Secondary care audit 2017/18 Good practice repository: case studies and examples from hospitals undertaking the clinical audit (Version 3: February 2018) Introduction 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. As part of the snapshot secondary care organisational audit (conducted between 3 April and 30 June 2017) question 6.9 of the dataset requested hospitals to develop and submit an improvement plan based on the audit data. Following an extensive review of the submitted plans some selected examples of good practice have been included. These entries can be identified by the asterisk (*) which follows their hospital and trust name. Do you have any questions? If you have any questions about any of the content, or would like more detail about any of the case studies, please contact the National COPD Audit Programme team on 020 3075 1526 / 1566 / 1565 or via email (copd@rcplondon.ac.uk). For further information on the National COPD Audit Programme, please visit www.rcplondon.ac.uk/copd
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) 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) Russells Hall Hospital (The Dudley Group NHS Foundation Trust) Musgrove Park Hospital (Taunton and Somerset NHS Foundation Trust) Peterborough City Hospital (North West Anglia NHS Foundation Trust) Ipswich Hospital (The Ipswich Hospital NHS Trust) Whittington Hospital (Whittington Health NHS 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) Darent Valley Hospital (Dartford and Gravesham NHS Trust)* Poole Hospital (Poole Hospital NHS Foundation Trust) Section 5: Non-invasive ventilation (NIV) Northumbria Specialist Emergency Care Hospital (Northumbria Healthcare NHS Foundation Trust) Pinderfields Hospital (Mid Yorkshire Hospitals NHS Trust) Queen s Hospital (Burton Hospitals NHS Foundation Trust)* Norfolk and Norwich University Hospital (Norfolk and Norwich University Hospitals NHS 11 St Andrews Place, Regent s Park, London NW1 4LE 2
Foundation Trust)* Section 6: Smoking Royal Sussex County Hospital (Brighton and Sussex University Hospitals NHS Trust) Colchester Hospital (Colchester Hospital University NHS Foundation Trust) Luton and Dunstable University Hospital (Luton and Dunstable Hospital NHS Foundation Trust)* Southend University Hospital (Southend University Hospital NHS Foundation Trust) Section 7: Oxygen Macclesfield District General Hospital (East Cheshire NHS Trust) Lister Hospital (East and North Hertfordshire NHS Trust) Queen Alexandra Hospital (Portsmouth Hospitals NHS Trust) Ipswich Hospital (The Ipswich Hospital NHS Trust) Royal Derby Hospital (Derby Teaching Hospitals NHS Foundation Trust) Norfolk & Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust)* Whittington Hospital (Whittington Health NHS Trust)* Queen Elizabeth Hospital King s Lynn (The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust)* Appendices NIV guideline wall chart - Submitted by Northumbria Specialist Emergency Care Hospital (Northumbria Healthcare NHS Foundation Trust) NIV Checklist Submitted by Pinderfields Hospital (Mid Yorkshire Hospitals NHS Trust) Norfolk and Norwich observation charts Submitted by Lister Hospital (East and North Hertfordshire NHS Trust) Anonymised drug chart Submitted by Ipswich Hospital (The Ipswich Hospital NHS Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 3
Section 1: Data collection and entry Back to contents Barnsley Hospital (Barnsley Hospital NHS Foundation Trust) 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. The team have a dedicated administrator to manage the data input There is a general sense of workload, passion within the team and a with commitment to improving the oversight lives of patients with COPD. from clinicians. This has freed up clinical time, and allows The team all believe that by the clinicians to focus on the clinical activity of the team. focusing the audit that it will A weekly audit snapshot email is circulated to the team, to help to deliver improvements in remind them of audit standards, to highlight what is going the delivery of care for patients well, and to bring in to focus areas that need improvement or where the team can try harder. 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. 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. Audit results [are] reviewed in service level meetings, as well as senior [ ] meetings to [ ] consider options for improvement. 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 4
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 the COPD team have taken front door acute areas such as the emergency ownership of the audit, with other department, acute assessment unit and short respiratory staff members collecting data stay unit. and providing general support. The CNS team identify patients using the patient 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. 11 St Andrews Place, Regent s Park, London NW1 4LE 5
