Improving adult asthma care: Emerginglearning from the national improvementprojects

NHS Improvement - Lung: National Improvement Projects

NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Foreword by Professor Martyn PartridgeProfessor of Respiratory Medicine, Imperial College London and Senior ViceDean, Lee Kong Chian School of Medicine, Singapore (A joint school byImperial College London and Nanyang Technological University)

IntroductionThe case for improvement work and a summary of the emerginglearning from the sites

Case studies

Acute Trusts

Guy's and St Thomas' NHS Foundation TrustReducing re-attenders at Accident and Emergency

Mid Yorkshire Hospitals NHS Foundation TrustAsthma Care Bundles

University Hospital of North Staffordshire NHS TrustAn Integrated Care Pathway for Accident and Emergency

Community Respiratory Teams

Sandwell Community Respiratory TeamReducing admissions and increasing community support

Clinical Commissioning Groups and Primary Care

Durham Dales Clinical Commissioning GroupPharmacists and Medicines Use Reviews

ESyDoc Clinical Commissioning GroupAn integrated approach to asthma care

NHS South West Essex Primary Care TrustTargeted Medicines Use Reviews through a Local Enhanced Service

References

Acknowledgements

Contents

NHS Improvement - Lung National Improvement Projects -Improving adult asthma care: Emerging learning from thenational improvement projects

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3CONTENTS

Martyn R Partridge

FOREWORD4

Foreword

At a time of financial stringency, itis important that we deliver care inthe most cost effective mannerand this will often involve usthinking outside the box andassessing new methods ofdelivering care. When doing so it isimportant that a full needsassessment is undertaken and thatall stakeholders are involved andwhere ever possible the innovationhas to be undertaken with a clearexpectation that the enhancementwill be extrapolable, deliverable,and sustainable.

In the first round of the NHSImprovement - Lung asthmaprojects, colleagues have shownremarkable innovation,perspicacity, and above alldetermination to improve the carewhich they are delivering to theirpatients with asthma.It is inevitable that over the years anumber of asthma projects havehad varying degrees of success, for

if there were one simple answerwe would have implemented itsome time ago. However, I havefound the observation of theseprojects at this mid-point stage tobe incredibly stimulating andinvigorating, and I congratulate allwho have been involved in thiswork. I look forward to the projectend in the summer when the fullextent of the learning can beshared.

Martyn R PartridgeProfessor of Respiratory Medicine,Imperial College London andSenior Vice Dean, Lee Kong ChianSchool of Medicine, Singapore (Ajoint school by Imperial CollegeLondon and NanyangTechnological University)

Martyn R Partridge

5INTRODUCTION

Background – the case forimprovementAsthma is a respiratory conditionwhich affects between 3 and 5.4million people in the UK(Department of Health OutcomesStrategy for Chronic ObstructivePulmonary Disease and Asthma:2011) with approximately 80% ofthose being over 18 years of age(Asthma UK). It is characterised byinflammation of the airways leadingto acute episodes known as‘attacks’. These exacerbations canoften be managed by the patientthrough medication and lifestylemodification but from time to timecan require treatment in Accidentand Emergency or an admission tohospital. In 2008/09 there were 49054 emergency adult admissions forasthma at a cost of £61 million tothe NHS, however it is currentlyestimated that three quarters ofthese are preventable (Right CareAtlas of Variation: 2011).

Because asthma symptoms havemany similarities with otherrespiratory conditions there is oftendual or misdiagnosis with otherillnesses such as COPD. Asthma istreated through a mixture of inhaled‘preventer’ steroids which are takenon a constant basis and ‘reliever’bronchodilators which are inhaled inthe event of worsening symptoms.Due to the plethora of drugs anddifferent combinations available forrespiratory patients the cost (and

Introduction

waste) to the NHS of these types ofmedications in the UK is high.Unlike COPD, asthma is not acondition in which patients willdeteriorate over time, butunfortunately it cannot yet be cured.With optimal self-management thegoal for nearly all people withasthma should be to lead a normal,healthy and active life, but this relieson a partnership approach betweenthe healthcare professional and thepatient in order to be trulysuccessful. The Outcomes Strategyfor COPD and Asthma (DH: 2011)noted that asthma is a conditionwhich is very poorly controlled. Italso highlighted the high number ofpreventable admissions and lack ofadherence in published guidelines(the gold standard is the BTS- SIGNAsthma Guideline: 2011), despitethe UK being a world leader in thisfield.

The aim of the NHS Improvement –Lung asthma work stream is to testwhich interventions have the biggestimpact on patient outcomes andexperience. This will help to ensurethat people with asthma aremanaged optimally in both primarycare and secondary care, to improvepatient outcomes and reduce thedemands placed on emergency care.

The improvement workIn May 2010, NHS Improvement –Lung invited NHS organisations towork in partnership on projectsdedicated to improving the asthmapatient pathway and to help addressthe variation in care that patientsreceive. Projects plans weresubmitted from a number of sitesincluding acute Trusts, primary careTrusts (PCTs) and communityorganisations to work in four keyareas of the pathway: improvingasthma diagnosis and medicinesoptimisation, transforming acutecare, chronic disease managementand integrated care.

The primary aims of the projects inthe national work stream are to:

• Define the patient’s pathway• Identify and reduce variation in thedelivery of care

• Challenge the system and test thecomponents of care that lead toconsistent and effectivemanagement of the condition

• Identify the success principles thatother organisations and teamscould learn from and adopt.

