Areas for improvement highlighted in the 2008 COPD audit are analysed and their implications for nurses, healthcare providers and patients are examined
Samantha Prigmore, MSc, BSc, RGN, is respiratory nurse consultant, St George’s Healthcare Trust; Nancy Pursey, BSc, is national COPD audit 2008 project manager, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London.
Prigmore, S., Pursey, N. (2009) Exploring the outcomes and implications of the latest national COPD audit. Nursing Times; 105: 38, early online publication.
Publication of the clinical strategy for COPD is expected at the end of the year and it is anticipated that this will provide a structure to improve management of the condition. The latest national COPD audit has shown that although services have improved since the last audit in 2003, there are key areas in COPD management that need to be improved. This article analyses the results of this audit and the implications for practice.
Keywords: COPD, Audit, Service improvement
This article has been double-blind peer-reviewed.
- People with COPD need information about their condition at all stages of the disease.
- Managed clinical networks need to be developed to ensure care is integrated.
- Patients need accurate assessment during acute exacerbations with access to hospital avoidance/early discharge schemes.
- Staff caring for patients who require non-invasive ventilation need ongoing education and updates.
- Links must be developed with palliative care services to ensure patients with COPD receive timely and appropriate symptom control and discussions about their views on end of life care.
The third national COPD audit was produced by a partnership between the Royal College of Physicians, British Thoracic Society and the British Lung Foundation and was funded by The Health Foundation (RCP et al, 2008). It has shown that care for patients with COPD has improved since the previous audit in 2003 (RCP and BTS, 2003). There has been an expansion of services and there is evidence that best practice guidelines (NICE, 2004) are being implemented across primary and acute care.
The audit has also highlighted that in some areas guidelines are not being followed, for example, the use of non-invasive ventilation (NIV) during an acute exacerbation of COPD. There are also inequalities in care for people during the terminal phase of illness and limited information available for patients about COPD services including end of life care.
The national COPD audit
All acute trusts in the UK were invited to participate in the audit, which includes:
- An audit of resources and organisation of care in acute units;
- A clinical audit of up to 60 cases admitted to hospital with an exacerbation of COPD during March-May 2008 including 90-day clinical outcomes.
The resources and organisational audit collected general data with more specific quality indicators for NIV, pulmonary rehabilitation, early discharge and oxygen services. Data on palliative care was also collected.
Thirty patients from each of the participating organisations were asked to complete an anonymous survey and hospital teams also sent a questionnaire to GPs of the first 30 audited patients admitted with a COPD exacerbation.
Primary care organisations (PCOs) were invited to participate in the audit and surveyed on the resources and organisation of care for people with COPD within their area. The audit’s aims are outlined in Box 1.
Some 98% of acute trusts and 73% of PCOs in the UK participated in the audit. Data included over 9,700 cases of COPD exacerbations, 2,800 patients and 2,700 GPs. Five reports have been produced (Box 2).
Box 1. Aims of the national COPD audit
The audit aimed to:
- Enable participating units to compare their performance against national standards;
- Identify resource and organisational factors that may account for observed variations in outcome;
- Facilitate improvement in quality of care;
- Identify changes since the 2003 national COPD audit (RCP and BTS, 2003);
- Collect data about the resources and organisation of COPD services in primary care organisations across the UK.
Box 2. National COPD audit reports
- Resources and Organisation of care in Acute NHS Units across the UK
- UKPrimary Care Organisations: Resources and Organisation of Care
- Clinical Audit of COPD Exacerbations Admitted to Acute NHS Units across the UK
- Patient Survey
- Survey of COPD Care within UK General Practices
The reports are available at tinyurl.com/copd-audit-2008
Implications for COPD services
The results of the 2008 audit identified an overall improvement in COPD services compared with the previous audit in 2003 (RCP and BTS, 2003). See Table 1.