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 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 11 St Andrews Place, Regent s Park, London NW1 4LE 6
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 7
Section 2: Review by a specialist within 24 hours Back to contents The national average of the percentage of patients receiving a review by a member of the respiratory team within 24 hours is 57%. (Calculated between February and December 2017) 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 at Royal United Hospital 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. 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. 11 St Andrews Place, Regent s Park, London NW1 4LE 8
These changes have been supported by the whole respiratory multidisciplinary team, and patients now receive enhanced medical, nursing, physiotherapist and pharmacist input regardless of 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. 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 9
Section 3: Spirometry Back to contents The national average of the percentage of patients for whom a spirometry result is available is 40%. (Calculated between February and December 2017) 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, On average, over 60% of patients at Norfolk and Norwich University Hospital have a record of spirometry in the case notes. so that 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. 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. 11 St Andrews Place, Regent s Park, London NW1 4LE 10
Spirometry results are also uploaded onto Windip (an electronic patient record system), providing ease of access to most recent spirometry result when 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. 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 11
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, since June 2017, over 80% 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. To find out more, contact details for York District Hospital can be obtained from the COPD audit team. Russells Hall Hospital (The Dudley Group NHS Foundation Trust) The Trust has an open access spirometry service for the GPs. We conduct spirometry on inpatients with suspected COPD as a priority. Spirometry is requested by e-referral and often by a chest physician on the respiratory post ward round. In February 2017 just over 80% of patients at Russells Hall Hospital had a record of spirometry. By November 2017 this figure has risen to just over 90% of patients. Spirometry is usually done within an hour by fully trained technicians. To find out more, contact details for Russells Hall Hospital can be obtained from the COPD audit team. 11 St Andrews Place, Regent s Park, London NW1 4LE 12
Musgrove Park Hospital (Taunton and Somerset NHS Foundation Trust) A bedside spirometry service is provided by the lung lab: o There is a spirometry request list which is maintained on one of the respiratory wards. In February 2017 just over 48% of o Medical staff in the hospital can request patients at Musgrove Park Hospital spirometry by adding cases to the spirometry request list, or alternatively by contacting the had a record of spirometry. By lung lab directly. November 2017 this figure has risen o All cases are reviewed by the COPD team. to 100% of patients. o The lung lab team undertakes a Monday to Friday spirometry round, taking the test to the patient, and records the results in the notes. New equipment allows electronic recording although this is still in further development to allow access from around the hospital. GP results cannot specifically be accessed, this is in development, but there is access to the patient primary care record via EMIS web. Peterborough City Hospital (North West Anglia NHS Foundation Trust) On average 56% of patients at Peterborough City Hospital had a record of spirometry between February and November 2017. The respiratory team (respiratory physiologists or respiratory nursing team) endeavour to perform and record spirometry on all respiratory patients where it is clinically appropriate and possible to do so. The spirometry results are then made available through patient records, electronically, making them visible to anyone with the appropriate clinical access. Results are also displayed in patient letters for which they use a specific template that ensures the letters are also marked up for the respiratory department. To find out more, contact details for Peterborough City Hospital can be obtained from the COPD audit team. Ipswich Hospital (The Ipswich Hospital NHS Trust) All spirometry tests performed in our hospital lung function lab are stored in the patient s electronic record in the investigations section under respiratory. This means that if a patient is admitted to hospital it is immediately apparent to medical staff if the patient has had the test before. On average 65% of patients at Ipswich Hospital had a record of spirometry between February and November 2017. We have a drop in service for spirometry in our lung function lab. Patients on the wards can have this test done on the day of request if necessary. To find out more, contact details for Ipswich Hospital can be obtained from the COPD audit team. 11 St Andrews Place, Regent s Park, London NW1 4LE 13
