6. COPD is projected to be the third
biggest killer by 2020
1990 2020
Ischaemic heart disease
CVD disease
Lower respiratory infection 3rd
Diarrhoeal disease
Perinatal disorders
COPD 6th
Tuberculosis
Measles Stomach cancer
Road traffic accident HIV
Lung cancer Suicide
Murray & Lopez 1997
7. Diagnosis
• Generally over 40 years1
• A smoker or ex-smoker (remember passive
smoking)
• Presentation with:
• cough
• excessive sputum
• dyspnoea (most common)
• Spirometry
• FEV1/FVC < 70%
• FEV1 – As per 2010 Guidelines
1. NICE 2010
8. No. of patients discharged with a diagnosis of COPD
900
800 830
700
600 587 617
500 508 531
400 380
300
200
100
0
2000 2001 2002 2003 2004 2005 2006 2007
Year
10. Service Model
• Primary Care Support
• Community Based Rapid Response
• Emergency Department Intervention
• Early Supported Discharge
• Community Clinics
• Education
• End of Life Pathway
11. Service Philosophy
To provide a comprehensive, integrated,
responsive community-focused COPD
service, for acute exacerbations and
ongoing chronic disease management,
which meets the diverse needs of City &
Hackney patients in a sustainable and
timely manner.
12. Who are we?
• 1 wte Nurse Consultant – Matthew Hodson
• 2 wte COPD Specialist Nurses
• 4 wte COPD Senior Staff Nurses
• 2 wte COPD Specialist Physiotherapists
• 1 wte COPD Team Administrator
• Medical Consultant Lead
Base: Respiratory Offices, Homerton Hospital
13. Patient
GP
Other Practice
health
professionals nurse
ACERS
Community Clinic
Matron
Emergency
Department
Medical
Wards
14. ACERS Core Features
• Opening Hours (7 days, 8 am – 7 pm)
• Response Time (<4 hrs for community referral)
• Length of Care Package for H @ H within the
community (approx< 8 days)
• Focus on 30 and 90 days post exacerbation
• Referral in to PR – ASAP after exacerbation
• Medical Support (Close links with hospital team)
15. Clinical Responsibility
• ACERS have regular contact with
Respiratory Consultant and SpR
• Easy access to hospital diagnostics
• Regular communication with Practice
Nurse & GP
• GP asked for input with non-respiratory
problems when appropriate
16. Hospital @ Home
• Admission Avoidance – SOS Calls
• Early & Supportive Discharge
• Links with Other Local Acute Hospitals
• Acute Intervention
• Weekly MDT & Links with Respiratory Team
• Up to 14 days intervention (HV/Telephone)
• Physiotherapy Intervention
• Post exacerbation PR offered
17. Specialist COPD Case Management
• Level 1 & 2 COPD case management
• Proactive disease management can make a real
difference to patients with a single condition
provided by a specialist team
• COPD main long term condition
• Support generic workforce in managing COPD in
community links with practice nurse
• Focus on 30 and 90 day follow-up – single
pathway
18. Community Clinics
• Diagnostic and therapeutic support to
practices
• Assist in case detection / diagnosis
• Follow up of exacerbations seen at home
• Advise in the management of “difficult”
problems
• Location Homerton Hospital
19. Education
• Support LES and Non LES practices in
providing direct education to the practice in
COPD.
• In practice join COPD Clinics with PN
• Named COPD Nurse links with Practice Nurse
• Direct Access to COPD Healthcare
professional – Via fax spirometry / phone
• Email Advice
20. Education - Challenges
• Key – self management
• Understanding and accepting diagnosis
• New diagnosis – where does it start?
• NICE 2010 Guidelines – update
• Rescue Packs
• Variety of inhaler choices – but why and MDI?
• Annual Reviews – making changes
21. Multidisciplinary working
– COPD care should be delivered by a multidisciplinary team that
includes respiratory nurse specialists & Specialist Ward Nurses
– Consider referral to specialist departments (not just respiratory
physicians)
Specialist department Who might benefit?
