A basic guide to the key principles every area should be adopting to provide good COPD care – if you do nothing else, start with these ten things and make sure they are in place for all your patients. This may be a helpful starting point for those new to commissioning for COPD services or for a stocktake for a local respiratory team. (October 2012)

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
NHS Improvement - Lung:
LUNG
First steps to improving chronic
obstructive pulmonary disease
STROKE (COPD) care
FIND
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2. FIND First steps to improving chronic obstructive pulmonary disease (COPD) care
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What you can do Why it matters How to do it
1. Identify, Many people are diagnosed with • Audit practice information
diagnose and COPD late in the disease systems to identify people
intervene progression. If we can diagnose who receive multiple
early and intervene earlier we can prescriptions for oral steroids
better manage the impact on and/or antibiotics.
patients and the burden of • Consider which patients
disease. Studies have shown should be assessed for COPD
that in the two to ten years prior or other conditions so that
to diagnosis, people are likely to you can start them on the
have consulted in primary care appropriate treatment pathway.
on multiple occasions for lower • Discuss with patients what
respiratory complaints and lower the disease is, and what they
respiratory tract infections, and can do, including advice
to have received multiple about smoking and exercise.
prescriptions for oral steroids • Back this up with written
and/or antibiotics. This suggests information for the patient,
there is scope for earlier but do not rely on leaflets
assessment and diagnosis. alone.
2. No Misdiagnosis is very common • Check practice registers – all
diagnosis and means patients are not on COPD diagnoses should have
without optimal treatment. This wastes spirometry undertaken and
quality medicines, time and money and recorded within the last 15
means that the patient’s months.
assured
condition may not be effectively • Review those with dual
spirometry managed. diagnosis of COPD and
asthma.
Spirometry is an essential • Train staff in undertaking
component of accurate quality assured spirometry
diagnosis, but must be and ensure only appropriately
performed correctly, according trained people undertake and
to existing guidelines, and interpret results.
interpreted accurately to be • Calibrate your spirometer.
valid. • Ensure you have a local
pathway for referral to your
Spirometry is not the only specialist services for
diagnostic test that should be additional tests when there is
undertaken for a correct diagnostic doubt.
diagnosis – other tests may be
needed such as CT scan.
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3. LIVIN First steps to improving chronic obstructive pulmonary disease (COPD) care
G
WIT
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What you can do Why it matters How to do it
3. Talk with Patients live with their condition • At diagnosis and review, plan to
patients every day and understand what spend more time with patients
about self they can do to manage its ensuring they understand the
management impact on their life, the less condition and what they can to
reliant they will be on health do to improve life with it.
services. Self management is • Refer appropriate patients to
not just about developing an pulmonary rehabilitation which
action plan, but about the supports effective self management.
process of planning and • Look at how much time is
understanding the requirements currently spent in primary care
and aspirations of the patient. seeing people with COPD and
co-morbidities in the course of
Take time to understand their the year. Consider whether you
motivation, aspirations, fears can organise care to provide a
and behaviour to help initiate care planning appointment to
change. address a number of concerns
and proactive intervention up
front. This needs to be 30
minutes plus but may save time
over the course of the year.
4. Check Poor inhaler technique is • Make inhaler technique checks
inhaler extremely common and part of every review.
technique at substantially reduces the • Take time with patients to
every effectiveness of the inhaled understand how they actually use
drug. If staff do not their medication and why, and
opportunity
demonstrate technique correctly what you can do to help them.
and check regularly, patients are • Ensure all staff have regular
unlikely to use their devices updates in use of devices and
effectively or get maximum demonstration of inhaler
potential benefit from their technique.
medication. If medicines appear • Use trainer devices for an
not to be working, patients may objective assessment and to
be prescribed additional help patients acquire and
medication that could be maintain optimum technique.
avoided and which could even • Work with your local
be harmful. pharmacists who can perform
inhaler technique checks as part
of medicines use reviews, to
enhance impact.
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4. LIVIN First steps to improving chronic obstructive pulmonary disease (COPD) care
G
WIT
H
What you can do Why it matters How to do it
5. Help Patients who understand their • Ensure all appropriate patients
patients to own symptoms, recognise have rescue medication and
recognise and changes and respond understand how and when to
respond to accordingly by starting use it.
medication and seeking advice • Ensure patients have a contact
exacerbations
early can manage exacerbations number for advice if they are
more effectively. uncertain what to do. If they
don’t, they will revert to A&E or
This can reduce demand for urgent appointments.
urgent appointments, A&E • Ensure all patients are followed
attendance and admissions. up after admission – acute units
can advise primary care of
admissions/discharges and
follow up arrangements.