6 INTRODUCTION

During the ‘testing’ phase of theprogramme, project teams areexploring the reality of making thishappen by taking stock of currentpractice and understanding theprocess of implementation to ensurepatients receive optimal care in achallenging environment. Prior tocommencing the work, the projectsites have been required to establishtheir service baseline throughanalysis of local qualitative andquantitative data and to understandthe variation in services and quantifythe aims they are working towards.The project teams were trained inservice improvement tools andtechniques including the ‘model forimprovement’ methodology andheld local events to process maptheir current pathways.

At this half-way point the teamshave begun to remove duplicationand waste from the pathway orspecific processes through differentways of working and serviceredesign. They are testing small scaleinnovations using a Plan, Do, Study,Act (PDSA) approach and aremeasuring productivity gains on amonthly basis to identify the impactof the improvements. During thefinal six months the sites willcontinue to evaluate, learn andretest to refine models of care.

COMPONENTS OF CARE THE WORKSTREAM IS TESTING

1. Supportive self-managementHypothesis: A written self-management plan with ongoing supportincreases a patient’s ability to better self-manage by providinginformation on what to do when feeling unwell to mitigate symptomescalation. This should lead to better patient outcomes, more patientcontrol when exacerbations occur and reduced need for a GPappointment or an attendance at a hospital.

Testing sites: All

2. Medicines Use Reviews (MURs) by appropriatelytrained pharmacistHypothesis: The MUR ensures optimal treatment and effective use ofmedication with the patient. This should reduce medicines waste andspend as well as improving patient outcomes and reducing the needfor emergency primary or secondary care interventions.

Testing sites: Durham Dales, NHS South West Essex

3. Defining and standardising care in the pathway accordingto the BTS-SIGN GuidelineHypothesis: The standardisation of care according to nationalguidelines in an acute setting supports patient safety and quickerpatient recovery from illness which reduces the risk of re-attendanceor readmission.

Testing sites: ESyDoc, University Hospital of North StaffordshireNHS Trust, Mid Yorkshire Hospitals NHS Foundation Trust, Guy'sand St Thomas' NHS Foundation Trust

4. Access to assessment and reviewHypothesis: Patients who receive education in self-management fromclinically trained staff who have training in asthma are able to self-manage more effectively and this will reduce the need for additionalprimary care appointments and potentially reduce emergencyattendances and admissions.

Testing sites: All

7INTRODUCTION

Summary of emerging learningThe emerging learning from theproject sites to date demonstratessome of the practical challengesaround implementing thoseelements of good asthma care thatwe already know to be effective.This highlights not only what worksand how people are doing it, butalso what barriers still exist andwhere we still need to find solutionsto enable people to adopt bestpractice.

• Data is essential for improvementand there is plenty of dataavailable to understand the currentcircumstances and drive change.However, it is important to taketime to identify what data aremost useful and to understand thebest way to present and use theinformation. Consistentlyrecording and collecting relevantdata is also needed to allowmonitoring of the impact ofchanges in care and to highlightany areas to target interventionswhere appropriate.

• Managing a condition such asasthma successfully often requirespatients to draw on both primaryand secondary care. Testing sitesare broadly supportive of theemerging principle that integrationbetween services is one way tomaximise use of local resourcesand manage patients moreeffectively, however there are stillbarriers around the practical stepsneeded to help organisations workmore closely together.

• There is significant variation in thedelivery of care and theconfiguration of and access toasthma care services around thecountry. One example of this wassignificant disparity in proactivefollow up by GPs following receiptof discharge summary issued fromthe acute Trust (which in itselfvaried from within 24 hours totwo weeks), which ranged fromevery patient to none.

Every pathway contains differenceswith varying adherence to the bestpractice national recommendations,for example some GP practices inthe projects supply limitless repeatprescriptions, others only supplyone script to those patients whoare overdue for review and thenno more until a healthcareprofessional has seen the patient.

Defining the current pathway withany issues or gaps is essential tounderstanding the current state ofthe local services and along withdata provides the foundation forfuture improvement work.

• Standardised care – for example,through the use of templates,proformas, care bundles, CQUINs(Commissioning for Quality andInnovation payments) andpathways – is strongly advocatedby all the project sites as apotential solution to variation inthe management of asthma anda way of improving patientoutcomes and experience of care.

• There is recognition amongstboth primary and secondary careclinicians that there are manyopportunities for meeting theproductivity and preventionagenda whilst improving thequality of services and outcomesfor asthma patients. Data fromsites has identified opportunitiesfor reductions in use of resourceacross the pathway, for example,in primary care - throughsystematic management of theasthma patient register and insecondary care, through targetedintervention on those whofrequently re-attend or who arereadmitted.

• A fundamental part of asthmacare is evidence-based supportiveself-management. Corecomponents of this consistentlyinclude a primary care annualreview, the delivery of educationfor patients (including inhalertechnique) by clinical staff withspecialist asthma knowledge inappropriate healthcare settingsand the clear explanation anddocumentation of a self-management plan.

8 INTRODUCTION

Barriers and IssuesClinical teams in each of the siteshave been working on differentparts of the asthma pathway. Eachsite has faced individual challengesand barriers however a number ofcommon themes have begun toemerge.

• Although clinicians understand thecomponents of optimal asthmacare and are familiar with the BTS/SIGN Guideline there iswidespread variation in adherenceto recommended practice. Forexample, in the administration ofwritten self-management plans.Although recommended, oneproject site found that less thanfive per cent of their diagnosedasthma patients had documentedand read-code recorded plans.

• Variation also exists amongsthealthcare professional in themanagement of the patientjourney specifically in secondarycare and in many cases no currentcare pathway was available orknown to staff in the emergencydepartments.

• There is a difference amongstorganisations involved in theimprovement work in theunderstanding and the utilisationof different healthcare providersand the role they can take. Forexample, in the use of pharmacistsand the sharing of information toand from primary care aroundMedicines Use Reviews.

