The Case for a COPD Discharge Bundle CQUIN in London

The case for a COPD discharge bundle CQUIN in London: recommendation of London Respiratory Team, implementing the national strategy for COPD

Why COPD in London?

London spends over £100m on COPD per year with an average of £5000 per year per inpatient with significant variation. In 2009/10 there was an average admission rate of 1.9 per 1000 practice population; the highest was in Tower Hamlets at 4.9. In Q1 2009/10 COPD was the second highest cause of emergency admission. In 2008-09 the total number of bed days or emergency hospital admissions for COPD as a primary diagnosis was 91,140. Average length of stay in London is 6.7 days ranging from 8.6 in Tower Hamlets to 4.9 in Hillingdon.

Nationally 13% of patients admitted to hospital with COPD die within 3 months and a quarter die within a year of admission. It is this significant unwarranted variation and use of urgent care which the COPD and asthma outcomes strategy (“the Strategy”) aims to address and which the NHS London Respiratory programme intends to reduce in London.

Why discharge?

Admitted patients are the most needy and vulnerable group of COPD patients and need the application of evidence-based care to improve their quality of life and reduce readmission. A systematic approach such as a care bundle ensuresthat all patients, including those not on respiratory wards get the specialist advice they need before discharge. Patients discharged from hospital following an exacerbation of COPD have high levels of deconditioning, depression (64%) and anxiety (40%) and uncertainty that drives help-seeking behaviour. Therefore there is a need for significantly improved hospital discharge procedures that can then be picked up by the community services through the provision of the services the patient is assessed for in hospital such as stop smoking; pulmonary rehabilitation and encouragement of self-management strategies[1][i]. This is reinforced in the Strategy.

Why a bundle approach?

The Strategy includes a number of evidence-based recommendations. The bundle incorporates the important ones to improve patient safety and quality of care by acute trusts. These bundles have been in use for two years in three London acute trusts: Imperial, North West London and St Georges following a systematic literature review by CLAHRC. The CQUIN was taken up by the hospitals within these trusts plus Kingston and the Whittington hospitals last year. The bundle should be used and applied to every patient admitted with an acute COPD exacerbation for over 48 hours, coded in primary or secondary position] whether on a respiratory ward or acute medical assessment unit or other medical wards. It should be personalised to the individual – not all components are needed for everyone. In this way it has the power to change clinical behaviour and achieve sustainable change. It is simple to use. And there is now a dedicated website where a recent peer-reviewed paper can be downloaded, as well as updates: It was also a finalist in the Health Service Journal Awards 2011.

Why a CQUIN?

The bundle[2] is a major step-up in care, but will only have a meaningful impact if it is implemented across a trust, requiring clinical leadership and management intervention. The CQUIN provides the right incentive to prioritise this. It is also a light-touch approach as it incentivises improvements in at least five evidence-based interventions. And whilst the ultimate aim is to keep people out of hospital as much as possible, hospitals will continue to care for many people with COPD because it is a progressive, terminal disease that can cause frightening breathlessness and also because there remain many undiagnosed people living in the community. Therefore a hospital CQUIN is valid.

What is the bundle proposed?

(i) Referral to smoking cessation service if a current smoker; (ii) Assessment of suitability and/or enrolment into a pulmonary rehabilitation programme; (iii) Have appropriate education, written information, self management plans and rescue packs for future exacerbations; (iv) Ensure that patient understands their medications and has demonstrated good inhaler technique whilst on the wards; (v) Ensure that they have appropriate follow up once discharged from hospital. These five elements are included in a checklist – see appendix. The checklist can be printed onto sticky labels that can be stuck into the person’s notes, completed by the clinician – eg the respiratory nurse specialist, before discharge and easily located by the coder.

Numerator: Number of patients admitted for more than [48 hours] with code:
J44.0Chronic obstructive pulmonary disease with acute lower respiratory infection OR

J44.1Chronic obstructive pulmonary disease with acute exacerbation, unspecified

in first or second position and are discharged with a completed care bundle (see note)

Denominator: Number of patients admitted [for more than x days] with ICD10 code J44.0 or J44.1in first and second positions.

Payment threshold: 75% in year one 2011/12 and 95% in year two 2012/13.

The bundle can be altered for local usage and can be updated into a collection tool with ease.

Appendices include example of patient checklist, and also clinician checklist

S Williams L Restrick

12 December 2011

Note:

Last year we used HRG code but because respiratory failure goes to a different HRG code, we’ve concluded that J44 is better. We discussed whether it should be just in primary position but concluded, from national data that you’d miss cases as some put dyspnea in primary position as presenting symptom. Would have missed 2,900 cases of COPD nationally. Some trusts would miss hardly any, as they properly follow the coding principle of putting the main condition to be treated in first position. Also, the point is, that this raises the bar by saying whether COPD is primary or secondary cause of admission, the person should have the discharge bundle. The final point is that ideally, we’d move to using the electronic patient record. However, the Audit Commission still regard medical notes as the gold standard. Therefore all elements of the bundle need to be recorded in the medical notes. The “sticky” makes this easier.

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Patient checklist (page 2 and sticker for staff page 3)

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Patient checklist (page 2 and sticker for staff page 3)

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[1]Gruffydd-Jones K et al. What are the needs of patients following discharge from hospital after an acute exacerbation of chronic obstructive pulmonary disease (COPD)? Prim Care Resp J 2007;16(6):363-368.

[2]this is an NINR CLAHRC for NW London development