Whittington Hospital (Whittington Health NHS Trust)* Formal lung function results are available on the On average 91% of patients at intranet for all staff. Whittington Hospital had a record GP spirometry results have been available via a of spirometry between February shared electronic record since 2016. and November 2017. Bedside spirometry is included in training for all medical trainees. Ward teams are enabled to do spirometry and hand held spirometers are available in every clinic room. All respiratory letters contain the spirometry results. 11 St Andrews Place, Regent s Park, London NW1 4LE 14
Section 4: Discharge bundles Back to contents The national average of the percentage of patients receiving a discharge bundle upon discharge is 61%. (Calculated between February and December 2017) 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. During the daily check of the patient system, the 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. Since May 2017 over 85% of patients at Lister Hospital received a discharge bundle. To find out more, contact details for Lister Hospital can be obtained from the COPD audit team. 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. Darent Valley Hospital (Dartford and Gravesham NHS Trust)* A discharge bundle was implemented in order to improve the uptake of referral to smoking cessation, improve continuation of care and to improve the rates of referral to pulmonary rehabilitation. The new discharge bundle was reviewed and agreed and added to the patient system pre-populated with patient demographics to allow easy access to all clinical staff. Between March and December 2017 on average over 60% of patients at Darent Valley Hospital received a discharge bundle. Some elements of the discharge checklist have also been added to the electronic discharge notification as compulsory fields to be filled in for any patient with an acute exacerbation of COPD. Rescue packs are also available and can be provided on patients discharge. 11 St Andrews Place, Regent s Park, London NW1 4LE 15
PR referrals have been made much less time consuming with the introduction of a shorter process referral is now via the trusts online service making referrals much less time consuming. Poole Hospital (Poole Hospital NHS Foundation Trust) The Dorset Adult Integrated Respiratory Team (DAIRS) at Poole Hospital screen the Acute Assessment Unit identifying patients requiring completion of the discharge bundle and then meet to discuss the priorities for the day. An electronic contact sheet is used to identify all aspects of the bundle that have been undertaken and is completed by the team on individual electronic patient record, thereby identifying a date and time and a reason why any aspect of the bundle may have been left incomplete. The recently appointed senior health care assistant provides assistance with aspects of the bundle. DAIRS are looking to introduce a screensaver across Trust PCs to promote awareness of the need for all COPD patients to be referred to the team. To find out more, contact details for Poole Hospital can be obtained from the COPD audit team. 11 St Andrews Place, Regent s Park, London NW1 4LE 16
Section 5: Non-invasive ventilation (NIV) Back to contents The national 75th percentile for patients receiving NIV within 3 hours of arrival is 37.5% (Calculated February 2017) Northumbria Specialist Emergency Care Hospital (Northumbria Healthcare NHS Foundation Trust) Our aim was to achieve prompt initiation of NIV on arrival to A&E. Our NIV guideline is tailored to avoid delays in initiation of NIV. E.g. conditions associated with good outcome do not require prior consultant approval and controlled oxygen trials are limited. our NIV guideline incorporates Door to Mask Time, subject to continuous rolling audit and with feedback. This seeks to establish recognition of acute hypercapnic respiratory failure as a medical emergency, and treatment with NIV as a time critical event, in A&E. Between February and October 2017 on average over 66% of patients that required NIV at Northumbria Specialist Emergency Care Hospital received it within 3 hours of arrival. NIV is delivered by a single team of physiotherapists, who move with the ventilator to the patient. Following stabilisation, the patient is then transferred to the Respiratory Support Unit. Physiotherapists who have completed annual training and passed a competency assessment may provide NIV. Neither consolidation, complicating an exacerbation of COPD or hypercapnic coma are considered contra-indications to NIV. Pinderfields Hospital (Mid Yorkshire Hospitals NHS Trust) NIV is initiated in A&E with support from Pinderfields and Pontefract Emergency Respiratory