• Traditional organisationalboundaries are often a barrier tocompleting the information loopto enable optimal patientmanagement for example, follow-up within 48 hours of discharge.Mapping the patient pathway withall stakeholders present can oftenreconcile differing procedures andtechnologies between healthcareproviders to allow informationexchange to be more timely andeffective.

Focus for the next six monthsThis mid-term guide represents thehalfway point in the progress of theproject sites within the asthma workstream. For the remainder of thetime left the project teams will befocussed on small testing ofinnovation and improvement usingPDSA cycles in the four differentareas of the pathway: improvingasthma diagnosis and medicinesoptimisation, transforming acutecare, chronic disease managementand integrated care.

The challenge will be to identifymodels of evidence-based bestpractice in each of these areas alongwith practical solutions forovercoming barriers and issues. Thefinal Asthma Improvement Guidewith all of the findings will bepublished in Autumn 2012.

Phil DuncanDirector - NHS Improvement Lung

Hannah WallNational Improvement Lead

CASESTUDIESACUTE TRUSTS

10 CASE STUDIES - ACUTE TRUSTS

BackgroundSet in the heart of the capital city StThomas’ A&E is one of the busiest andlargest departments of its kind inEngland, seeing hundreds of emergencypatients every day.

Early in 2010 the respiratory nursingteam at St Thomas’ undertook asnapshot audit of asthma attendances toA&E, and this revealed a surprisingly high30 day re-attendance rate of just below30% and this highlighted a problemwhich they wanted to improve upon.

Karen Newell, Respiratory NurseSpecialist and project lead, felt that inorder to reduce re-attendances theyneeded to work more proactively withtheir asthma patients on discharge andhelp healthcare professionals in A&Eincrease their knowledge to feel moreconfident about working with asthma.

This project is supported by a myriad ofstakeholders including: the respiratorynursing team, Accident and Emergencystaff, the London Ambulance Service(LAS), Lambeth and Southwark GPs andAsthma UK.

Project aimsThe primary aim of this project is toreduce adult asthma re-attendances atA&E within 30 days by 20% of 2010/11baseline by May 2012 as an indicator ofbetter control and quality of life.

Guy's and St Thomas' NHS Foundation Trust

Reducing adult asthma re-attenders atAccident and Emergency

DataA significant amount of quantitative andqualitative data has been sourced inorder to help the project understand theproblem it is aiming to solve prior toimplementing any potential solutions.

Quantitative data was derived from thehospital’s electronic patient systems. Thisrevealed that in 2010/11, 94 patients re-attended at A&E for primary diagnosis ofasthma. Of these, 19 were deliberatelyexcluded form the targeted cohortbecause they were always admitted dueto the severe nature of their asthma (andtherefore not a suitable cohort for thistype of intervention).

The 75 remaining had made 218attendances in the period. Of these, 143were re-attendances (16.1% of totalasthma attendances) and just over halfof these were re-attendances within 30days of previous visit (52%). The majoritywho had two or more attendanceswithin 30 days were always dischargedfrom A&E.

Ethnically most patients were white andgeographically most patients had aLondon postcode. In terms of method ofpresentation from the data available asignificant proportion were brought in byambulance and then went on to bedischarged from the A&E (60%).

Qualitative data was gathered by use ofsemi-structured telephone interviewswith a random sample from the 75patients cohort. This revealed fascinatingdata around individual approaches toself-management, sources of informationand guidance, why patients attendedA&E and what they felt they neededfrom healthcare professionals.

Reason for attending A&E was mainlybecause of an exacerbation (87%).However, 14% of the attendancesdocument the patient had run out ofinhaler medication although the timingsaround this require further investigation.Other reasons cited include: inability toaccess GP and lack of knowledge ofother out of hours providers.

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Achievements to date• 84 (of 94) A&E nursing staff have beentrained in inhaler technique so thatthey feel confident teaching andassessing inhaler technique

• This has also led to the implementationof a placebo box and an updatedasthma folder, which includes therecently updated local asthmaguideline

• An A&E asthma proforma (following aPDSA cycle) has been introduced backinto use within the department toensure that patients are cared for asper BTS/ SIGN Guideline, whichincludes a discharge checklist withreferral to GP within 48 hours, anAsthma UK co-branded ‘AsthmaPatient to GP’ letter and blank self-management plan for the patient totake to a GP follow-up appointmentand an Asthma UK’s After YourAsthma Attack leaflet

• The internal referral pathways into thesevere/ difficult asthma clinic whenpatients have experienced an acutesevere asthma attack or have difficultasthma have been reviewed

• The external referral pathway has beenreviewed and updated by way of anelectronic flag on the patient recordthat prompts the hospital staff to giveinformation on discharge including theGP referral letter

• A bespoke Asthma Action Plan hasbeen designed and sent to local GPsfor use - triple branded with AsthmaUK and NHS Improvement - Lung.

Successes and challenges• Bureaucratic process and time scalese.g. setting-up the internal referralpathway involved many conversationsand favours from people

• Unforeseen delays e.g. the asthmaproforma launch in A&E was delayeduntil the arrival of a set of drawers thathoused and paper form, the letter andthe leaflet in one place

• Highlights have included: re-introducing the proforma in A&E, co-branding on the letter and the actionplan, working with enthusiastic peopleand the gems revealed in the data.

Patient and Public InvolvementA patient representative was present atthe process mapping event and threepatient representatives are sent themonthly project report. The telephoneinterviews from the 75 re-attenderscohort involved eliciting the views of thepatients.

“I am really lookingforward to seeing theoutcome of this project, as Ithink the impact will beextremely positive for a lotof people.”