Table 1. National COPD audit 2008 compared with 2003 results
|Service||2003 national COPD audit||2008 national COPD audit|
|Early discharge schemes||44%||59%|
Acute units and PCOs were asked to identify COPD services available or in the developmental stages (see Table 2). The results suggest that COPD services are high on PCOs’ long term conditions agenda.
Table 2. Acute unit and PCO responses to COPD service availability/development
|Service available or in development||Acute unit response||PCO response|
|Early discharge scheme||59%||90%|
(within early discharge scheme)
|Long term oxygen assessment||76%||97%|
|Formal referral pathway to palliative care||66%||78%|
NIV is an effective method of treating acidotic respiratory failure, and is recommended as the first choice of treatment for persistent hypercapnic respiratory failure associated with COPD exacerbations (NICE, 2004). It can decrease mortality and the need for intubation (Ram et al, 2003) and results in fewer complications when compared with usual care (Ram et al, 2003). It is also associated with reduced length of hospital stay (Peter et al, 2002).
Traditionally this method of ventilation had been provided in intensive care or high dependency areas but it can be safely delivered in general medical wards (NICE, 2004; BTS, 2002; Plant et al, 2003).
The audit found that 20% of the clinical cases presented in acidotic respiratory failure, with a further 7% developing it while in hospital. This suggests that over one-quarter of admissions with a COPD exacerbation need ventilatory support but only 12% receive it.
The results highlight that only 15% of the decisions not to escalate treatment to ventilation were taken by a respiratory consultant and in 11% of cases the decisions were taken by very junior medical staff.
Ongoing training for all staff involved in caring for patients receiving NIV was poor. Some 48% of organisations did not meet the audit standards in full and less than half (46%) had locally adapted written protocols for managing patients with COPD who need NIV.
Long term oxygen therapy reduces mortality in patients with COPD (Medical Research Council, 1981). Oxygen guidelines (BTS, 2006; RCP, 1999) give clear guidance on when oxygen should be prescribed and recommend that an assessment should be carried out before prescribing long term oxygen therapy, including ambulatory oxygen.
The audit identified that follow up arrangements recommended in the BTS (2006) guidelines for patients receiving long term oxygen therapy and ambulatory oxygen were poor (56% and 41% respectively) in acute units. Only 58% of acute units provide written information for patients receiving home oxygen.
Pulmonary rehabilitation is a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise patients’ physical and social performance and autonomy (NICE, 2004).
The NICE (2004) COPD guidelines recommended that pulmonary rehabilitation should be offered to patients who consider themselves functionally disabled by COPD. Rehabilitation can lead to statistically significant improvements in health related quality of life, exercise capacity and also reduce dyspnoea (Lacasse et al, 2006; Ries et al, 1997).
The national COPD audit set 11 quality standards, with many units meeting them all in full, suggesting high quality programmes. Only 49% of units undertake an annual audit of the service, including numbers of patients attending and patient satisfaction.
It is important that patients continue to exercise if they are to benefit from the effects of pulmonary rehabilitation, but only 30% of units provide a programme to facilitate ongoing exercise run by trained staff in the community.
Early discharge schemes
Evidence suggests there is no difference in the length of an episode of care between patients in early discharge schemes versus staying in hospital (Ojoo et al, 2002; Davies et al, 2000). Readmission rates and mortality rates are similar (Cotton et al, 2000) and therefore early discharge schemes can be seen as a safe way of caring for selected patients with COPD (Ram et al, 2004).
In the UK there has been an increase in admission avoidance schemes, which involve assessing patients by a multidisciplinary team to determine if admission to an acute hospital is necessary. There is limited evidence to support this practice.
The audit found an increase in the number of units providing a high-quality early discharge scheme, up from 44% in 2003 to 59% in 2008. Forty-one per cent of units are not able to offer home care as an alternative to hospital care.
The majority of schemes are run by respiratory nurse specialists (85%). Some units (36%) with an early discharge scheme offer admission prevention and 56% offer rapid discharge within 48 hours. However, only 24% offer a seven day service with the majority providing the service for five days a week.
