This report is the second in the current round of the 2014 secondary care component of the national Chronic Obstructive Pulmonary Disease (COPD) audit and covers the description of clinical care in the acute hospital setting. It builds on the experiences of the three previous audits since 1997 and it reflects not only the performance of the hospital services but also the generally improving long‐term care for patients with COPD.
Key recommendations
We suggest that these recommendations are discussed carefully at departmental/trust board/clinical commissioning group (CCG)/health board level, and within local respiratory programme groups.
For commissioners
- Oxygen prescribing should be linked to local/national care quality initiatives (CQUINs).
- The provision of hospital smoking cessation services should be linked to local/national CQUINs.
- Hospitals, CCGs and health boards should review the availability of their early/supported discharge services for COPD patients; these schemes should extend their service to cover weekends.
- Hospitals, CCGs and health boards should clarify and formalise their pathways to improve referral to early/supported discharge teams and community pulmonary rehabilitation programmes; respiratory specialists should take a lead in this process.
For providers
- To improve access to specialist care (performance against NICE QS 10, 11):
- Patients admitted with COPD exacerbation should receive a respiratory specialist opinion within 24 hours, 7 days a week.
- Hospitals should appraise carefully their staff rosters at weekends and on Mondays, the former having the lowest rate of discharges and the latter having the highest rate of admission and the longest times to clinical review.
- Patients with COPD exacerbation who need onward hospital care after their stay on the medical admissions unit should be managed in a respiratory ward. Hospitals should reappraise their complement of respiratory beds to ensure that it reflects their size and respiratory/COPD admission burden.
- To improve the recording of key information and hence onward care (performance against NICE QS 1, 8, 10, 11 and BTS emergency oxygen/BTS NIV guideline), the following should be noted at admission, ideally as part of an admission care bundle:
- Confirmation that the patient has a COPD exacerbation on the basis of symptoms and spirometric evidence.
- The presence or absence of consolidation on the chest X‐ray (treatment for pneumonia should commence if there is consolidation).
- The estimated Medical Research Council (MRC) breathlessness score in the weeks prior to the current exacerbation.
- The initial oxygen saturation, alongside confirmation that oxygen has been prescribed and titrated to a target saturation.
- The blood gas analyses components of the DECAF (Dyspnoea, Eosinopenia, Consolidation, Atrial Fibrillation) score (10) – this could usefully become an integral part of the admission documentation for patients with COPD exacerbation, just as the CURB 65 score is for pneumonia.
- To improve the management of respiratory failure – oxygen (performance against NICE QS 8, 9, 10, 11 and BTS emergency oxygen guideline):
- Units should ensure that they have a mandatory, rolling training programme in place to support better prescribing and titration of emergency oxygen therapy. The training programme should extend to all medical and nursing staff, and should be a core topic within junior doctors’ induction programmes.
- To improve the management of respiratory failure – NIV (performance against NICE QS 10, 11 and BTS NIV guideline):
- Units should ensure that a written proforma is deployed for patients receiving NIV. The proforma should provide fields in which to record the time and value of each blood gas, the time of NIV application and NIV pressures. It should be freely available wherever NIV is used. The NIV proforma should be demonstrated as part of junior doctors’ induction programmes.
- Patients requiring NIV should have access to level 2 care; there should be at least one staffed level 2 bed on the respiratory ward, dependent upon demand and the size of the hospital, in which NIV can be administered according to accepted clinical guidelines.
- To improve the recording and documentation of spirometry (performance against NICE QS 1, 2, 3, 10):
- All hospitals/units should make spirometry results, normally available on lung function laboratory software, accessible from every computer desktop via their IT department’s browser system/intranet.
- All admission units and respiratory wards should have a basic portable spirometer as part of their standard equipment.
- All hospitals/units should introduce mandatory training for key health professionals to ensure that the measurement/recording of spirometry is understood and undertaken, when National COPD Audit Programme: Clinical audit of COPD exacerbations admitted to acute units in England and Wales 2014 appropriate, as part of routine practice.
- To improve the administration of smoking cessation advice (performance against NICE QS 5):
- All hospitals/units should have a fully funded and resourced smoking cessation programme delivered by dedicated smoking cessation practitioners.
- To improve the coordination of care at discharge, and hence onward care, hospitals/units should ensure that their discharge information contains the following information, ideally as part of a discharge care bundle (performance against NICE QS 1, 5, 6, 12):
- MRC breathlessness score in the period prior to admission
- latest spirometry (date and value)
- body mass index (BMI)
- evidence of any decision made around escalation of care, and who has been involved in that decision
- evidence that smoking cessation support has been given to current smokers
- evidence that a pulmonary rehabilitation referral has been made, or is considered inappropriate at the present time
- identification of those with type 2 respiratory failure who are at risk of oxygen toxicity (and confirmation that an oxygen alert card has been issued)
- clear evidence that follow‐up has been arranged (hospital team, community team, GP).