Guy’s and St Thomas’ asthma patient(2011)

What’s next?• Further analysis of the data tounderstand the reasons behind the re-attendance so that they can be evenmore responsive to the patientpopulation

• PDSA results from small scale testingof proforma, discharge letter andaction plan and monitoring ofimplementation e.g. audit of usage ofproformas

• Work with the LAS to furtherunderstand ambulance call-outs forasthma.

Contact detailsKaren NewellSpecialist Respiratory Nursekaren.newell@gstt.nhs.uk

12 CASE STUDIES - ACUTE TRUSTS

BackgroundPinderfields General Hospital is one ofthree district general hospitals in theregion (along with Pontefract Generaland Dewsbury General Hospital). Thehospital has recently moved into a newbuilding which has created theopportunity for respiratory patients toenjoy state-of-the art facilities.

The respiratory team recently decided tolook at ways in which they couldimprove care for asthma patients. Theyhad already established a designateddifficult asthma service and wanted toimpact upon admissions (Wakefield hasthe highest admission rates in theregion). Therefore the respiratoryprogramme manager for NHS Wakefieldand District, Lisa Chandler, and a newrespiratory consultant, Dr JamesMcCreanor, considered this an ideal timeto implement a new asthma ‘bundle’(supported by a Commissioning forQuality and Innovation payment -CQUIN) to streamline and standardisecare asthma patients received at A&E, onthe ward and at discharge.

Mid Yorkshire Hospitals NHS Foundation Trust

Asthma care bundles

Project aimsThe high level aims of the project are:• To reduce asthma readmissions within28 days of discharge by 20% from2010/11

• To increase compliance with asthmadischarge through the bundle, inparticular: review of inhaler technique,record of completed self-managementplan, record of recommendation forGP and/or specialist follow-up.

DataA 2009 BTS asthma audit highlightedthat Pinderfields General Hospital re-admissions (within one month) weremore than double that of the nationalaverage (19%). The same audit alsohighlighted a lack of education andinstruction to patients. Only 19% wereasked to see their GP followingadmission and only 16% received awritten action plan, compared to thenational figures of 34 and 38%respectively.

In 2010/11 there were 210 admissions toPinderfields. Of these 60 (29%) werereadmitted for acute exacerbation ofasthma within 28 days of previousdischarge. A more recent audit (June andJuly 2011) reviewed the performancebefore the introduction of the carebundle. From the 24 patients coded ashaving been seen for an exacerbation ofasthma in these two months, only 14were completed admissions. One patientself discharged, one patient died, onewas an incorrect diagnosis and sevensets of notes were not available. Of these14, only one had a record of inhalertechnique review (7%) and none had aself-management plan.

Baseline re-admissions for Pinderfields 2010/11

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Achievements to date• Diagnostic work around data includingreview of admissions, readmission andlength of stay

• A process mapping exercise anddischarge case note audit to establishthe cohort to focus on – 28readmissions (more than oneadmission and less than 10 admissions)

• Education for staff in A&E and on thewards around the discharge checklist

• Agreement on universal patientinformation to be used across the Trust

• A care bundle was piloted prior tolaunch (using a plan, do, study, actapproach) to allow for evaluation andrefinement prior to widespread launchin November

• A patient satisfaction questionnaire isnow in use

• A discharge letter for patients fromA&E (adopted from St Thomas’Hospital) is now in use.

Successes and challenges• The team found it difficult to get theprotected time needed to develop andpilot the care bundle

• Working with A&E staff to educatethem on asthma and to implement thebundle has paved the way for futurejoint working

• Process mapping afforded the chanceto bring clinicians from differentbackgrounds and patients together toenvisage the whole pathway forasthma sufferers

• The support from the informationteam is vital and excellent

• Using data and root cause analysis todiagnose the right ‘problem’ was key.The data from previous years revealedsome concerns around length of staybut more recent data showed this wasno longer an issue. Furtherinvestigation revealed this has beenrecently mitigated by a new hospitalwide in-reach team and so the focusreturned to readmissions.

Patient and Public InvolvementAsthma UK patient representatives werepart of the process mapping event.

What’s next?• An audit of records of patientsreadmitted within 28 days is beingundertaken to identify any themes thatappear to contribute to theirreadmission

• The impact of the closure of PontefractA&E resulting in the majority ofpatients being redirected to thePinderfields site will need to beconsidered in terms of effect on data

• Monitor compliance with the carebundle at Pinderfields with regularreviews to identify and resolve risks orissues.

Contact detailsLisa ChandlerRespiratory Programme Manager –Public Health NHS Wakefieldlisa.chandler@wdpct.nhs.uk

The Mid Yorkshire project team (l-r) Jacqui Pollington,Lisa Chandler and Dr James Creanor

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BackgroundUniversity Hospital of North StaffordshireNHS Trust is currently spread across threesites in Stoke-on-Trent serving apopulation of approximately half amillion people in urban and semi-ruralareas.

Within North Staffordshire a ‘Fit for theFuture’ transformation project and anexciting move into a new Private FinanceInitiative hospital have been developedto improve people’s access to highquality healthcare. As part of thereorganisation of emergency services anUrgent Care Centre has been embeddedwithin the A&E department and theClinical Decision Unit is expanding withthe move with the potential to changethe usual care for adult asthma patients.

The UHNS emergency department wasone of 147 departments that took partin the College of Emergency Medicine(CEM) Asthma Audit in 2009/10. Theresults of the audit showed there wereareas for improvement and the asthmaclinical nurse specialist, Angela Cooper,and consultant physician, Dr MartinAllen, felt that the modernisation of thehospital facilities signalled theopportunity to begin looking at ways inwhich asthma care within acutemedicine, respiratory wards and thecommunity as well as A&E could beimproved by using better communicationand knowledge of patient flow.