Team (PERT) team and Respiratory on call. On average over 70% of patients that required NIV at Pinderfields Hospital received it within 3 hours of arrival. NIV checklist for patients is available on hospital intranet ED guidelines. Patients are transferred to dedicated 11 bed acute care unit to allow for prompt initiation of NIV under specialist care input. This dedicated unit is due to increase to 14 beds. Queen s Hospital (Burton Hospitals NHS Foundation Trust)* In order to improve their NIV service they introduced: o triaging and cohorting of COPD patients to the respiratory ward, o a review of all patients with hypercarbic respiratory failure secondary to COPD requiring NIV, o a rolling education programme on care of respiratory patient for nursing staff working within medicine and surgery and, o developed training and competency for medical and nursing staff in NIV with an annual refresher course encouraged. In March 2017 33% of patients that required NIV at Queen s Hospital received it within 3 hours of arrival. This increased to 50% of patients by November 2017 which is above the national 75th percentile for NIV within 3 hours of arrival. 11 St Andrews Place, Regent s Park, London NW1 4LE 17
Norfolk and Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust)* The COPD audit in 2014 identified delayed initiation of NIV from admission at our hospital with an average time (median) from admission to NIV of 10.8 hours compared to 4.1 hours nationally. The percentage of patients receiving NIV within 3 hours of admission at our hospital was 0% compared to 42.4% nationally. These figured raised concerns therefore NIV was identified as a high priority for improvement at our trust. An initial step to improving this was to introduce NIV guidelines. We understood that early review of patients and prompt decision making would be essential in order to see marked change. As a result we needed to ensure that patients would be managed on a ward that had capability to provide NIV and that these patients would be reviewed by the respiratory team on a daily basis. We therefore developed 2 acute NIV bays on our respiratory ward with the availability of 1-2 beds for acute admissions 24 hours a day. This allowed for the urgent provision of NIV without delays occurring in the emergency centres also devoid of the need to manage complex bed moves which would have incurred further delays. We ensured that appropriate NIV protocols/guidelines were put in place for both the initiating, monitoring and discontinuing of treatment. In February 2017 0% of patients that required NIV at Norfolk and Norwich University Hospital received it within 3 hours of arrival. By June 2017 this figure had risen to 50% of patients. We ensured that we had the most appropriate nursing staff for the respiratory ward/niv bays by providing additional training for nursing staff caring for these patients nursing management of NIV, CBG/ABG sampling. 11 St Andrews Place, Regent s Park, London NW1 4LE 18
Section 6: Smoking Back to contents The national 75th percentile for prescription of smoking cessation pharmacotherapy to current smokers is 34%. (Calculated February 2017) Royal Sussex County Hospital (Brighton and Sussex University Hospitals NHS Trust) Has a higher than average percentage of recorded current smokers prescribed stopsmoking pharmacotherapy. As part of Brighton and Hove NHS Smoking Cessation Service the city public health department funded a full-time Smoking Cessation Service Lead (Anna Fairhurst) initially for 3 years (October 2014 to October 2017) which has been extended for a further 2 years. Anna aims to see all patients admitted to RSCH who are current smokers to give stop smoking advice. She ensures stop-smoking pharmacotherapy is prescribed and is at the correct dose for the patient s need. All patients who are ready to quit will receive cessation advice and behavioural support. These patients then receive telephone support post discharge and are invited in to smoking cessation (SC) outpatient department (OPD) clinic to have their carbon monoxide validated. Those who are not able to attend hospital OPD will be sign posted them to the appropriate community stop smoking service. This includes a domiciliary service for housebound patients. Anna s presence around our acute medical unit (AMU), A&E and wards raises the profile of smoking cessation in the trust and is a reminder of the importance of prescribing stop-smoking pharmacotherapy. She accepts on-line referrals for patients she has not been able to see, contacts them post discharge so that they can be seen by her in outpatients or alternatively refers them on to other appropriate stop-smoking services. Anna reports her KPIs quarterly: o Number of patients seen: 76 (In Q4 2016 2017) o Number of patients set a quit date: 76 o Number of patients quit at 1 month: 60 remained quit at 4 weeks (63% CO validated) All our cardiac rehabilitation specialists have