff is then reviewed in service level meetings as well as senior contracting and governance meetings to discuss compliance and consider options for improvement. 11 St Andrews Place, Regent s Park, London NW1 4LE 3
Lister Hospital (East and North Hertfordshire NHS Trust) The hospital has an acute chest team (ACT) comprising of a respiratory consultant and two respiratory clinical nurse specialists (CNS). Between them they provide seven day cover of front door the COPD team have taken acute areas such as the emergency department, acute ownership of the audit, with other assessment unit and short stay unit. respiratory staff members collecting The CNS team identify patients using the patient data and providing general support. system BIMS. The CNSs begin completing the audit data collection forms upon first contact with the patient. Once forms have been started, they are left in a file in the team office, to be picked up by other members of the team. Respiratory CNS also cover the wards, and if a patient has moved out of the respiratory ward before ACT see them, the respiratory CNS team will outreach to the ward to provide assessment and complete the audit sheet. The CNS team check the patient system every day to see if patients are still under admission. If any data is missing from the collection forms, a member of the CNS team will visit the patient to complete this information and to complete the discharge bundle. If any information is unclear, notes are requested. When the patient is discharged, the team check the discharge summary for evidence of use of NIV etc. If any information is unclear, notes are requested. To ensure all data is being captured, a list of COPD admissions is requested monthly through the hospital coding database to check which patients have either been missed or added in error due to incorrect coding. Patients that were missed (which could have been due to various reasons, including out of hours admission, incorrect coding etc), are added to the audit system. The team will regularly monitor their local delivery of data collection and entry, and will review if needed. The two core CNSs who lead the COPD team have taken ownership of the audit, with other respiratory staff members collecting data and providing general support. Musgrove Park Hospital (Taunton and Somerset NHS Foundation Trust) There are 17 members of the local audit team including consultants, junior doctors, respiratory nurses and geriatricians. The MAU and COPD team identify cases each day (weekend admissions are identified on the Monday) and notes are requested at the end of each week. Junior doctors are conducting QI projects using the data entered into the audit, and development of these will be discussed at each team meeting. There is a rota allocating a week of data entry per team member on a rolling basis. If a team member is unable to fulfil their week of data entry, then the team will work to cover it. The lead clinician has made themselves available to deal with any data entry queries. The coding team periodically search for missed cases by discharge code. 11 St Andrews Place, Regent s Park, London NW1 4LE 4
All audit team members have access to the appropriate shared drives, such as the respiratory shared drive, regardless of which department they are based in. The audit team meet every 4-6 weeks to review progress and discuss their data. Royal Albert Edward Infirmary (Wrightington, Wigan and Leigh NHS Foundation Trust) Royal Albert Edward Infirmary is the acute medical site for Wrightington, Wigan and Leigh NHS Foundation Trust. The team is a multidisciplinary team of specialist respiratory nurses, and healthcare assistants, as well as a lead consultant. There is a dedicated team of people working hard to complete this audit and improve patient care. Patients are identified retrospectively via clinical coding; with the clinical audit department producing a list of patients weekly. Data is then collected on a data collection form, which is inputted by the audit department. The trust has helped facilitate quality improvement initiatives resulting from this audit, which will have direct patient benefits in the future. Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) Dorset Adult Integrated Respiratory Service (DAIRS) is a multidisciplinary team of specialist respiratory nurses, physiotherapists and HCAs plus a lead consultant. They run a seven day service. They are supported by the respiratory team, which includes five respiratory consultants and lead registrar, who answer any clinical queries arising. The hospital clinical audit team have been able to do all of the data inputting. It is a real team effort and everyone has really bought into the audit as it fits in well with the DAIRS team values. Before the audit, the team did a lot of work planning how to manage the data collection, data entry and the quality improvement (QI) projects which would arise from the data. The team went round the hospital promoting the team itself, explaining the aim of the audit and encouraging clinicians to contact them as soon as possible if they have COPD patients on their wards. They visited the doctor Grand rounds, meeting the acute medical and elderly care consultants, and communicated with the trust to prepare for the audit s start. The team does all of the data collection, with one or two people a day screening 11 St Andrews Place, Regent s Park, London NW1 4LE 5