University Hospital of North Staffordshire NHS Trust

An integrated care pathway for A&E

Project aimsThe high level aims of the project are:• To understand the current adultasthma patient journey through A&E,the Clinical Decision Unit (CDU) andthe Urgent Care Centre

• To identify delays in patient care,including those that can increaselength of stay and lead to admissionto the Clinical Decision Unit

• Introduce a new adult asthma carepathway for use in A&E and across theorganisation

• To identify interventions which willproduce a 10-20% reduction in lengthof stay.

DataThe results of the CEM audit from2009/10 showed that A&E at UHNS wasbelow the national average for severalkey indicators such as measuring PEF andrespiratory rate on arrival. It was also15% above the national average foradmissions.

Casualty card data between 1 May and30 September 2011 revealed there were48 attendances for asthma at A&E inthat period. Thirty patients had notaccessed a medical review immediatelyprior to attending the emergencydepartment, 14 had experienced a mildexacerbation, 33 experienced amoderate/severe exacerbation and onehad a life threatening exacerbation.

The majority of attendances were femalewhich correlates with national findings.The main reason for attendance was foran infective exacerbation or increase inasthma symptoms. All patients attendingthe emergency department receivednebulised bronchodilator as opposed tometered dose inhaler and spacer delivery(contrary to BTS-SIGN AsthmaGuideline). Through reviewing casualtycards peak flows were recorded in mostpatients but were not consistently done.

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Achievements to date• A process map of the patient journeythrough the emergency portals hasbeen completed

• A review and analysis of the A&Ecasualty card attendance data hasbeen completed

• A patient focus group has elicitedcomments, suggestions and themesfor areas of improvement

• The Integrated Care Pathway (ICP) hasbeen designed and a PDSA cycle hasrefined the final version launched inJanuary.

Successes and challenges• The management of change andmoving into a new building has beenchallenging

• Locating casualty cards for analysisproved difficult

• The engagement of emergency carestaff along with acute respiratoryphysicians and specialist nurses hasbeen encouraging

• Early results from the patientsatisfaction questionnaire who havealready had intervention from theasthma service are positive.

Patient and Public InvolvementA patient has viewed and commented onthe process map (patient journey) andwritten a report for NHS Improvement –Lung. Patient satisfaction questionnaireshave been completed and returned by58 of 100 patients who since May 2011have had support and intervention fromthe asthma team and a patient forummeeting was held on the 18 January2012 for those who had attended A&Ewithin the past 12 months.

What’s next?• The creation of an adult asthmapatient database from A&E data

• Staff education and training sessionson asthma for A&E staff

• Audit of the use of the ICP in A&E• Semi-structured interviews with adultasthma attenders

• A&E attendances to be referred to therespiratory nurse

• Collate data from the care pathwayand data analyst regardingattendances, admissions and ength ofstay to assess for changes andimprovements in care

• Evaluate the success of the patientforum; if beneficial considerdeveloping as a regular programme.

Contact detailsAngela CooperAsthma clinical nurse specialistangela.cooper@uhns.co.uk

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CASESTUDIESCOMMUNITYRESPIRATORYTEAMS

“I was eventually referredto the CRS and since then, Ihave received a brilliant,personalised service byvarious members of theteam. Their skills andprofessionalism performedwith a seven day per weekhome-visit service, hasenabled me to manage thecondition and lead arelatively normal life.”

Sandwell CRS Patient (2011)

BackgroundThe Community Respiratory Service (CRS)in Sandwell is a multidisciplinary teamproviding assessment, treatment andmanagement to those with respiratoryillnesses. The aims of the service (whichis now part of Sandwell and BirminghamHospitals NHS Trust) are to: reduceavoidable admissions, minimise hospitallength of stay and provide care closer tohome for respiratory patients.

Previously the majority of the referralswere for patients with COPD and lownumbers of referrals for asthma werereceived from GPs and secondary care -despite Sandwell having high prevalence(over 7% as measured by the Quality ofOutcomes Framework) and highadmission rates for asthma.

Initial thoughts were that high asthmaattendance and admissions at the acuteTrust may be due to healthcareprofessionals in the area not referringtheir patients to the team due to lack ofawareness of the service available.

Sandwell Community Respiratory Team

Reducing admissions and increasingcommunity support

Although the CRS were well utilised bythe NHS for other respiratory conditionsthey felt that the time was right to domore to support the management ofasthma patients in the locality.

Project aimsThe three high level aims of theproject are:• To reduce adult hospital admissions ofasthma by 10% from 2010/11 baseline

• To ensure that by May 2012, 80% ofthe patients on the CRS asthmaregister will:• have a confirmed asthma diagnosisusing spirometry

• have a self management plan inplace

• receive appropriate education• have a review and ensure correctinhaler technique

• regular reviews to ensure patientsare managing their asthma

• To increase the referral rate of asthmapatients into the service by 50%.

DataSandwell’s GP registered population isapproximately 320,000. The boroughhas a large ethnic minority populationwith high levels of deprivation. There are69 practices including three new Darzipractices and a walk in centre.

Sandwell and West BirminghamHospitals NHS Foundation Trust providehealth care services for around 300,000people, seven out of 10 who are Black orAsian.

In 2010/11 there were 106 referrals toCRS. Baseline data showed room forsignificant improvement as:• Only 44 had diagnosis confirmed byspirometry

• 19 were given a self-management plan• 62 had their inhaler technique checkedand were given education

• 0 had scheduled follow up.

Baseline data on referrals 2010/11

17CASE STUDIES - COMMUNITY RESPIRATORY TEAMS

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The number of admissions between 1May 2010 and 30 April 2011 at SandwellGeneral Hospital was 236, with 171admissions lasting for two days or less.Between 1 May 2010 and 30 April 2011there were 638 A&E attendances due toasthma.