Physiotherapy People with excessive sputum
Dietetic advice People with BMI that is high, low or
changing over time
Occupational therapy People needing help with daily living
activities
Social services People disabled by COPD
Multidisciplinary palliative People with end-stage COPD (and their
care teams families and carers)
[2004]
24. Outcomes that matter
• Improved Survival
• Earlier and Accurate Diagnosis
• Improved Quality of Life
• Slower disease progression
• Reduced exacerbation rate
• Reduce hospital admission & re-admission rates
• High Quality End of Life care
• Patient centred quality care
25. What does patient centred
COPD care look like
Practice
nurse
Community
GP Matron
27. Key Messages to bottle up ..
• Earlier Diagnosis
• Smoking as treatment for COPD
• Responsible Prescribing
• Pulmonary Rehabilitation
• Responsible oxygen prescribing
• Living with advanced COPD
28. …but now what do with them?
• Recognise that there is fantastic
work already happening within
current work places.
• Integration across primary and
secondary care is key in
improving the patient pathway:
- join up working
- reduce repetition
- no silo working
- patient centred care
29. Quality COPD Service
• Proactive and opportunistic case finding to minimise the impact of late
diagnosis on individuals and the healthcare system
• Quality assured, accurate diagnosis and assessment of severity and ongoing monitoring
and review of the condition through a proactive chronic disease management model.
• People with COPD are screened, assessed and managed with
pharmacological and non-pharmacological interventions in line with
NICE/quality guidelines
• People with COPD are educated and supported in the management of their
condition so that they can become active partners in care.
• Effective prevention and management of exacerbations and of hospital
Admissions
• Effective palliative, end of life care and bereavement support for people with COPD
31. Many available..
• Contact your local COPD or
Respiratory Specialist within
your local hospital or
Community Health Services
• Explore the hospital or
community website – use
COPD as a search term
• Identify your oxygen champion
• Who is leading on
Pulmonary Rehabilitation
within your local area
32. National & Resources
• National Institute for Clinical Excellence – NICE 2010 Update Guidelines
for the management of COPD in primary and secondary care
• British Lung Foundation
• Primary Care Respiratory Society (PCRS)
• NHS Improvement Programme – Lung Work stream
• NHS London Respiratory Team
• IMPRESS (BTS and PCRS)
• Association of Respiratory Nurse Specialist
33. NHS London Respiratory Team
www.london.nhs.uk/what-we-do/improving-your-services/better-quality-services/london-respiratory-team
35. National COPD Project
• Prevent COPD readmissions
• In line with NICE guidance
– Self Management Plans
– Rescue Packs
• Antiobiotic: change in sputum colour
• Corticosteroid: ↑ breathless and/or wheeze
• Admissions 1º Δ of COPD Exacerbation
• NICE: all patients who have had an exacerbation OR are
at risk of an exacerbation should get a self mx plan &
rescue medicines
38. And finally…
Even after the
COPD Annual Review
with the Practice Nurse the next
day the patient presents to the
ED department and says…
40. Acknowledgements
Team
Dr A Bhowmik Respiratory Consultant
Jane Osei-Wusu COPD Clinical Nurse Specialist
Ailsa Dann COPD Clinical Physiotherapist
Arthur Tadique COPD SSN
Edmer Sayat COPD SSN
Aminata Gbla COPD SSN
Aziza Zina & Team Team Administrator
• Nancy Hallett – Chief Executive
• John Coakley – Medical Director
• Dylan Jones – General Manager for Medicine
• Louise Olley – Head of Nursing GEM
• Mervyn Freeze – Assistant GM
42. NECLES HIEC
• Reducing door to mask
time for type 2 respiratory
Lung failure
Improvement
Projects • Reducing readmissions
through provision of self
management packs
• Research to develop the
first COPD Patient
Reported Experience
PREMs Measure
• For sub- acute and
community dwelling
patients
• Benchmarking quality and
cost of COPD care across
A Year in the 4 boroughs in ONEL
Life • Providing targeted and free
training opportunities for
Primary Care Clinicians
43. A Year in the Life
Dashboards of COPD Training opportunities Building sustainable
quality care indicators delivered: changes through
circulated: Accredited spirometry networks:
Co- production of training, COPD Building awareness of
dashboards and masterclasses, Practice quality interventions
templates nurse mentorship in Making connections
Using data to drive COPD management & between teams
improvements spirometry clinics,
issuing self management Facilitating COPD leads
plans to continue improvement
process
44. Data dashboards
for smoking
status, severity of
disease, annual
reviews
performed
46. COPD training opportunities
• Accredited spirometry training
• Practice Nurse mentorship in COPD
management
• COPD masterclasses
• Performing the COPD annual review
and issuing a self management plan
• Consultant education sessions in
Practice