Heartlands Hospital is a large inner city teaching hospital with a busy Accident and Emergency department and an Acute Medical Admissions Unit staffed by a mixture of acute physicians and specialist physicians.
When BTS called for applications to participate in the care bundle project in 2012, Heartlands had just conducted the first audit of COPD inpatient care since my appointment as new COPD lead. This had shown low rates of completion of several aspects of good COPD care, such as referral for pulmonary rehabilitation. We also had re-admission rates marginally above the national average.
In addition, we had undergone several external reviews of various aspects of COPD care, and it had been suggested by one that our mortality rate for patients cared for by respiratory was higher than the national average. Whilst this was most likely due to the fact that we are a three-site Trust and most of those requiring inpatient NIV come to Heartlands, hence our patients were more unwell, it was apparent that we needed a simple way in which to improve care quality.
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The 3 months from October to December 2012 were spent preparing for the introduction of the care bundles, gaining feedback on proposed local forms through grand rounds and email circulations to medical teams. We launched the Care Bundles on 1st January 2013 and spent the ensuing 9 months trying to encourage use of the bundles, re-educating and collecting data.
We issued pocket sized cards which staff could attach to their ID badge detailing some of the bundles to serve as an easily accessible reminder. The COPD discharge bundle was really taken up by our Clinical Nurse Specialist (CNS); part way through the year one of our CNSs left to take up a post in AMU and was our ‘respiratory champion’ there for a while.
Towards the end of the project our local CCG showed interest in using the COPD discharge bundle as a CQUIN; our experience and data gathered during the project was useful in negotiations.
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At the end of the pilot period, we had entered 283 CAP cases, 190 COPD admissions and 209 COPD discharges into the BTS audit web tool. 10 CAP care bundles, 59 COPD admission care bundles and 160 COPD discharge care bundles were completed.
There were various challenges during the project, the hardest of which was trying to encourage care bundle use in the ED, a department in which neither I nor the COPD nurses worked. Constant education and reminders were necessary; pocket cards were particularly useful for this, although our Trust was not able to fund them. In the end educational funding was provided by a pharmaceutical company.
Prior to implementation of the CQUIN we planned to make some systematic changes to nurse education on AMU and respiratory wards. This was to make sure that the bundle could be delivered independently of CNS on most of the wards with high numbers of COPD patients. The CQUIN was helpful in this regard and we felt much more prepared for the continuous data collection of the National COPD audit as a result. I found it difficult to get colleagues in other departments engaged in some elements of change, for instance it was hard to get a process mapping session done due to time constraints for a lot of the teams.
I overcame some of the difficulties that arose from this by running separate events with particular groups, such as an evening event for junior doctors. However, gaining senior Trust support to release staff from their day to day roles to do an event together would perhaps have been better for team-building. In the current NHS climate, where teams in acute care are often stretched, this may not be a realistic goal.
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We successfully ran a service development and improvement plan and then a CQUIN on COPD bundles. This aided me in getting a Clinical Nurse Specialist (CNS) to one of our hospital sites as it was apparent they would not achieve the CQUIN without new specialist staff to support the ward staff in delivering it. The business case was only possible by demonstrating that CNS input can have a major effect, by using BTS care bundle project data from our CNS at other sites. More recently we have employed a respiratory consultant with specific AMU sessions which aids the team there in keeping bundles on their day to day ‘radar'.
We have also used the learning from the project to inform quality improvement (QI) projects in related areas such as inpatient smoking cessation. In addition, we are better-informed about how to set-up a regional QI network for respiratory trainees, where projects will utilise national data collection including from projects like this. We are hopeful such a network would promote innovative practice quickly and effectively to increase care quality standards across our region.
If I was running the project again I would get other teams outside respiratory more involved from the start and would particularly ensure that nursing matrons were involved early on – for instance to mandate training for band 6 staff and above via e-learning, thus aiding adoption more widely than would otherwise have been possible relying on goodwill alone.
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