Achievements to date• A process mapping session has beenheld and actions identified

• Baseline data on previous year’sreferral has been completed andanalysed

• An electronic asthma project datacollection tool has been developed

• Electronic care plans for SystmOnehave been developed and are waitingfor final approval

• The team has been trained in the useof the Professor Martyn Partridge self-management plan for all patients

• The referral criteria for the service isfinalised

• A meeting has been arranged withA&E to develop pathways for referringto the CRS team

• A demand and capacity exercise hasbeen instigated

• Spirometry is now being conducted onall those who meet criteria withinproject scope

• A GP information leaflet has beendeveloped and printed.

Successes and challenges• Creating electronic templates to easedata collection and extracting datathat is actually a true representation ofwhat has happened was challengingand work is still in progress to ensuredata is accurate

• Manual review of case notes forbaseline data was time consuming

• Using the media to advertise theproject.

Patient and Public InvolvementAsthma UK and a patient and carer werean integral part of the process mappingevent and a patient satisfactionquestionnaire ‘before’ and ‘after’ as partof the project work.

What’s next?• Complete the demand and capacityexercise and analyse data

• Develop GP awarenessposter/algorithm for GP’s consultationroom inclusive of referral criteria andprocess to encourage greater referralsfrom primary care and target the GPpractices with high admission rates,high prevalence and high medicinesspend to raise awareness of the service

• Meet with the A&E departmentlead nurse to develop awareness ofservice and referral pathway andexplore options for referral process

• Electronic care plan to be uploaded toSystmOne (electronic patient record)for all clinicians to use which willenable the team to report outcomes

• Begin to audit case notes of the CRSfrom May 2011 onwards to ensurecompliance with the 80% BTS/ SIGNAsthma Guideline compliance e.g.inhaler technique, self-managementplan etc.

• Explore possible future models of carebased on a higher demand and beginto PDSA clinic sessions.

Contact detailsKelly Redden-RowleyRespiratory Physiotherapist/ Clinical Leadkelly.redden-rowley@nhs.net

CASESTUDIESCLINICALCOMMISSIONINGGROUPS ANDPRIMARY CARE

20 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE

BackgroundDurham Dales Clinical CommissioningGroup are a consortia of 12 GP surgeriesin the North East serving a population ofover 90 000.

In 2010, a small scale pilot between oneGP practice and one pharmacy wasundertaken over a three month period inBishop Auckland where pharmacistsoffered a Medicines Use Review (MUR)to asthma patients who had missed theirannual review and were over usingreliever inhalers. The initial datasuggested that over half of the patientsbenefited from the service and thisevidence supported a bid to roll theproject out in other surgeries in theconsortia as an improvement project.

In May 2011, seven practices agreed totake part and a joint working agreementwas established with pharmaceuticalcompany GlaxoSmithKline as a result oftheir previous work in the locality onCOPD. The lead pharmacist, PatriciaKing, from the original pilot work thenapproached pharmacists whichneighboured participating practices andas a result 15 pharmacies are now takingpart.

Durham Dales Clinical Commissioning Group

Pharmacists and Medicines Use Reviews

Project aimsThe high level aims of the project are:• To up skill health care professionals inthe participating practices in theirunderstanding and management ofasthma patients consistent with theBTS/ SIGN Guidelines and to ensure allthose involved in delivering MURs aretrained and competent to do so

• For participating pharmacists - toundertake 500 MURs in total

• For patients to have increasedawareness and understanding of theirconditions and be able to beresponsible for their own diseasemanagement.

DataThere are currently 56,172 patientsregistered with the seven participatingGP surgeries with a total of 3,698patients on their asthma register (aprevalence of 6.6%).

Achievements to date• This project was greatly aided by theintroduction of the new nationalpharmacy contract which came intoforce on 1 October 2011 which meantthat respiratory patients became oneof four key groups pharmacists arenow asked to specifically target forMURs.

The main achievements of the project todate are:• Process map completed withstakeholders

• Three cohorts identified forpharmacists to target: those whomissed their last annual review, thoseon more than 1000mg of inhaledcorticosteroids and those who havebeen prescribed more than six bluereliever inhalers in one year (frompharmacist own records)

Process mapping event at the Durham Dales

21CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE

• All participating pharmacists have beentrained by GSK on delivering asthmaMURs e.g. inhaler technique, self-management plans, use of the AsthmaControl Test questions etc.

• A patient satisfaction questionnaire isbeing given to the patient prior to anMUR and then sent to the patient sixmonths after

• Letters are being sent out to patientson the surgery asthma registers whoare identified as have not attendedtheir last annual review asking them tosee either their GP or pharmacist

• A schematic is available forpharmacists in the delivery of an MURand for any follow up

• A monthly MUR reporting form hasbeen designed and trialled forpharmacists to use in order to recordhow many MURs they haveundertaken to send back to therelevant GP surgeries and the DurhamDales CCG Project Manager

• A monthly newsletter is sent out to allparticipating GPs and pharmacies.

Successes and challenges• Confidentiality issues with GP practicessharing patient identifiable informationwith pharmacists has resulted in anopportunistic rather than proactiveapproach to patient lists

• Another pharmacy contractrequirement – the New MedicinesService – is impacting on pharmacists’capacity to undertake the MURs withtargeted asthma patients

• The engagement and enthusiasm ofthe participating pharmacists has madejoint working easy and the GSKmentoring of pharmacists has beenvery well received.

Patient and Public InvolvementAn asthma patient representative is partof the Project Steering Group whichmeets monthly and has been at all otherevents associated with the improvementwork e.g. process mapping day.