received level 2 Intermediate SC training and support cardiac patients as these patients appear highly motivated following their shock cardiac event. A&E doctors are also trained at Brief Intervention and offer very effective SC advice. Brief Intervention training sessions are actively promoted on an on-going/rotational basis to cover all new nursing staff, doctors and other healthcare professionals. For the period April 2017 to October 2017 the Royal Sussex County Hospital has on average been prescribing smoking cessation pharmacotherapy to 52% of current smokers compared to a national average of 25%. Training is the key to appropriate referrals being made. Doctors advising on the importance of smoking cessation have also played a key role in our success. To find out more, contact details for Royal Sussex County Hospital can be obtained from the COPD audit team. Colchester Hospital (Colchester Hospital University NHS Foundation Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 19
The trust has a consistently higher than national average prescription of smoking cessation to current smokers. 100% of patients admitted for an exacerbation of their COPD are asked about their smoking history. 62.7% of those still smoking are willing to uptake further smoking cessation. The success rate of them stopping has been high. On further admissions 62.2% of patients remain an ex-smoker. The trust became smoke-free within the ground in March 2017. Since this time all current smokers have been offered nicotine replacement therapy (NRT) on admission. 100% of current smokers at Colchester Hospital were prescribed smoking cessation in April 2017. Since this time the trust continues to offer smoking cessation consistently higher than the national average. Smoking cessation is addressed via the COPD care bundle prior to discharge from hospital. All COPD patients are seen by the COPD clinical nurse specialist (CNS) and offered smoking cessation treatment and further counselling to help them to quit. Those patients that require further support are referred to the community smoking cessation team. To find out more, contact details for Colchester Hospital can be obtained from the COPD audit team. Luton and Dunstable University Hospital (Luton and Dunstable Hospital NHS Foundation Trust)* In order to improve smoking cessation support we set up a stop smoking executive board which included both primary and secondary health and care professionals. We promote smoking cessation in the hospital via posters that contained referral information. We initiate a twice weekly ward round by smoking specialists and run ad-hoc outpatient smoking cessation clinics. In addition we have devised a local smoking cessation guideline which includes the initiated prescribing of NRT as inpatients. On average 34% of current smokers at Luton and Dunstable Hospital were prescribed smoking cessation in between March and December 2017. This is in line with the national 75th percentile for prescription of smoking cessation. Southend University Hospital (Southend University Hospital NHS Foundation Trust) In March 2017 just over 18% of current smokers at Southend Hospital were prescribed smoking cessation. By December 2017 this figure had has risen to 60% of current smokers. Every weekday the respiratory clinical nurse specialists team identify and review all patients admitted with COPD. All patients are asked about smoking status and referrals are made to the stop smoking advisor. The referral slip is left in chest clinic. A full time smoking cessation advisor is located within Southend Hospital to respond swiftly to inpatients. Current smokers are also provided with the smoking cessation team contact details. 11 St Andrews Place, Regent s Park, London NW1 4LE 20
On the respiratory unit, all current smokers are identified on the white board. A stop smoking advisor attends the wards daily to identify these patients. Leaflets about smoking cessation and the contact details for the smoking cessation team are widely available in the trust. A dedicated smoking cessation group has been established and regular meeting and reviews of the processes are held. All current smokers have a current smoker stamp within the medical notes on admission. All patients Heart and Chest clinic are asked at each appointment they attend about their smoking status, if current smokers they are offered smoking cessation. To find out more, contact details for Southend University Hospital can be obtained from the COPD audit team. 11 St Andrews Place, Regent s Park, London NW1 4LE 21