for new patients admitted into the ED/AMU and elderly care wards with an exacerbation of COPD via electronic ward handovers and admission systems. They have a clipboard system, which ensures completed and partially completed data collection forms don t become mixed, and means anyone from the team can pick up a form on any day. Most of the audit forms are completed as inpatients, and they are reviewed on a regular basis (almost daily). Once a patient is discharged, the audit forms are quality checked, and any missing information is requested through the electronic notes system. Royal United Hospital (Royal United Hospitals Bath NHS Foundation Trust) Data entry for the continuous audit is carried out by a small team, consisting of a dedicated 0.4 whole time equivalent (WTE) band 6 specialist nurse, supported by a 1WTE respiratory GP trainee post. The 0.4WTE band 6 post is a new post that has been funded by the trust solely to help run the audit. the team [feel a] focused approach will [be] sustainable in the long term, and [will have] more robust data entry. Although the audit entry team is smaller than in other trusts, the team feel that this focused approach will be more sustainable in the long term, and will allow for more robust data entry. 11 St Andrews Place, Regent s Park, London NW1 4LE 6
Section 2: Review by a specialist within 24 hours Hull Royal Infirmary (Hull and East Yorkshire Hospitals NHS Trust) The Acute Respiratory Assessment Service ARAS) More than 80% of patients at Hull consists of four specialist nurses. The ARAS Team, in Royal Infirmary are seen by a combination with a dedicated in-reach consultant provide a daily (5/7) service to patients requiring respiratory specialist within 24 specialist respiratory input. Predominantly patients are hours. first seen in the acute medical unit following admission from the emergency department. However, respiratory referrals are also received from other inpatient wards. Referrals are received either via telephone, bleep, paper, or on the electronic bed management system (Cayder) via a virtual ward. In order to ensure the respiratory service is seeing all appropriate COPD patients, daily files are also provided by the trust s central information services team, who report on all patients admitted to the hospital via the emergency department with a working diagnosis of COPD or asthma. The clinical audit officer visits the wards daily to link with the clinical and administration teams to identify any patients suitable for review. Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) The local audit team realised that an area they needed to improve upon was ensuring that team members classified as specialists (ie. able to diagnose and treat an exacerbation of COPD) are sent to COPD patients as soon as they are identified. They have made the specialists (who may be a consultant, specialist registrar, or specialist healthcare professional) aware of this. They are usually able to find one member of the team available on weekends. Between 60 and 80% of patients at Royal Bournemouth Hospital are seen by a respiratory specialist within 24 hours. Royal United Hospital (Royal United Hospitals Bath NHS Foundation Trust) Royal United Hospital (RUH) is a busy district general hospital with a catchment area of around 450,000, typically admitted around 450 patients with COPD exacerbations per year. From the 2014 audit the team found that only 16% of COPD exacerbations were seen by a respiratory specialist within 24 hours of admission, as there is no dedicated respiratory take. Prior to the audit, only 16% of COPD exacerbations were seen by a respiratory specialist within 24 hours. Now, 85% of COPD exacerbations are seen by a member of the respiratory team within 24 hours of admission. These changes have been supported by the whole respiratory multidisciplinary team, and patients now receive enhanced medical, nursing, physiotherapist and pharmacist input regardless of where they end up within the hospital. The respiratory team therefore made a number of patient pathway changes across the medical division, to both improve access to respiratory expertise closer to the front door, as well as introducing a COPD discharge bundle. These changes have been supported by the whole respiratory multidisciplinary team, and patients now receive enhanced medical, nursing, 11 St Andrews Place, Regent s Park, London NW1 4LE 7
physiotherapist and pharmacist input regardless of where they end up within the hospital. Typically 85% of patients now see a senior member of the respiratory team within 24 hours of admission. Patients are identified each morning from the admissions list. In addition, the admitting medical team are encouraged to notify the respiratory team of any admissions via a dedicated email address. 11 St Andrews Place, Regent s Park, London NW1 4LE 8
Section 3: Spirometry Barnsley Hospital (Barnsley Hospital NHS Foundation Trust) The team have open access to spirometry within the unit, so there is no need to book the patient in for an appointment, and therefore there is no delay to patients being discharged. Medical doctors have received education about the On average, over 60% of patients at Barnsley Hospital have a record of spirometry in the case notes. requirement of spirometry for the diagnosis and assessment of the severity of COPD. There is a daily in-reach respiratory team visiting the acute medical unit, to review all respiratory patients and identify those patients that need spirometry. Norfolk and Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust) Historically data sharing between primary and secondary care has been challenging. There is a local lung function lab within the respiratory outpatient department, as well as dedicated consultant physician and consultant nurse COPD clinics. Clinic letters are available electronically throughout the hospital, so that On average, over 60% of patients at Norfolk and Norwich University Hospital have a record of spirometry in the case notes. patients who have been seen in the outpatient clinic in the last five years will have a hospital record of spirometry. There is also a specialist respiratory nursing team within the department whose remit includes providing inpatient bedside spirometry where appropriate. Pinderfields Hospital (Mid Yorkshire Hospitals NHS Trust) There is a local drive within the CCG for all GP practices to do quality assured spirometry. Spirometry results are entered onto Systm1, which has shared access between primary and secondary care, and is accessible both on site and remotely. This includes 90% of primary care centres. Spirometry results are also uploaded onto Windip (an electronic patient record system), providing ease of access to most recent spirometry result when 11 St Andrews Place, Regent s Park, London NW1 4LE 9
