Breakout 4.3 Building a caring future - Liz Norman Lung Improvement Programme – Transforming Acute Care Senior Respiratory Nurse Specialist NHS London Respiratory Team Lead Consultant Respiratory Physician, Whittington Health & NHS Islington Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Lung Improvement Programme – Transforming Acute Care
Liz Norman Senior Respiratory Nurse Specialist
Elizabeth.Norman@nhct.nhs.uk
0191 293 4253
3 Streams
• NIV – reducing door to mask time
• COPD Extended Care Bundle
• Increasing access to specialist care
• Door to mask time
• Specialist care
• LOS
• Readmission rates
1

2. Improving access to specialist care
What we did – RNS
• Independent facilitator
• Use of data to drive change
• Identified what got in the way of doing the job
• Time –often doing the bare minimum
• Fragmented day/week, overstretched and interrupted
• General dogs body for extra work no one else picks up
• Lack of understanding from others about the role and
time pressures
• Managing patient expectations
• Session held to ‘drill down’ barriers
• Identified what we could do to change and RNS key aims
Using job plans for more efficiency
• Sessional job plans for structure and focus
• Demand and capacity work with OSM
• Identified peaks and troughs in work pattern
• Restructured each RNS week -Based on information from
mapping event, RNS priorities and demand and capacity figures
– Reduced O/P clinics – now working to full capacity
– Reduced Supported discharge visits – freed up time
for work identified as a higher priority (FoH)
– Organised time for admin and teaching
– Prioritised acute care/assessments for inpatients as
key to quality patient care and staff/job satisfaction
2

3. Why focus on acute care?
• The RNS team identified the following:
– Patients are the reason we do our job
– Every inpatient should have a specialist
assessment
– Assess all patients and see all newly diagnosed patients
– Promote early discharge
– Identify sick patients – prompt NIV – ensure sick patients transferred
to a respiratory ward
– Promote self management
– Reduce length of stay
– Reduce re-admissions
Data –% COPD patients stay on a
respiratory ward
3

4. Recovery post austerity measures
Number patients seen by Respiratory Nurse Specialists
80
70
60
50
2009
40
2011
30 2012
20
10
0
Aug Sept Oct Nov
Month
Implementing a Care Bundle
• Aim:
– 6 quality standards for all patients with COPD
– Design of the document
– Engaging staff to implement - Target those with
the least resistance! Those who already input with
the patient we used the pharmacists!
– Staged roll out
– Data collection – recruit your audit team
– Feedback on performance
4

5. Length of stay by ward and site
Length of stay
WGH P = 0.66 NTGH P = 0.0046
14.0
12.0
10.0
Days
8.0
6.0
4.0
2.0
0.0
Bundle
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Bundle
bundle
Bundle
bundle
Bundle
bundle
Bundle
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Bundle
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Bundle
bundle
Pre
Pre
Pre
Pre
Pre
Pre
Pre
Pre
Mean Median W2 Mean Median W17 Mean Median W18 Mean Median
W2 WGH W17 WGH W18 NT NT W24 NT W24 NT
WGH WGH
Readmissions
30.0%
Re - Admissions with respiratory cause
30 day readmissions
25.0%
90 day readmissions
Readmission rate
20.0%
15.0%
10.0%
5.0%
0.0%
bundle pre bundle bundle pre bundle bundle pre bundle bundle pre bundle
W2 WGH W17 WGH W18 NT W24 NT
5

6. NIV
• In Situ:
– Established Physio led service
– Robust protocols
– Consultant support for difficult decision making
• Aims:
– Controlled oxygen as default throughout the
hospital
– Minimise delays “door to mask time”
Predicting mortality in AECOPD requiring
ventilation
Steer, Gibson, Bourke: ERS 2012, NIV prize
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7. NIV
• Mapping event – identified delays (door to mask
time)
• Walked through the process on the shop floor
– This identified simple steps for improvement – i.e
supply of blood gas syringes
• Used data to inform decisions
– Local data
– Research evidence on mortality
– Continuous feedback – data collected
NIV – Reducing Door to Mask Time
• Human factors: clinician and physio
– Inappropriate extended controlled O2 trials
– Feedback and support
• Organisational
– CXR request by triage nurse?
• Median time from assessment to CXR = 19.5 – 65
mins
7

8. NIV
• Root cause analysis for specific problems
• Individuals taught when necessary
• Education package targeted two groups:
– Consultants & Emergency care staff
– Physiotherapists
– Education package focused on improved decision
making
– Emphasised support available/treatment protocols
Median door to mask time
8

9. Learning
• Project management
• Time to reflect and develop
• Using evidence and local data to inform decisions
• Linking national and local data
• Identifying risks and gaps
• Knowing what is good
• How to manage change
• The strategy can be applied to other
conditions/departments
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