What’s next?• Continue to engage with thepharmacies on a monthly basis toensure data is being returned to theproject team and sufficient numbers ofMURs are being done

• Visit each pharmacy to discuss theproject and process and offer furthersupport

• Organise and deliver educationalsession for all pharmacists anddispensing practice lead to distributelung models and train on how to usethem

• Work with practices to extract theirdata, analyse and collate information.

Contact detailsVikki ReedProject Manager – Durham Dales ClinicalCommissioning Groupvictoriareed@nhs.net

Kathryn KempIntegrated Healthcare Manager –GlaxoSmithKlineKathryn.x.kemp@gsk.com

22 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE

DataESyDoc have 18 practices which eachhold an asthma register. The registershave been searched for patients who areaged 18 years or over and potentially fallinto one or more of the four cohorts (seepyramid above – red, amber or greendenotes priority to be seen in clinic).

Surrey and Sussex Hospitals NHS Trust isthe main acute site for the area andservices a total population of 400,000patients. Last year there were 86admissions with a primary diagnosis ofasthma.

BackgroundESyDoc is a Clinical CommissioningGroup of 19 practices in Surrey coveringa population of around 170,000.

Dr Vijay Kumar, a GP at BirchwoodPractice, had already led a successfulproject on improving COPD care withinthe consortia during 2009. Throughfurther analysis of the COPD data theydiscovered that variation in asthma careexisted across the ESyDoc patientpopulation and felt the time was right toaddress the issues.

Given the success of their earlier jointwork in 2010 they decided to undertakean improvement project in conjunctionwith Sussex and Surrey Hospitals NHSTrust. The project is also supportedthrough a formal joint workingagreement with pharmaceuticalcompany AstraZeneca.

Project aimsESyDoc and their partners firmly believethat: asthma is controllable, there shouldbe no unnecessary deaths from asthmaand that a secondary care respiratoryclinician should be consulted if there is adecision to admit an asthma patient whopresents at A&E.

ESyDoc

An integrated approach to asthma care

As an extension of these beliefs theproject is focussed on four key workstreams with their own aims. These are:

1. Diagnosis – increasing the prevalenceof asthma from 5.3 to 5.8% throughproactive case finding and analysis ofpractice registers

2. Chronic Disease Management –inviting cohorts one, two and three(see pyramid above) in for a structuredreview in line with the BTS/ SIGNAsthma Guideline, and ensuring thatat least 75% of all those invited areseen in asthma clinics and that 50%of those seen leave with an up-to-date action plan

3. Medicines Optimisation –optimising medication for patients

4. Transforming acute care –standardising care pathways andreducing admissions by 10% in theacute Trust.

23CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE

Achievements to date• Three process mapping events havemapped the diagnosis pathway, theroutine care pathway and the acutepathway

• The identification of patients withindefined cohorts and inclusion criteria

• A clinical lead has been identified ineach constituent practice

• A small scale pilot of review clinics(using a PDSA approach) has beenundertaken to evaluate a standardtemplate and the use of the ProfessorMartyn Partridge or Asthma UK self-management plan

• Specific asthma clinics in everyconstituent practice throughoutESyDoc have been created

• The care planning approach has beenagreed with both patients andclinicians

• Training opportunities have beenadvertised to all clinical staff in thepractices

• A pre and post clinic patientquestionnaire has been launched

• A&E attendance data is beingidentified and compiled into aninformation format to ascertain thebaseline position, understand thedemand/need and set goals forreduction

• A new asthma care pathway has justbeen launched at the acute Trust.

Successes and challenges• Variability in the use of self-management plans with patients hasprompted the project team to ensureall practices are using either theProfessor Martyn Partridge or theAsthma UK self-management plan

• Initial register searches showedconflicting data regarding numbers ofasthma patients on QOF and what theQuintiles search had extracted (asrequested by AstraZeneca). This wasremedied by re-running the data setwith improved filters to enableincreased data integrity

The ESyDoc project team• The A&E attendance data is not easilyvisible which has made it difficult tocreate a baseline

• All constituent practices have signedup to the project.

Patient and Public InvolvementAll patients that have attended the pilotclinics as part of this project havereceived and completed a questionnairepre and post appointment and this willcontinue when further clinics are rununtil the end of May 2012. Patientrepresentatives were present at theprocess mapping events and attend allthe project steering group meetings.

What’s next?• Focused communication for allstakeholders

• Newsletter for all practices• Re-run and analysis of the data fromthe registers

• Continue with post clinic evaluations• Acute Integrated Care Pathwaymonitoring and evaluation

• Identification of work streammonitoring i.e. what data to capture,when and how

• Host clinical workshop to highlightaims, objectives and to raise awareness

• Development of an asthma datadashboard

• Appropriate and timely education forclinicians

• Review lessons learned and refinepatient pathways.

Contact detailsDr Vijay KumarGP - Birchwood PracticeVijay.Kumar@gp-h81037.nhs.uk

24 CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE

• Generated, proofed and preparedstandard proformas for the directedMUR, generation of a care plan(Professor Martyn Partridge version),recording of data, patient consent,collection of data (electronically)around current medication andreporting back to the LPC.