Section 7: Oxygen Back to contents The national average of the percentage of patients admitted with an exacerbation of COPD that were prescribed oxygen was 70%. Of those on average 97% of patients were prescribed oxygen to target saturation. (Calculated between February and December 2017) Macclesfield District General Hospital (East Cheshire NHS Trust) The oxygen prescription is printed within the patient drug prescription sheet. Since February 2017 100% of The oxygen guidelines are available in a laminated form patients at Macclesfield District within all clinical areas. General Hospital were The integrated respiratory team are on ward everyday prescribed oxygen to target reviewing patients and providing guidance to staff in saturation. relation to oxygen administration. The Chronic Respiratory Early Warning Score (CREWS) has been introduced. Junior doctors and nursing staff are regularly trained in oxygen prescription. To find out more, contact details for Macclesfield District General Hospital can be obtained from the COPD audit team. Lister Hospital (East and North Hertfordshire NHS Trust) We have a 7 day respiratory service comprising of a respiratory consultant and clinical nurse specialist which enables us to capture patients admitted within 24 hours to implement an appropriate management plan. The respiratory nursing team is active in education, auditing, and reinforcing the importance of oxygen prescribing and titration to achieve target level oxygen saturations. Oxygen has a dedicated area on the prescription chart to enforce prescription to set target saturation. In addition a nurse s signature is required on each drug round. We have a dedicated respiratory nurse leading in oxygen that, through the use of screen savers on every PC in the Trust, re-enforces the message. 90% of patients admitted to Lister Posters are displayed next Hospital with an exacerbation of to the oxygen outlet to COPD were prescribed oxygen, remind the nurses about and 100% were prescribed to prescribing and target target oxygen saturation. saturation. We are in the process of implementing individual oxygen target saturation notes to stick above each patient s bed to remind nursing staff when giving oxygen and performing observations. We promote the use of the BTS oxygen competency e-learning tool on our 11 St Andrews Place, Regent s Park, London NW1 4LE 22
knowledge centre, and provide a certificate to staff that complete it. Our oxygen lead nurse has worked solely on our respiratory ward for 3 months implementing the change over to the use of the Norfolk and Norwich observation charts, which are designed specifically around the target oxygen saturations. To find out more, contact details for Lister Hospital can be obtained from the COPD audit team. Queen Alexandra Hospital (Portsmouth Hospitals NHS Trust) Historically our trust had a below average rate of oxygen prescription. Since September 2017 100% of In the 2015 BTS Emergency Oxygen Audit Queen patients admitted to Lister Alexandra Hospital had oxygen target saturations Hospital with an exacerbation of prescribed for only 35% of patients who were using oxygen, compared to a national rate of 53%. COPD were prescribed oxygen, and all were prescribed to target Our Specialist COPD Team began work in October 2017 and in our first month we have managed to improve oxygen prescription to 100% for our COPD patients. oxygen saturation. The trust uses a prescription card that is pre-printed with a range of target saturations to select from. The COPD Specialist Team aims to review patients with an acute exacerbation of COPD within 24 hours of their admission. Part of the team s admission bundle is to ensure that oxygen is prescribed to target saturations where appropriate. The team promotes the completion of the prescription, liaising with the medical team responsible for the patient s care. To find out more, contact details for Queen Alexandra Hospital can be obtained from the COPD audit team. Ipswich Hospital (The Ipswich Hospital NHS Trust) Our paper drug chart is pre-populated with oxygen. The prescriber has only to sign, date the prescription and ring the target saturation appropriate to the patient. The oxygen section on the chart is located next to a DVT prophylaxis pre-printed prescription. We encourage junior doctors to ensure both oxygen and DVT prophylaxis are prescribed appropriately. On average 97% of patients admitted to Ipswich Hospital that required oxygen for an exacerbation of COPD were prescribed it. Of those 100% were prescribed to target oxygen saturation. To find out more, contact details for Ipswich Hospital can be obtained from the COPD audit team. Royal Derby Hospital (Derby Teaching Hospitals NHS Foundation Trust) The trust has achieved consistent high rates of oxygen prescription within the national COPD audit and previous BTS Oxygen audits. In addition our practise in this area has been awarded an innovation award and has been recognised as outstanding by CQC. The trust has an oxygen team, comprising a respiratory clinician lead and 3 specialist nurses. The service is integrated, looking after home oxygen patients and with a clinical nurse 11 St Andrews Place, Regent s Park, London NW1 4LE 23
