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How to manage… exacerbations

of COPD, asthma &… in hospital

Delivering high value integrated care

with KREDIT? Dr Louise Restrick, NHS London Respiratory Team Lead

Consultant Respiratory Physician, Whittington Health & NHS Islington

Improving Outcomes

Right Care Doing the right things and doing things right

Right diagnosis including severity

Addressing respiratory failure and breathlessness

Structured admission & care planning conferences?

Value framework

KREDIT

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Patients present with breathlessness…

Frightening … and disabling

Clinicians focus on respiratory failure

Aligning and sharing

agendas…

Frightening !!!

Breathlessness and hypoxaemia

pathways of care

Breathlessness

Hypoxaemia

=

Low oxygen saturation

Breathless

with normal

oxygen

saturation

Low oxygen saturation

but not breathless

Present to ED

Breathless

and low oxygen saturation

Care at home?

Respiratory failure

treatment in

hospital

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Right Care for Respiratory Failure

Getting the diagnosis right Exacerbation is not the same as pneumonia …

Assessing severity and prognosis …

Getting oxygen therapy right High flow O2 increases mortality - from 7% to 11%*

Using Non-Invasive Ventilation

appropriately 11% given NIV had metabolic acidosis…*

* Roberts et al NCROP Thorax 2011:66;43-48

Right Care for Respiratory Failure

…NOT EASY

Need clinicians with

respiratory diagnostic

& treatment knowledge,

skills & expertise

Appropriate NIV halves mortality due to respiratory

failure in acute exacerbations of COPD

from 20% to 10%

Getting it right saves lives

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Value Framework

Health

Outcomes Patient defined

bundle of care

Cost Value =

Health Outcomes

Cost of delivering

Outcomes

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

NB Outcomes as defined by patients & their families So we have to ask & listen …

What patients & families tell us…

‘I don’t want to die’

‘breathlessness is frightening and

disabling’

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Right Care for disabling

breathlessness…NOT EASY

Need long term condition

clinicians with behaviour

change & motivational

interviewing skills

To deliver evidence-based support for patients

to stop smoking as treatment for sick smokers

To enable patients to

benefit from pulmonary

rehabilitation

Kindness

Respect

Empathy

Dignity

Interest

TRUST

KREDIT* Respiratory Teams’ Shared Values …

*Whittington Health, London Respiratory Team and …

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COPD ‘Value’ Pyramid What we know…. Cost/QALY

Support to stop smoking

is key TREATMENT for

sick smokers …

Where are the sick

smokers?

… in our hospital beds

Triple Therapy

£35,000-£187,000/QALY

LABA

£8,000/QALY

Tiotropium

£7,000/QALY

Pulmonary Rehabilitation

£2,000-8,000/QALY

Stop Smoking Support with pharmacotherapy £2,000/QALY

Flu vaccination £1,000/QALY in “at risk” population

Is current smoking an issue in COPD?

2010 ERS Audit

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Effect of smoking on hospital

admissions for COPD and

asthma ….and???

For every 1% increase in prevalence of smoking in your COPD

population there is a 1% increase in COPD admission rates

For every 1% increase in prevalence of smoking in your asthma

population there is a 1% increase in asthma admission rates

Emergency respiratory admissions: influence of practice,

population and hospital factors Purdey S et al

J Health Services Research Policy 2011;16:133-40

Changing how we think about smoking

Tobacco dependence

Sick smokers are admitted to hospitals - acute and psychiatric

Evidence based quit smoking treatment is the most important

treatment for sick smokers:

Behaviour change support and quit smoking medication

‘Smoking kills, stopping works’ Sir Richard Peto 2012

Delivering value in tobacco dependence

Top 10 Questions …

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Does your hospital have a BTS Quit

Smoking Champion lead?

Do your consultants believe that Quit

Smoking treatment is high value for their

patients?

Does your hospital provide NRT

routinely on admission for smokers?

Are your hospital staff able, & confident

to, prescribe Quit Smoking medication?

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Do you have a Quit Smoking service for

patients and staff in the hospital?

Do your hospital staff know your Quit

Smoking advisors and refer to them?

