Context
Chronic obstructive pulmonary disease is the name given to a collection of long-term conditions that affect the lungs, including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have trouble breathing in and out due to long-term damage to the lungs, usually because of smoking. COPD usually affects people aged > 35 years, although most diagnoses occur in people in their fifties or later.
Epidemiology of chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease is one of the most common respiratory diseases in the UK and it is estimated that the number of people with a diagnosis is 1.2 million, although around 2 million more may have undiagnosed COPD. Along with lung cancer and pneumonia, COPD is one of the three leading contributors to respiratory mortality in the UK; there are 30,000 deaths from the disease each year.1
The majority of people with COPD also have other medical problems, most commonly ischaemic heart disease (which occurs in some 25% of patients).2 Many people discharged from hospital after an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) also report feelings of depression (64%) and anxiety (40%), with > 80% having at least one other condition, such as coronary heart disease.2 This multimorbidity means that managing the health-care needs of people with COPD is challenging for patients, carers and health-care professionals.3–5
Chronic obstruction pulmonary disease and emergency hospital admissions
Chronic obstructive pulmonary disease accounts for 10% of emergency hospital medical admissions, which total > 90,000 annually in the UK.2 Nearly one-third of these patients are re-admitted to hospital within 28 days of discharge,6 and this proportion is steadily rising, with a 2% increase in re-admission rates between 2003 and 2008.2 During the same time period, in-hospital mortality rates fell slowly – estimated at 7.5% in 2003, 7.7% in 2008 and 4.3% in 2015.2,6 As well as being an important cause of emergency admissions, COPD is the second most common cause of emergency admission to hospital1 and the fifth largest cause of re-admission,1 costing the NHS an estimated £491M per year. Overall, the number of admissions has increased by 50% in the last decade and COPD now accounts for one million bed-days per annum. These figures suggest that acute, urgent and emergency COPD health care will continue to challenge the NHS for the foreseeable future and create considerable pressure on managers and clinicians to work to resolve the issue.
Evidence-based chronic obstructive pulmonary disease care
Emergency admissions to hospital for long-term conditions, including COPD, form part of the NHS Outcomes Framework.7 A Royal College of Physicians Audit6 found that, on average, patients spend 8.7 days in hospital during an admission for COPD but also highlighted wide variation in terms of both treatment provision and outcomes among hospitals. This disparity was particularly marked in relation to mortality. It also showed that a significant proportion of the observed variability could be explained by availability and access to expert care and evidence-based interventions. This presents a potential opportunity to improve outcomes for patients with COPD by ensuring that their care is consistently provided to a high standard.
Chronic obstructive pulmonary disease care bundles
One example of an evidence-based intervention is the use of care bundles. These are simple tools used with the aim of reliably achieving delivery of clearly specified elements of care.8
Care bundles are sets of evidence-based interventions, elements of which are known to optimise clinical outcomes. A bundle is a structured way of improving the process of care and thereby improving patient outcomes. It is a short, straightforward set of evidence-based clinical interventions or actions that, when performed, reliably improve patient outcomes. The bundle resembles a list, but the way in which a bundle is created is unique. The care processes described in the bundle should be both necessary and sufficient. If any element of a care bundle is omitted, it means that the care being monitored will be less effective than if all the elements are delivered.
It is, therefore, a cohesive unit of actions that must all be completed to achieve the best outcomes. The elements of any care bundle should also be based on the best available evidence. A bundle should focus on how care is delivered as well as what care is delivered. Care bundles should also be easy to monitor, so each component of the bundle can be recorded as either completed or not completed. This clarity can allow variance from agreed practice to be easily measured and any defects repaired.
Improvement theory suggests that, properly implemented, the use of care bundles should enable clinical teams to concentrate on a range of measurable activities and optimise associated outcomes. In practical terms, this should mean that protocol-based care bundles for COPD will enable staff to see quickly what course of action should be taken, when and by whom, and that this will result in standardisation of practice in the treatment of patients. COPD care bundles could also be an important tool in improving the quality of care, as any deviation from the agreed care pathway can be measured easily, enabling systemic factors that might inhibit provision of best care to be identified and subsequently addressed.9
Admission and discharge care bundles for COPD were developed by the British Thoracic Society (BTS) in association with NHS Improvement.9 Care bundles are being implemented in health care as a way of focusing improvement efforts on a defined set of factors and actions which contribute to the achievement of a clearly specified aim. However, apart from some evidence from the USA and from a couple of pilot studies in the UK, the impact of care bundles on processes and outcomes of care is poorly understood.
The content of the COPD care bundles is based on interpretation of published evidence of interventions that improve patient outcomes. It was felt that a single care bundle could not encompass the range of measures required.9 Therefore, two sets of care bundles were derived: one to be completed at the point of hospital admission (admission care bundle), aimed at reducing in-hospital mortality for COPD and reducing length of stay, and a bundle to be completed before discharge from hospital (discharge care bundle), aimed at reducing re-admissions. Together, these comprise a set of evidence-based actions that, when completed in full, should lead to an improvement in the overall care of patients admitted to hospital with an AECOPD. The process by which the BTS COPD care bundles were developed is described in detail in the summary report.9 Further detail about each of the bundles is summarised below.