specialist (CNS) who acts as in reach oxygen nurse for the trust. We have developed a trust wide guideline for the safe prescription of oxygen therapy based on the prescription of target saturations for all patients admitted to the trust irrespective of their presenting complaint. All patients admitted are issued with target saturations wristbands. We have developed an automated electronic alert within our results management system for all acute hypercapnic respiratory failure patients. The alert highlights these patients and takes the teams through a care bundle. We have an active oxygen safety We have developed an 88-92% template on the group, chaired by the trusts head of electronic EWS monitoring system which has improved titration of oxygen. patient safety. Our in reach nurse visits wards with more frequent oxygen use, to prompt safe management, early weaning of patients on oxygen and supports initiation of home oxygen. Weekly audits are performed on the ward areas looking at prescription of oxygen and this is fed back to the wards and the respiratory performance dashboard. Prizes are occasionally awarded to the best performing areas! Chronic hypercapnic respiratory failure patients are identified from the community by the addition of an alert on the whiteboard system that is accessed by primary and secondary care. Regular training during induction is provided in oxygen safety. An e-learning training pack has been developed to ensure nurses are updated every 3 years. To find out more, contact details for Royal Derby Hospital can be obtained from the COPD audit team. Norfolk & Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust)* The National COPD audit in 2015 had shown that oxygen prescribing was poorly conducted in the trust. We set up a working group and invited the main stakeholders in the unit, including trust management. The working group developed an action plan to improve oxygen prescription which included: o reviewing existing guidance, o ensuring that an official operating policy was in place, On average 85% of patients o ensuring that patient medication records and admitted to Norfolk & Norwich oxygen charts were fit for the purpose of University Hospital that required prescribing oxygen, oxygen for an exacerbation of o developing a training package to be made COPD were prescribed it. Of those available on the trust learning site, 100% were prescribed to target o identifying oxygen champions, and oxygen saturation. o developing a communication strategy. Improvement within the trust was measured by regular spot checks of oxygen prescribing and titration and also participation in the national COPD audit and previous BTS emergency oxygen audit. 11 St Andrews Place, Regent s Park, London NW1 4LE 24
Whittington Hospital (Whittington Health NHS Trust)* We have a long-standing oxygen prescription chart that is included on the single drug chart for every patient admitted to the hospital. Our FY1 and FY2 receive oxygen prescribing teaching including practical procedures induction which has received excellent feedback. On average between February and December 2017, 99% of patients admitted to Whittington Hospital that required oxygen for an exacerbation of COPD were prescribed it. Of those 100% were prescribed to target oxygen saturation. Oxygen prescribing guidance is included on our COPD proforma and the oxygen guidelines, aligned with BTS guidelines, are available on our intranet. Queen Elizabeth Hospital King s Lynn (The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust)* In order to improve on the low number of patients requiring oxygen being prescribed it they introduced the following: o Regular monitoring via oxygen audits, this ensured that oxygen was only delivered by those that had been appropriately trained, o Teaching and informing junior doctors of good practice on departmental induction as well as snapshot educational sessions. o Educational posters on oxygen administration were disseminated, as well as screen savers implemented on trust PC s. On average between February and December 2017 92% of patients admitted to Queen Elizabeth Hospital King s Lynn that required oxygen for an exacerbation of COPD were prescribed it. Of those an average of 93% were prescribed to target oxygen saturation. 11 St Andrews Place, Regent s Park, London NW1 4LE 25
Appendices Back to contents NIV guideline wall chart - Submitted by Northumbria Specialist Emergency Care Hospital (Northumbria Healthcare NHS Foundation Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 26
NIV Checklist Submitted by Pinderfields Hospital (Mid Yorkshire Hospitals NHS Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 27
11 St Andrews Place, Regent s Park, London NW1 4LE 28
Norfolk and Norwich observation charts Submitted by Lister Hospital (East and North Hertfordshire NHS Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 29
11 St Andrews Place, Regent s Park, London NW1 4LE 30
Anonymised drug chart Submitted by Ipswich Hospital (The Ipswich Hospital NHS Trust) 11 St Andrews Place, Regent s Park, London NW1 4LE 31