Chronic Obstructive Pulmonary Disease (COPD): best practice guide

8. What Best Practice Looks Like - Recommendations from the COPD Working Group

The preceding chapters have given an outline of best practice to improve the patient journey for those living with COPD and experiencing exacerbations that require specialist input. What follows are the key recommendations from the interrogation, research, case studies and data accumulated over the course of the meetings of the national group and its subgroups together with the above outputs from the COPD session at the 6EA Event.

1. Reducing ED attendances

• Creating a new default process: rather than patient to GP then ED and automatic admission to hospital, increase use of Community Respiratory Teams, district nurses, and support/advice from GP practices when no appointments are available. Also use Third Sector support. Incorporate strategies to prevent admission such as discharge to assess (providing diagnostics as an outpatient and calling patients back into hospital for further assessment/treatment).
• Professional to professional advice: telephone support for GPs and ambulance teams to help prevent admissions.
• Individualising care: patients that are already known to the relevant clinical services will benefit from care that is based on what is normal for the patient, and the avoidance of over-medicalisation (Realistic Medicine – see above).
• Community Virtual Wards: utilising ‘at risk of admission’ data and information to support and manage care proactively, led by GP and Primary Health Care/Community teams. Involving carer and patient in care needs.
• Anticipatory Care Plans ( ACPs) that detail a patient’s medical, physical and social needs and describe what is normal for this particular individual. Ideally these should be readily accessible in a single document online or may even be carried by the patient.
  
• Patient education: raise awareness of the services available to support them. Empower patients to know what they need to do to stay well and engender good self-management processes including exacerbation management and maintaining physical activity.
• Development of rescue medications for suitable patients supplied to appropriate patients using a PGD (patient group directive) by community pharmacy.
• Community pharmacy support for patients with COPD using Chronic Medication Service care planning to support patient education and/or identify potential or real care issues.
• Access to psychological therapies and assessment of psychological distress to reduce anxiety and improve mood and coping skills.

2. Reducing admissions and readmissions

• A multidisciplinary approach should be adopted wherever possible. This should include nurses, doctors, allied health professionals ( AHPs), pharmacy, social care but above all, the patient should be involved in all decision-making. Psychology also has a clear role to play here as readmissions may not be due necessarily to an exacerbation but because the patient’s condition is causing them to panic and increase their respiratory rate.
• Respiratory specialists taking referrals directly from the ED. Allied Health Professionals, psychologists and respiratory nurse specialists attending ED to reduce unnecessary (re) admissions and to promote facilitated discharges. Enhanced triage by a senior emergency physician may also support the process of reducing unnecessary admissions.
• Early pulmonary rehabilitation should be initiated as soon as possible after a hospitalisation (ideally 4-6 weeks). Focus also needs to be given to prevent deconditioning of patients during an exacerbation and maintain muscle strength through early mobilisation and specific exercise regime (endurance training, interval training, walking exercise, neuromuscular electrical stimulation etc.). Consideration should also be given to home rehab programmes through CRT-like services following discharge from hospital especially when the patient is frail and not suitable to attend community rehab programmes.
• Technology-Enabled Care including ‘digital postcards’, a COPD app, Florence, a text-based messaging service that brings telehealth directly to patients and online support.
• Central information hub: for all patients with long-term conditions including COPD. This may be through NHS 24 or online.
• COPD care bundle: which focuses on optimising the patient journey.
• Connected care across primary and secondary services built on good communication between the pre-hospital and secondary care environments. Effective use of an Anticipatory Care Plan for each patient should link into multidisciplinary meetings for high risk patients that are prone to attend frequently.

3. Reducing Length of Stay

• Rapid discharge with enhanced care team: Hospital at Home (see Case Study No. 2).
• ‘Red-Green Days Visual Management System’: Here the focus is on closely interrogating how many days of a patient’s acute admission to hospital actually require to be spent in an
  in-patient bed.
• The Daily Dynamic Discharge Approach: This is one of the key areas of the 6EA programme which focuses on the three elements of: daily ‘whiteboard’ meetings that have representation from the multidisciplinary team; assigning an estimated date of discharge ( EDD) to each patient’s admission; and introducing ‘golden-hour’ ward rounds whereby high acuity patients are seen first, then those that are ready for discharge; all these elements help to streamline flow through organisations so that patients are discharged earlier in the day, more discharges are made per week and overall length of stay is reduced. (see: http://www.gov.scot/publications/daily-dynamic-discharge-approach-guidance-document/)
• Support from ANPs and other specialist nursing care: Patients do not always need to be seen by a doctor or even a respiratory medical specialist; we should link into our ‘non-medical’ resource of AHPs, nurses and specialist paramedics wherever possible.
• Dedicated psychology input in such models: the more severe COPD spectrum patients come with a huge burden of anxiety and other psychosocial concerns.
• Role of third sector involvement: The Scottish Pulmonary Rehabilitation Action Group ( SPRAG) endeavours to raise the profile of Pulmonary Rehabilitation and improve quality of this multi-disciplinary service across Scotland. Also Grapevine in Edinburgh can help with social issues (See following case study).