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Reducing hospital admissions and improving the diagnosis of COPD in Southampton City: methods and results of a 12-month service improvement project.

ABSTRACT: The British Lung Foundation highlighted Southampton City as a hotspot for patients at future risk of chronic obstructive pulmonary disease (COPD) exacerbations due to severe deprivation levels and a high undiagnosed level of disease based on health economic modelling. We developed a strategy spanning primary and secondary care to reduce emergency admissions of patients with acute exacerbations of COPD and increase the diagnosed prevalence of COPD on general practitioner (GP) registers closer to that predicted from local modelling.A comprehensive 3-year audit of admissions was performed. Patients who had been admitted with an exacerbation to University Hospital Southampton three or more times in the previous 12 months were cohorted and cared for in a consultant-led, but community based, COPD service. Within primary care, a programme of education and case-based finding was delivered to most practices within the city.Thirty-four patients were found to be responsible for 176 admissions (22% of total COPD admissions) to the hospital. These 34 patients required 185 active interventions during the 12-month period but only 39 hospital admissions. The 30-day readmission rate dropped from 13.4 to 1.9% (P<0.01), confirming the contribution the cohort made to readmissions. Prior to the project, the registered Quality Outcomes Framework prevalence of COPD within the city was 1.5; after just 1 year of the project, the prevalence increased from 1.5 to 2.27%.The use of medical intelligence to investigate the underlying processes of COPD hospital admissions led to an effective intervention delivered in a consultant-led model.

SUBMITTER: Wilkinson T

PROVIDER: S-EPMC4532163 | biostudies-other | 2014

REPOSITORIES: biostudies-other

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Project description:Admissions for exacerbations of chronic obstructive pulmonary disease (COPD) present a significant proportion of patients in the acute medical take. The British Thoracic Society (BTS) provides guidelines for time specific interventions, that should be delivered to those with an acute exacerbation of COPD through the admission care bundle. These include correct diagnosis, correct assessment of oxygenation, early administration of treatment, recognition of respiratory failure, and specialist review. Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) chose improvement in acute COPD care to be a local Commissioning for Quality and Innovation (CQUIN) scheme, which enables commissioners to reward excellence by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. The effects of initiatives put in place by senior clinicians had waned, and further improvements were required to meet the CQUIN target. The aim of the scheme was to improve compliance with the BTS guidelines and CQUIN scheme for patients admitted with an exacerbation of COPD. Specific bundle paperwork to be used for all patients admitted to the Trust with an exacerbation of COPD was introduced to the Trust in June 2014, with training and education of medical staff at that time. This had improved compliance rates from 10% to 63% by September 2014. Compliance with each intervention was audited through the examination of notes of patients admitted with an exacerbation of COPD. Compliance rates had plateaued over the last three months, and so a focus group involving junior medical staff met in September 2014 to try to increase awareness further, in order to drive greater improvements in care, and meet the CQUIN requirements. Their strategies were implemented, and then compliance with the CQUIN requirements was reaudited as described above. The December 2014 audit results showed a further improvement in overall COPD care, with 73% of patients receiving all elements of the COPD admission care bundle, versus 63% in September 2014. Appropriate blood gas analysis, nebuliser administration, and respiratory review also improved. Prescription of steroids and antibiotics remained static, with 96% of patients receiving these treatments within four hours in the emergency department (ED). The only criteria which showed a decline was appropriate oxygen prescription, which dipped from 97% to 87%. After the effect of initial strategies plateaued, this quality improvement project facilitated a further increase in compliance with the CQUIN targets, both improving patient care, and safeguarding continued CQUIN funding. There is further work to be done to maintain and support further improvement in standards, and to encourage use of the COPD admission bundle paperwork for documentation purposes.

Project description:Blood tests are a seemingly basic investigation, but are often a vital part of directing patient management. Despite the importance of this everyday process, we indentified the potential for improvement of the current phlebotomy service in our hospital, as both junior doctors and phlebotomists reported a lack of communication and standardised practice across the wards. Resulting delays in obtaining blood test results can impact detrimentally on patient safety and management. We designed a survey which highlighted inefficient handovers and discrepancies between wards as driving factors behind this. We therefore aimed to improve communication between phlebotomists and doctors, as well as the overall organisation of the service. This took the form of the "Phlebotomy Box," a box file system offering a set location for blood stickers to be situated. The box concept was optimised on a series of medical and surgical wards, incorporating multidisciplinary feedback from relevant teams. We measured how many untaken bloods were handed over to medical staff continuously, both pre- and post implementation of the phlebotomy box. Our baseline ward demonstrated poor handover rates of untaken bloods, ranging from 0% to 40%. This increased to a consistent 100% following introduction of the Phlebotomy Box and ongoing staff education. Once optimised, the box was trialled on a further two medical wards and one surgical ward, achieving 100% handover from an initial 0% to 67%. Quantitative improvement was also reflected qualitatively in widespread staff surveys, with overwhelmingly positive support and acceptance. In summary, the Phlebotomy Box innovation has led to 100% of untaken bloods being effectively handed over. We have demonstrated a significant improvement in communication and efficiency within the phlebotomy service, with tangible benefits to patient care, as minimising time lags can prevent delays in clinical decisions. The phlebotomy box represents a simplistic, sustainable intervention that could be easily replicated in other Trusts.

Project description:In recent years medical handover has been identified as an increasingly important area for hospitals to improve upon, in light of the changes in shift patterns for doctors. Significant changes to weekday handover had recently been successfully introduced at Broomfield hospital. Weekend handover remained a concern, with an electronic and paper system being used simultaneously. Our objectives were to introduce a new electronic handover system for weekend handover at Broomfield Hospital and improve the organisation of the weekend handover meeting to promote patient safety. Doctors involved in weekend handover were surveyed using a questionnaire, to establish insufficiencies in the weekend handover process; where both the electronic ExtraMed system and paper were being used inconsistently. A new weekend handover system was introduced together with a new user-friendly electronic handover database, addressing the identified difficulties in the current system. These changes met the medical handover guidelines set by the Royal College of Physicians. Three months after the launch of the new system, doctors were re-surveyed using a modified questionnaire to assess the impact our changes had made. Before changes were implemented only 12% of doctors surveyed used the electronic system for weekend. Eighty-nine percent found sorting through jobs time consuming and 67% were handed jobs to them meant for a different grade of doctor. Only 41% were aware who to hand weekend discharges to. Subjective assessment of safety was 3.18 out of 5. The electronic system was felt to be time consuming and complicated. After execution of the new weekend handover process, 100% of doctors reported using the electronic system for weekend handover. Only 47% of doctors felt sorting through jobs was time consuming and 89% of doctors were aware who to handover weekend discharges to. Subjective assessment of the safety of weekend handover improved to 3.84 out of 5. Informal interviews on the ward revealed a high degree of satisfaction with the new weekend handover system. In conclusion we found that a structured, well organised weekend handover meeting together with an effective electronic handover system improves the quality of medical weekend handover.

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Reducing hospital admissions and improving the diagnosis of COPD in Southampton City: methods and results of a 12-month service improvement project.

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