Again, written information for patients and carers is poor with only 39% of units meeting the full quality standard for this.
COPD has a long disease trajectory and patients experience symptoms that are often difficult to control. It is difficult to predict when an individual may be reaching the terminal phase of the disease and therefore end of life discussions are often avoided and only occur during an acute event.
The audit results identified that only 13% of units provide information about end of life care when patients are in a stable state. This suggests that sensitive discussions about care and treatment wishes are addressed when patients are acutely unwell or not at all.
Palliative care services are ideally placed to help plan end of life care. Patients with COPD are likely to have less access to specialist supportive and palliative care than those suffering from lung cancer despite having similar symptoms and death rates (Varkey, 2006; Gore et al, 2000). The audit found that under half of acute units (49%) have a formal referral pathway to palliative care services.
Patients with COPD should benefit from improved access to palliative care services recommended in the end of life strategy (Department of Health, 2008). The audit identified that 66% of participating acute units planned to develop or improve palliative care services in the future.
Management of acute exacerbations
An exacerbation is a major event in the natural history of COPD and can have a negative effect on prognosis.
The audit results captured events leading to an exacerbation and treatment patients received following admission to hospital.
Before admission, 90% of patients were known to have COPD, and the data obtained via the GP survey suggests these patients had frequent exacerbations and were regular users of primary care resources in the 12 months before admission. Some 31% attended the GP surgery three or more times in the month before an admission to hospital and 74% attended once.
Sixty seven per cent of hospital units have local guidelines for assessment, 75% for treatment, but only 45% for follow up after discharge.
Results from the previous audit (RCP and BTS, 2003) demonstrated high morbidity and mortality associated with an exacerbation requiring hospital admission. Inpatient mortality was 7.5%, 31% of patients were readmitted and 15.5% died within three months. There has been little change since 2003 in the inpatient mortality (7.7%), but overall mortality rates at three months have reduced to 13.9%.
It is clear there have been improvements in inpatient care with an increase in speciality respiratory wards. A respiratory specialist healthcare worker now sees 78% of patients during admission.
Patient experiences of COPD
The patient survey, based on a group admitted or recently discharged with COPD exacerbations, found 83% report frequent exacerbations, with 68% experiencing a respiratory infection or flu- like symptoms in the month before admission to hospital. Some 57% noticed a change in phlegm colour/volume before admission.
This suggests there is a lead-in phase to an exacerbation that provides opportunities for early intervention such as self management, which may help to reduce the impact and shorten length of the exacerbation. However, only 23% of patients had a written plan for self management and 24% had a supply of antibiotics and corticosteroids to administer at home.
Over half (57%) said they were able to seek advice over the phone from their GP, respiratory nurse or hospital doctor. Hospital admissions are common, with 60% reporting they had been admitted in the previous year and 66% felt they would still have needed to be admitted even if they had more help at home.
COPD management is provided by a combination of hospital clinics and patients’ GP surgeries and appears to be relatively poor as they are not receiving regular check ups. Only 55% of patients have regular check ups in primary care and 42% in acute care.
The DH is developing a national clinical strategy for COPD, due to be launched later this year. It will provide a structure to drive forward management of COPD from prevention and early detection, to managing acute and stable phases, through to end of life care.
It is clear that services for patients with COPD need to span both primary and secondary care, and integrated care is needed to overcome some of the discrepancies in services provided in acute units and PCOs (Table 2).
The national clinical strategy is likely to recommend that managed clinical networks are introduced to encourage joined up planning and provision of COPD services, ensuring equitable and cost effective treatment options delivered by a competent and experienced team.
We would like to thank the members of the steering and implementation groups, participants and patients.
- COPD is a common and often undiagnosed condition. Its symptoms can significantly affect patients’ quality of life and interventions have been proven to reduce morbidity and mortality
- The condition has economic implications, mainly due to hospital admissions which may be avoidable.
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