Services Offered:

• Outpatient Quit Smoking Clinics: for patients and staff

• Inpatient Assessment for Quit Smoking Support

• Special Clinics – Pre-operative Assessment & Maternity Support for smokers to quit

Do your hospital staff routinely offer

‘Very Brief Advice’ to every smoker?

Online training module

WWW.NCSCT.CO.UK/VBA

‘This training is relevant to anyone who comes into

contact with smokers… GPs, practice nurses, hospital

doctors, pharmacists & other healthcare professionals.

… certificate on successful completion to provide

evidence of continuing professional development

(CPD).’

Do your hospital staff have and use behaviour

change skills to support smokers to stop?

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Do your hospital decision makers

believe that Quit Smoking treatment is

high value for patients and staff?

Do your commissioners believe that

Quit Smoking treatment is high value

for patients and staff?

Developed by CLARHC Hopkinson et al Thorax 2012:67:90-92

Increasing the value of care in COPD

COPD Discharge Bundle

Pre Bundle %

With Bundle %

18 100

14 68

55 98

59 91

41 39

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Developed by CLARHC Hopkinson et al Thorax 2012:67:90-92

CQINS to incentivise high value care

2011

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One story from a respiratory ward 50+ year old man

Schizophrenia since 20s

Tobacco addiction: 60 pack-years

Cannabis addiction:100 joint-years

Severe COPD

Lives alone, isolated, not working

13 admissions and 112 bed-days in 2 years

Further emergency admission: ‘Unable to breathe’ & severe

(acute on chronic type II) respiratory failure …

Due to exacerbation/worsening of severe COPD & smoking

tobacco and cannabis ie sick smoker

Treated on respiratory ward including non-invasive ventilation

& quit smoking interventions …

Disabled by breathlessness

Scared to use lift to his xth floor flat

Too breathless to go up stairs indoors

Sleeping on piece of foam under stairs

Electricity had been turned off

50+ year old man

What he told us mattered to him

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High risk of premature death

Current care model not working

Under-treated schizophrenia preventing respiratory treatment

Untreated tobacco and cannabis addiction

Unsafe home situation

Bed-days +++

Respiratory team: physician, ward sister, nurse specialist,

physiotherapist, occupational therapist, quit smoking advisor

Mental health team: care co-ordinator, dual diagnosis specialist,

psychiatrist invited but unable to attend

Housing officer

Patient

Care Planning Conference

why and who

Londoners dying from smoking

‘1 in 5 deaths due to smoking’

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Identified care and treatment gaps and needs

Named actions and responsibilities

No social worker...

Smoking as tobacco addiction NOT a life-style choice

Anti-psychotics safe – regular depot injection given

Community respiratory support at home

Common needs assessment by mental health team

Rehoused to supported ground level accommodation

Care Planning Conference:

what

Person-centred integrated care

• Alive

• Ground floor warden controlled flat

• Mental health good, goes out regularly

• Still smoking but much less

• Supported at home by GP, warden, mental health

team and community respiratory team as needed

• Mostly telephone follow-up

• No admissions in 2012 or since …

Integrated care: care planning conference

Outcomes for 50+ year old man

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Respiratory Physician

Respiratory

Nurse

Specialist

Mental

Health

Key

Worker

Quit

Smoking

Advisor

Person-centred integrated care in hospital

Care planning in out-patients too

Delivering high value care for exacerbations

of …LONG-TERM conditions in hospital • Workforce with the right competencies and interests

– Respiratory knowledge, skills and expertise

– Long-term conditions interest and expertise

– Behaviour change and motivational interviewing skills

• Design pathways around exacerbations of LTCs not episodes

– Acute medical assessment unit model does not work for these patients!

• Structure to admission – green days not red days

– Safe respiratory failure care

– Quit smoking support & medication as treatment for all sick smokers

– COPD discharge bundle interventions

– Diagnose & optimise care of all underlying long-term conditions

• Levers – CQINS, measure value outcomes

– Mortality & days at home in year or bed-days/year

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A respiratory provider manifesto

I am a long term conditions clinician

I care about value

I know how to assess and support patients

and drive improvements

I work in a team

I personally deliver high value care