Successes and challenges• Since the initial project plan in May2011 there have been changes in thecommunity pharmacy national contract(introduction of the New MedicinesService and the MUR targets inOctober 2011). This development hasdelayed the start of the asthma projectbut there have been some benefits:much of the original training outcomesplanned for project sites are met bythe training workshops andaccreditation requirements for NMS,and as asthma is one of the eligibleclinical conditions for both NMS andtargeted MURs participants will havecompleted relevant continuingprofessional development on this topic

• The inclusion of South Essex as aHealthy Living Pharmacy Pathfinder sitehas again delayed the implementationof the project but it does mean thatthe sites involved in both projects willhave Health Champions among theirsupport staff who may be well placedto approach customers and initiateconversations about the service, andthe pharmacists involved will havecompleted appropriate leadershiptraining to consider best use of skillmix

• The prescribing and admissions dataobtained from the PCT informationteam is not suitable for the size andscope of this project, and therefore agreater emphasis will need to beplaced on pharmacy PatientMedication Record (PMR) data andpatient follow-up interviews formeaningful reporting and evaluationof the project.

BackgroundThere is currently a high prevalence ofasthma and significant asthma relatedsecondary care activity within theprimary care Trust borders. Access tomedical practitioners is variable andthere is significant potential opportunityto improve asthma care.

This work was initiated at the request ofmedicines management driven byfeedback from GP practices andcommunity providers regarding the sortsof problems they were having inreviewing and following up some hard-to-reach asthma patients.

It was suggested that pharmacistengagement - through use of MedicinesUse Reviews - would ease difficultiespractices were having in accessingcertain patients. Pharmacists have a highlevel of contact with residents in the PCTarea and are engaged in a whole rangeof service delivery. They also speak arange of languages which will assist intargeting some of the hard to reachgroups.

The project itself is a collaborativebetween the Local PharmaceuticalCommittee (LPC), the PCT, MedicinesManagement, GP practices, communityservices and consultants from the acutehospital. Eight pharmacies in the localarea who are already part of theDepartment of Health ‘Healthy Living’initiative have signed up to a localenhanced service (LES) agreement todeliver at least 400 MURs to asthmapatients collecting scripts.

NHS South West Essex

Targeted Medicines Use Reviews (MURs)using a Local Enhanced Service (LES)

Project aimsThe overarching aims are to: improvecare, reduce morbidity and impact onsecondary care resource use throughservice delivery via communitypharmacies.

The specific aims with regard to the 400MURs and the LES agreement are to:• Improve patients’ adherence to theirasthma treatment regimen through anumber of extended education andsupport interventions

• Reduce asthma medicines waste,including through poor complianceand prescription management

• Reduce inappropriate prescribing,including unconventional regimen andover-prescribing

• Reduce avoidable unscheduled andsecondary care activity for primary careasthma patients.

DataIn 2009/10 there were 400 056 peopleregistered with the 78 GP surgeries inSouth West Essex. The asthmaprevalence in the PCT was just over 6%and there were 309 emergencyadmissions.

Achievements to date• Process mapping of current pathway inJune 2011

• Undertaken a ‘world café’ (a methodwhich makes use of an informal cafefor participants to explore an issue bydiscussing in small table groups) withcommunity pharmacists to canvass thelevel of interest and willingness toengage in this work

• Identified eight pharmacies who arepart of the ‘Health Living Initiative’with track record of service delivery,particularly extra-contractual, centredaround cardiovascular health checks,for further training and support

• Delivered a training session andresource pack to up-skill pharmacistsand staff to undertake the enhancedwork

25CASE STUDIES - CLINICAL COMMISSIONING GROUPS AND PRIMARY CARE

Patient and Public InvolvementThe service has a built in element forboth patient satisfaction and datacapture of patient reported outcomemeasures (e.g. shortness of breath,difficulty with normal activities, numberof times patient has had to resort to useof rescue plan) as part of the MUR+process.

What’s next?• To deliver training to staff andpharmacists in time for Januaryinitiation of project

• To continue to monitor performancemonthly and feedback to practices ofpractitioner’s progress and learningderived from project delivery, and tofeed these into the QIPP agenda.

Contact detailsBalbir (Bill) Singh SandhuAssociate Director /Head of MedicinesManagementBalbir-singh.sandhu@swessex.nhs.uk

26 REFERENCES

COPD and Asthma Outcomes Strategy for England and Wales (DH: 2011)www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974

Asthma UKwww.asthma.org.uk

NHS Atlas and NHS Right Care (Problems of the Respiratory System, Atlas ofVariation: 2011 version)www.rightcare.nhs.uk/index.php/nhs-atlas/atlas-downloads/

British Guideline on the Management of Asthma (BTS/ SIGN: 2011)www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx

Professor Martyn Partridge asthma action planning softwarewww1.imperial.ac.uk/medicine/people/m.partridge/

References

NHS Improvement - Lung would like to thank all national improvement project sitesfor their hard work and dedication to improve quality and care for people withasthma, and for their contributions to this document.

In addition, the following people have provided a source of expertise and supportand their help is gratefully acknowledged:

Professor Martyn Partridge

Professor Sue Hill – National Clinical Director for Respiratory Services

Dr Robert Winter - National Clinical Director for Respiratory Services

Members of the Asthma Clinical Project Steering Group: Dr Bernard Higgins,Jan Gould, Dr Dermot Ryan, Dr Mike Thomas and Simon Selo (Asthma UK)

Kevin Holton, Department of Health Head of Policy for Respiratory Services

Bronwen Thompson, Department of Health Policy Lead for Asthma

Phil Duncan, Director, NHS Improvement - Lung

Catherine Blackaby, National Improvement Lead, NHS Improvement - Lung

Ore Okosi, National Improvement Lead, NHS Improvement - Lung

Catherine Thompson, National Improvement Lead, NHS Improvement - Lung

Zoë Lord, National Improvement Lead, NHS Improvement - Lung

Alex Porter, Senior Analyst, NHS Improvement - Lung

For more information please contactHannah Wall, National Improvement Lead for AsthmaEmail: hannah.wall@improvement.nhs.uk

ReferencesAcknowledgements

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