• Record exacerbations in primary
care so that you can identify
patients whose condition and
treatment may need review.
6. Review People with severe COPD are • Ensure you are assessing and
people often not reviewed frequently recording disease severity
according to enough. This can lead to poor accurately and consistently.
their disease management and more • Check that patients are on the
frequent exacerbations. appropriate treatment
severity in a
pathway for the severity of
timely manner their disease. Treatment choice
depends on symptoms as well
as FEV1 (NICE guidelines
2010).
• Check that patients who are
eligible have been referred for
pulmonary rehabilitation and
are offered support to stop
smoking as these are effective
interventions for COPD.
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5. LIVIN First steps to improving chronic obstructive pulmonary disease (COPD) care
G
WIT
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What you can do Why it matters How to do it
7. Do not Home oxygen is a treatment for Promote the message to staff
prescribe chronic hypoxaemia and NOT a and patients that ‘oxygen is not
oxygen for treatment for breathlessness. It a treatment for breathlessness’
‘breathlessness’ is a drug and should only be and that there are often more
prescribed where clinically appropriate ways to manage
and ensure
indicated otherwise it is of NO breathless patients.
prescribing benefit and potentially harmful
remains to some patients. Ensure only patients who have
clinically been assessed by a specialist
appropriate In PCTs that have introduced a service are prescribed oxygen and
and cost review of their oxygen registers that they receive ongoing review.
effective coupled with the introduction of This involves measuring both
through a formal assessment service up oxygen saturations and blood
formal to £400,000 has been saved in gases and reviewing other clinical
one year. If the scale of savings data together with supplier data
assessment
were replicated across England, on usage, flow rate, duration
and ongoing it is estimated that they could and equipment.
review amount to between £10-20m.
Rationalise therapy in line with
clinical need and undertake
supported withdrawal of oxygen
providing no clinical benefit.
8. Oxygen Some patients with COPD or Oxygen alert cards and 24%
alert cards other long term chest conditions masks (recommended in the
should be can become sensitive to medium BTS 2008 guideline) can avoid
provided for or high doses of oxygen. This hypercapnic respiratory failure
does not happen to everyone by alerting healthcare
at risk
with these conditions, only a professionals that patients are
patients small number, therefore, if sensitive to oxygen. Oxygen
oxygen is needed by these alert cards should be issued
patients, it should be given in a to all at risk patients on
controlled way and monitored discharge as part of the
carefully. discharge planning process.
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6. N THING First steps to improving chronic obstructive pulmonary disease (COPD) care
HE
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! G
N
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WRO
What you can do Why it matters How to do it
9. Specialist Early senior review can reduce Identify how many people are
review for length of stay and prevent not on the respiratory pathway /
every patient avoidable admission. Only 53% respiratory ward or do not
admitted for of patients are looked after by a receive specialist care.
respiratory physician during their
COPD
inpatient stay. Demand and capacity analysis can
exacerbation help identify how you can reduce
within 24 the time until specialist review
hours occurs. Look at processes for
patient assessment, review and
discharge planning.
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7. G
TO W First steps to improving chronic obstructive pulmonary disease (COPD) care
A
RD
ND S THE E
What you can do Why it matters How to do it
10. Discuss COPD is a terminal illness, but • Discuss end of life care needs
end of life care progression and deterioration is with appropriate COPD
needs with often unpredictable due to patients
appropriate disease trajectory. • Give timely information and
offer the opportunity to
COPD patients
Proactive approaches are patients to decide how they
and ensure important to ensure that want their care to be
they are patients, carers and professionals delivered at end of life
included on are prepared for end of life and • Raise the topic with patients
end of life that informed choices are made. during a period of wellness as
registers opposed to an acute care
setting following an acute
exacerbation
• Ensure COPD patients are
included on end of life
registers. Prognostic indicators
e.g. GSF should be used in
primary care to regularly
assess COPD patients to
determine eligibility for being
added to the end of life care
register. Typically, COPD
patients should make up
around 14% of the
care registers.
7

8. NHS
CANCER
NHS Improvement
DIAGNOSTICS
NHS Improvement
HEART
NHS Improvement’s strength and expertise lies in practical service
improvement. It has over a decade of experience in clinical patient
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demonstrates some of the most leading edge improvement work in
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Working closely with the Department of Health, trusts, clinical networks,
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improvements with over 250 sites across the country as well as providing
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www.improvement.nhs.uk Publication Ref: IMP/LUNG0003 - August 2012
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