Chronic obstructive pulmonary disease admission care bundle
The COPD admission care bundle is designed to facilitate co-ordinated and timely care for patients admitted to hospital with an acute exacerbation of COPD.9 The first bundle element aims to ensure that a correct diagnosis of AECOPD has been established. The diagnostic process begins with a history and physical examination and should be supported by early availability of an electrocardiogram (ECG) and chest X-ray. These two diagnostic tests are, therefore, key to supporting successful completion of admission bundle item 1. The aim of this bundle element is to allow alternative diagnoses to an acute exacerbation of COPD to be excluded (e.g. pneumonia, heart failure, cardiac ischaemia). Spirometry is excluded, as this measurement is considered unreliable in the context of an acute admission.
Early recognition and response to hypoxia is critical; however, patients with severe COPD may have a reduced hypoxic respiratory drive. An oxygen assessment should be undertaken and the correct target range prescribed within 30 minutes. For patients with COPD, a target saturation range of 88–92% is suggested pending the availability of blood gas results.10
Staff should recognise and respond to respiratory acidosis within 1 hour of admission. Patients with the highest mortality from COPD following hospital admission are those who are admitted in respiratory failure; thus, early recognition and an appropriate response to respiratory acidosis are key to improving early mortality.10 This requires an arterial blood gas for all patients admitted to hospital with oxygen saturations of ≤ 94% (on air or controlled oxygen). Following interpretation of the results of this investigation, early assessment for suitability for non-invasive ventilation (NIV) is required. Current guidelines suggest that patients should be placed on optimum medical therapy (controlled oxygen and nebulised therapy) for 1 hour, following which the need for NIV should be assessed.
Correct prescription of medications (including nebulisers, steroids and antibiotics) is also necessary. Medication (steroids and nebulisers) should be administered to patients within 4 hours of admission. This is important, as the mean mortality rate among patients admitted to hospital with an infective exacerbation of COPD is 7.7%.6 Their treatment and assessment should be timely, as for any other seriously ill patient. Correct prescription of medications (including nebulisers, steroids and antibiotics) within 4 hours is appropriate given the severity of some COPD patients’ condition.
Finally, as results of the 2003 national COPD audit suggest that review by a respiratory specialist reduces in-hospital mortality,6 and given that the majority of deaths occur within 72 hours of admission, all patients admitted with an acute exacerbation of COPD should be seen by a member of the respiratory team within 24 hours of admission. This could be a specialist nurse or physiotherapist, specialist registrar or consultant. In the BTS pilot, provision of a prescription for oxygen therapy had the greatest impact on mortality. Patients seen by respiratory specialists had markers of COPD exacerbation severity suggesting a higher level of acuity but had a lower mortality than those seen by non-specialists.11 The components of the admission bundle are reflected in the acronym DARTS (Box 1):
In full, the components of the admission bundle are:
Statement 1 – a correct diagnosis of AECOPD should be confirmed.
Statement 2 – an oxygen assessment should be undertaken and the correct target range prescribed within 30 minutes.
Statement 3 – recognise and respond to respiratory acidosis within 1 hour of admission.
Statement 4 – medication (steroids and nebulisers) to be administered within 4 hours of admission.
Statement 5 – review by respiratory team to take place within 24 hours of admission.
Chronic obstructive pulmonary disease discharge care bundle
At 25–30%, the 90-day re-admission rate for patients discharged following an admission with COPD is high but, as yet, there is little evidence for individual interventions that consistently reduce this figure.6 Structured discharge planning is one intervention that has been shown to reduce further hospital admissions.12 A consensus was reached on the key elements of a COPD discharge bundle. It was agreed that the elements should be aimed at ensuring that patients have been assessed appropriately prior to discharge and are confident in the use of their medications. It was also felt to be important that patients have ready access to advice and assistance should they deteriorate following discharge from hospital.