required. Respiratory nurse clinics and some medical clinics routinely do a spirometry at each visit. There is a rigorous data collection process in place, including a data quality check to ensure that all mandatory data items are completed prior to audit upload, and ensuring data completeness. Since the audit began, Pinderfields hospital have had over 60% of patients with a record of spirometry in the case notes, with above 80% since April 2017. Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) The local team realised from initial scoping that availability of spirometry was a key area they would need to improve upon. The medical teams have now been made aware they need to ensure that diagnosis of COPD has been made with spirometry, otherwise the patients cannot be classified as COPD. There have been focused teaching activities conducted locally to enhance this. Previous spirometry is now routinely and actively sought from either previous outpatients or GP records. Every patient identified has their notes reviewed, including checking for recent spirometry. If there is no spirometry available or the spirometry is inconclusive, the team are able to access inpatient spirometry via the lung function test department or the integrated respiratory service. Between 80 and 100% of patients When a patient has inpatient spirometry showing an at Royal Bournemouth Hospital obstructive ratio, and the team are able to diagnose have a record of spirometry in the the COPD but not the severity, it is ensured that patients have a follow up in a respiratory hospital case notes. clinic if it is a new diagnosis. Royal Lancaster Infirmary (University Hospitals of Morecambe Bay NHS Foundation Trust) On average, over 60% of patients at Royal Lancaster Infirmary have a record of spirometry in the case notes. All results from the OPD appointments and clinical investigations are entered electronically onto the hospital system for the team to review. The team are able to access spirometry results from GP surgeries. The respiratory nurses routinely question diagnosis, and conduct and record inpatient spirometry. 11 St Andrews Place, Regent s Park, London NW1 4LE 10
Torbay Hospital (Torbay and South Devon NHS Foundation Trust) Since the audit began, Torbay hospital has gone from between 20 and 40% of patients having a record of spirometry, to over 60% having a record available. When a patient attends an outpatient clinic for COPD, spirometry tests are done as part of the appointment process (whether it s a first visit or a follow-up appointment). The clinical team produce a monthly list of cases admitted based on the information system. This is then passed to the spirometry team who go through their records, and fill in the data available. The data manager then enters the information into the audit. The data manager has a chasing strategy in place for missing or incomplete records. York District Hospital (York Teaching Hospital NHS Foundation Trust) The hospital team complete spirometry on their patients, as they have a system in place that enables physiotherapy assistants to perform spirometry when requested. Good contact in place with GPs for requesting most recent previous record. On average, over 60% of patients at York Hospital have a record of spirometry in the case notes. The team are proactive in contacting primary care for spirometry results to confirm diagnosis if necessary. 11 St Andrews Place, Regent s Park, London NW1 4LE 11
Section 4: Discharge bundles Hull Royal Infirmary (Hull and East Yorkshire Hospitals NHS Trust) Nearly 60% of patients at Hull Royal Infirmary receive a discharge bundle. The Acute Respiratory Assessment Service (ARAS) consists of four specialist nurses. The ARAS team are responsible for completing the Best Practice Tariff discharge bundle and the early supported discharge package, with support from the consultant and ward teams, as well as in conjunction with the lung function, home ventilation and other sub-speciality respiratory services as required. Lister Hospital (East and North Hertfordshire NHS Trust) Discharge bundles are begun upon first contact with the patient. Over 60% of patients at Lister During the daily check of the patient system, the Hospital receive a discharge bundle. clinical nurse specialists (CNS) will visit any patients found to be still in the hospital, both to complete the audit data collection and the discharge bundle. Royal Bournemouth Hospital (The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust) Over 80% of patients at Royal Bournemouth Hospital receive a discharge bundle. The local audit team work with a dedicated team of two health care assistants who complete all of the COPD discharge bundles for the team. The team work together to ensure that as many discharge bundles are completed as possible. 11 St Andrews Place, Regent s Park, London NW1 4LE 12
Do you have any questions? If so, please contact the National COPD Audit Programme team on 020 3075 1526 / 1566 / 1565 or via email (copd@rcplondon.ac.uk). Our address is: The National COPD Audit Programme, The Royal College of Physicians, 11 St Andrew s Place, Regent s Park, London, NW1 4LE. For further information on the National COPD Audit Programme, please visit www.rcplondon.ac.uk/copd 11 St Andrews Place, Regent s Park, London NW1 4LE 13