Aims and objectives:
To facilitate the safe early discharge of all COPD patients admitted with an exacerbation, in order to reduce the length of hospital stay and reduce the number of admissions and readmissions
Objectives
To form two cross town COPD Community Care (NCCC) teams at Queens Medical Centre (QMC) and Nottingham City Hospital Trust (NCHT)
To assess all patients admitted to NCHT and QMC with an exacerbation of COPD
To identify those suitable for early discharge and facilitate a safe early discharge
To prevent admission/readmission
To offer nurse-led community follow-up after discharge and on-going support
To provide a self-management plan for all patients
To reduce smoking in this client group
To provide a NCCC direct contact telephone number
To optimise diagnosis through spirometry
To optimise COPD treatment in accordance with NICE guidelines
To develop links with primary care, intermediate care, social services and members of the multidisciplinary team within Nottingham City, Broxtowe and Hucknall and Rushcliffe PCT's
To develop a community pulmonary rehabilitation programme
To develop a database for the scheme in order to evaluate the effectiveness of the pilot
Support for the change:
The pilot is enthusiastically supported and overseen by a lead respiratory consultant at each hospital and the PCT's funding the scheme. Research has advocated the benefits of early discharge schemes and supported by NICE. A 2001 Cochrane review has also confirmed that pulmonary rehabilitation can help to relieve breathlessness and fatigue.
Patient and public influence:
From the experience of and feedback from a previous smaller scale 'homecare' service, the respiratory consultants and COPD nurses recognised that the service needed to be expanded, as there were not enough resources for all COPD patients to benefit from the scheme. The expansion of the nursing team has freed up extra time to ensure more patients are assessed as soon as possible after admission and support is in place for the subsequent increase in home visits.
Impact on the workforce:
Two full-time nurses have been employed at both hospitals to back up a smaller scale service that has already existed since 2000. In order to accelerate the discharge process, additional training to expand clinical nursing skills is also underway. These include, the ordering of diagnostic investigations such as blood and x-rays, prescribing medicines within a specific management plan and the setting up of a nurse-led COPD clinic at NCHT. Two part-time Senior Physiotherapists have been appointed to run the community pulmonary rehabilitation programmes and two clerical officers have also joined the teams to give administrative support and input data.
Measuring the results:
Quantitative data is being collected through a database set up specifically for the scheme. Data is collected on demographic details, number of patients assessed, those taken on to the scheme and length of hospital stay. The data also seeks to ascertain whether the NICE COPD guidelines are being adhered to. For example the respiratory drugs prescribed, whether they have had diagnosis confirmed by spirometry, whether they are up-to-date with the flu/pneumonia vaccinations and whether smoking cessation advice is being offered. The pulmonary rehabilitation is also being evaluated to ascertain whether the programme has improved exercise tolerance.
Qualitatively patients' views of the pulmonary rehabilitation programmes are also being evaluated via a questionnaire. We are in the process of developing a tool to evaluate the patients' experience of the scheme.
Various presentations have been made to the GP's from the PCT's funding the pilot to raise awareness of what the scheme offers and how it can benefit them.
Improved performance:
As the scheme is still in the early stages, data collection is still in progress. It is hoped that it will show that admission, readmissions and length of stay are significantly reduced and therefore saving money, whilst giving patients the type of service they prefer. Formal data will be available by March 2005.
However, initial data from patients satisfaction questionnaires on the first rehabilitation sessions, indicates there were high levels of satisfaction, with most patients reporting that pulmonary rehabilitation had improved their overall health. Group discussion during pulmonary rehabilitation education sessions is also extremely positive, with patients reporting improved quality of life after being on the NCCC scheme.
Reflecting diversity:
1 in 4 emergency hospital admissions is due to a respiratory problem and more than half are due to COPD itself (British Thoracic Society 2001). In 2003/2004 1100 patients were admitted as emergencies to NCHT and QMC with COPD, with each admission being estimated at £3000 (Bandolier 2002). Nottingham has several deprived areas, particularly within the City PCT, which is associated with a high percentage of smokers and consequently COPD. Often these patients live alone and require on going psychological as well as physical support.
Sharing the learning:
As well as promoting intersectoral collaboration with other agencies, PCT's and Intermediate Care, the teams have actively "spread the word" throughout both hospitals by attending Ward Manager and Senior Managers meetings, putting up posters on every ward, as well as articles in Trust magazines and the intranet. The have also made links with the National Primary Care Development Team participating in the Phase III Collaborative work on COPD, whose aim is also to reduce the number of COPD hospital admissions. Each PCT has a COPD Link Nurse who liaises directly with GP practices.
Outstanding features:
Firstly, we believe our scheme for the first time gives COPD patients some control over their management and a choice of where they are managed. The Self-Management Plan enables patients and carers to understand and manage exacerbations. This documents also aids communication between the COPD team, the patient and their GP, thereby helping to bridge the gap between secondary and primary care.
Secondly, our six community-based five-week pulmonary rehabilitation programmes of exercise and education are an innovative way of providing a forum where patients can access group therapy in their own local health centres. Previously there was only one hospital-based programme, which had a long waiting list.
Finally, in order for the pilot to be a success, nursing staff have had to be prepared to expand their clinical skills and some are already qualified as supplementary prescribers.