The discharge bundle incorporates five elements. The first bundle element states that all patients should have their respiratory medications and inhaler technique assessed prior to discharge. On direct questioning, 98% of respiratory patients report using their inhaler correctly; however, on testing, only 8% showed the correct technique.13 This problem can be exacerbated in the elderly, for whom issues such as visual acuity, manual dexterity and cognitive impairment can act as additional barriers to correct inhaler use.14 However, correct use of inhalers is associated with improved outcomes for patients, including a reduction in the risk of exacerbations and hospital admission.15 Repeated instruction is required to ensure that inhaler technique is optimised.16
Second, all patients should receive a written plan for how to manage a further acute exacerbation of their COPD and should receive a discharge pack of ‘emergency’ drugs prior to discharge. Self-management plans in COPD teach patients how to carry out disease-specific elements of self-care. They appear to be associated with improved well-being and a reduced risk of hospitalisation.17 Early treatment of COPD exacerbations is associated with a more rapid recovery from the acute episode, reduced risk of hospitalisation and better health-related quality of life.18 Self-management strategies are a complex intervention and the optimum form and method of delivery of self-care education are not yet clear. The provision of self-management education and a discharge drug pack, as part of the bundle intervention, is intended to assist the patient in optimising self-management of subsequent exacerbations with the aim of reducing the risk of re-admission. However, it is recognised that this is an element of the care bundle with a less secure evidence base as well-conducted trials of self-management have highlighted that not all patients become successful self-managers. Therefore, not all individuals will experience improved outcomes.19,20
The third discharge bundle element is that smoking status should be assessed together with a willingness to quit and, in the case of those patients indicating a wish for further assistance, a referral should be made to a stop smoking programme. Smoking remains the biggest preventable cause of death and disease in the UK and accounts for approximately 50% of health inequalities between socioeconomic groups.21 In a study of factors predicting short- and medium-term mortality in hospitalised patients aged > 65 years, current smoking was the factor associated most strongly with risk of death during the follow-up period.22 Exposure to cigarette smoke has also been associated with an increased risk of hospital re-admission within 1 year after discharge following an admission with an infective exacerbation of COPD.23 Finally, two-thirds of smokers expressed a wish to stop smoking when asked if they wished to quit.24 It is clinically effective and congruent with the bundles’ aim of reducing risk of death and hospital re-admission to include a clear focus on smoking cessation. Clinicians should, therefore, use every patient contact to explore the patient’s wishes about stopping smoking.
The fourth bundle element states that all patients should be assessed for their suitability for pulmonary rehabilitation prior to discharge. Systematic review of the evidence base for the benefits of pulmonary rehabilitation concludes that rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances patients’ sense of control over their condition. Pulmonary rehabilitation therefore forms an important part of the long-term management of stable COPD.25 However, the provision of pulmonary rehabilitation in the period immediately following hospital discharge for an exacerbation has also been shown to improve patient well-being in addition to reducing risk of hospital re-admission.26–28 Review of the enablers and barriers to physical activity in COPD patients identified hospital admission as an opportunity to work with patients to overcome practical and psychological factors preventing patients from increasing activity levels.29 Therefore, clinicians should aim to actively recognise and address barriers to physical activity.
Finally, community follow-up within 2 weeks of discharge from hospital should be organised. When it is not possible to achieve this, consideration should be given to the establishment of a system whereby patients are contacted by telephone following their discharge from hospital and are offered the opportunity for support. Follow-up for patients following an exacerbation of COPD provides an opportunity to review patients’ medication and offers the opportunity to identify those patients experiencing an early deterioration following discharge. The best timing, mechanism and venue for this follow-up is not yet clear. However, respiratory follow-up of patients within 30 days of discharge is associated with a reduced risk of re-admission.30 The same benefits may also be obtained through telephone follow-up by the hospital team when this is supported by a comprehensive package of care, including the opportunity for early reassessment in the event of a deterioration.31 The discharge bundle is reflected by the acronym TAPSS (Box 2):
In full, the components of the discharge bundle are:
Statement 1 – all patients should have their respiratory medications and inhaler technique assessed prior to discharge.
Statement 2 – all patients should receive a written plan for how to manage a further acute exacerbation of their COPD and should receive a discharge pack of ‘emergency’ drugs prior to discharge.
Statement 3 – smoking status should be assessed together with a willingness to quit and, in the case of those patients indicating a wish for further assistance, a referral should be made to a stop smoking programme.
Statement 4 – all patients should be assessed for their suitability for pulmonary rehabilitation prior to discharge.
Statement 5 – community follow-up within 2 weeks of discharge from hospital should be organised.
Partnership with the British Thoracic Society
This study was conducted in partnership with the BTS, which had previously undertaken a pilot evaluation of the introduction of COPD care bundles.9 The pre-existing commitment by some implementation trusts to delivering care bundles and the roll-out of the BTS training programme precluded delivery of a study using a randomised controlled trial design. We, therefore, selected a controlled before-and-after study as the most robust study design to measure any association between care bundles and better costs and outcomes of AECOPD care. This study, therefore, included a group of acute hospital trusts that agreed to deliver the COPD care bundle intervention as well as a group of broadly comparable trusts that did not deliver the intervention during the study period. It involved three different levels of data collection and analysis using mixed-methods research to build a comprehensive data set with which to evaluate the effectiveness, efficiency and acceptability of the care bundle package.
In summary, this research is intended to provide independent evidence of the impact of COPD care bundles on hospital admissions and re-admissions. It also provides information on how a co-ordinated care package might improve quality of care, equity of access, patient and carer experience and service delivery for COPD patients within the acute setting, considering cost implications and implementation challenges. The research also explores potential enablers and inhibitors of the delivery of the COPD care bundles. Going forward, the research could also inform the development and delivery of care bundles for other health conditions.
