Respiratory Care BundlesProfessor Thida Win

Lister HospitalThida.win@nhs.net

November 2012 - December 2013 21 NHS Trusts in England and Wales a care bundles-based approach to quality

improvement in the care of patients admitted to hospital with an acute exacerbation of COPD (AECOPD) and Community Acquired Pneumonia (CAP)

BTS (British Thoracic Society)Care Bundle Project

High level data 11,748 patients admitted with AECOPD 14,451 patients admitted with CAP

Patient level data on processes and outcomes of care 3,266 COPD admissions 2,563 CAP admissions

1,438 bundles were used

use of a care bundle was associated with a reduction in 30 day in-patient mortality from CAP from 13.6% to 8.8%.

The presence of an oxygen prescription was also associated with a reduction in length of stay for those with COPD

Benefits

COPD admission bundle with outcomes of care demonstrated a statistically significant reduction in mortality from AECOPD in patients in whom oxygen was prescribed at admission (OR 0.22

95%CI 0.05-0.88) and in patients in whom care was delivered within 4

hours of admission (OR 0.60 95% CI 0.42-0.87)

This is the first time that use of a COPD bundle has been associated with a reduction in in-hospital mortality!

Mortality

COPD Care Bundle (Acronym: DARTS) Diagnosis Assessment (for oxygen) Recognition (of acidosis) Timely medications Specialist review

Care Bundle Components

COPD Discharge Care Bundle (Acronym: TAPSS) Technique (inhalers) Action plan Pulmonary rehabilitation Smoking Cessation Specialist follow-up

Care Bundle Components cont..

Pneumonia Care Bundle (Acronym: COST) Chest x-ray (CXR) Oxygen (assessment) Severity (Scoring) Timely & appropriate treatment

Care Bundle Components cont..

14/15 Trust replied 4 Trusts not using Care Bundles at time of survey,

but 1 was implementing Majority (9) use a COPD discharge-bundle 1 uses admission and Pneumonia bundle (KL) 3 use asthma bundle addition to discharge bundle

(Add/ Ip/South) 1 use pneumonia and admission bundle addition

to discharge bundle (JP) 2 on Respiratory wards, 2 at MAU and 10 at All

EoE Care Bundle Survey

L&D Princess Alexandra (Harlow) Peterborough

Trusts not using Care Bundles

3 Trusts achieved >90% use of discharge bundle Southend West Herts E&N Herts

Success

Help readmissions 25% reduction in readmission (Ipswich) Some found difficult to say specific benefit

due to partial effects- pathway, specialist review, education, staff change over etc

Benefit

CCGs Staffing Support Evidence CQUIN will ensure delivery of care bundle

Barriers to implementation

Care Bundles effective in improving reliability and reducing unwarranted variation in care

Wide implementation of Care Bundles is feasible Evidence suggested CAP, and COPD admission

bundle shows mortality benefit Emergency Oxygen prescribing & timely care

essential components Value of Clinical Specialist Leadership to ensure

success Most EoE Trusts use care bundles, but uncertainty

of their components and outcomes

Conclusions