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Emergency care model cuts death rates from chronic lung disease

Admitting patients with chronic lung disease directly into respiratory specialist care from the emergency department could save lives across the NHS, as one hospital is demonstrating

Admitting patients with chronic lung disease directly into respiratory specialist care from the emergency department could save lives across the NHS, as one hospital is demonstrating


Northumbria Specialist Emergency Care Hospital. Picture: Alamy

Death rates from chronic lung disease are being slashed at an emergency care hospital in Northumbria due to an innovative model that sees patients admitted directly into respiratory specialist care from an emergency department.

Research at Northumbria Specialist Emergency Care Hospital showed a substantial fall in death rates of patients admitted with an acute deterioration of chronic obstructive pulmonary disease (COPD), both in hospital and 30 days after discharge.

Combining both periods, mortality fell from 18.1% to 10.4% for those who required ventilation, and from 6.2% to 4.3% for those who did not.

‘Wider adoption of these standards across the NHS will save lives’

Stephen Bourke, consultant in respiratory medicine and clinical lead for COPD  

The hospital, at Cramlington near Newcastle upon Tyne, opened in June 2015 as the UK’s first emergency care hospital, with a new approach to patient care.

Fifth-biggest killer in the UK

This includes direct transfer from emergency department to specialist wards, consultant reviews seven days a week, specialist consultants on call round the clock and a respiratory support unit for non-invasive ventilation.

3 million

people in the UK have COPD

When the hospital opened staffing ratios improved, the pathway was streamlined and a structured multidisciplinary daily review was introduced.

Length of stay fell by a day, and readmission rates were similar at 30 days but higher at 90 days. However, this is thought to be due to more patients surviving their initial hospital stay than under traditional models of care.

Improving COPD care is a major issue for NHS hospitals. The condition is the second most common reason for hospital admissions and the fifth-biggest killer in the UK, accounting for 25% of all deaths from lung disease.

Unacceptably high in-hospital death rates

But the Inspiring Change report by the National Confidential Enquiry into Patient Outcome and Death, published in 2015, showed major failings in care, with unacceptably high in-hospital death rates for COPD patients who had an acute deterioration of their disease requiring ventilation.

The report revealed that a quarter of this cohort was dying in hospital and found care was rated as less than good in 80% of the cases reviewed.

Specialist respiratory nurses are a key part of the drive to improve COPD care at the Northumbria trust. This includes a Hospital at Home service which supports patients to receive care in their homes that previously would only have been available as an inpatient.

There is also a more traditional supported discharge service for patients at intermediate or high risk of readmission and outreach services.

Care for COPD patients ‘dreadfully neglected’

Research on reduced death rates, presented at a British Thoracic Society meeting in December, analysed almost 6,300 COPD patients from January 2013 to the end of 2016, with comparisons made before and after the launch of the new hospital. The population characteristics showed similar demographic and clinical features.

25%

of COPD patients with an acute deterioration disease requiring ventilation die in hospital.

Source: National Confidential Enquiry into Patient Outcome and Death

The study found more than 97% of patients who required non-invasive ventilation (NIV) were admitted under a respiratory doctor, and length of stay in hospital was reduced, from nine to eight days for ventilated patients and from four to three days for patients not requiring ventilation.

Stephen Bourke, consultant in respiratory medicine and clinical lead for COPD and NIV services at the trust, says that care for COPD patients has generally been ‘dreadfully neglected’.

Lack of investment and focus

Even before the new hospital opened, Northumbria Healthcare NHS Foundation Trust had been providing better COPD care than many other areas, with a focus on improving access to prompt treatment.

In many areas there has been lack of investment and focus in ensuring that COPD patients receive the best management and treatment, and many smoking cessation services have been slashed, Dr Bourke says.

Providing 24/7 access to respiratory consultants was a major change when the new hospital opened.

‘If you come in with pneumonia, for instance, there is a high chance on a Saturday or Sunday that in most hospitals you would be under a gastroenterologist and handed to a specialist team subsequently,’ Dr Bourke says.

‘That doesn’t seem ideal. The key difference was to move to a situation that if you came in with a respiratory problem you were under a respiratory consultant. There is a much better chance of being seen by the right specialist at NSEC, be it Saturday, Sunday or 8pm on a Wednesday.’

The respiratory support unit at the emergency hospital has high staffing ratios, allowing one member of staff to two patients.

‘We would advocate the opening of a specialist unit with appropriate staffing levels in every hospital in the country’

Stephen Bourke

Setting up of NIVs is led by physiotherapists from this team, who take the ventilator to the patient in ED, start the therapy, stabilise them, then move them to the respiratory support unit.

There is a ‘door to mask’ time target for those requiring NIV, and acute respiratory failure is recognised as a medical emergency.

Patients assessed seven days a week

Liz Norman, senior respiratory nurse specialist at North Tyneside General Hospital, manages the three specialist nursing teams at the trust, which focus on chronic lung disease, lung cancer and an oxygen team.

Among the initiatives working directly from the emergency hospital is the Hospital at Home service specifically for patients with COPD.

‘Patients tell us they feel it is a very individualised and personal service’

Liz Norman, senior respiratory nurse specialist

This team assesses patients seven days a week. If patients have a low score on a risk assessment tool, the team can arrange for them to go home with the necessary equipment and medication.

At home, patients can be visited frequently and receive treatment such as IV antibiotics and NIV.

Nurses taking on more responsibility

‘When they come into hospital they will be reviewed by a consultant, then a respiratory nurse assesses the risk,’ Ms Norman says. ‘If both are in agreement then the patient is handed over to the nurse and she manages all the care from then on.’

10%

Mortality fell from 18% to 10% at Northumbria Specialist Emergency Care Hospital for COPD patients requiring ventilation.

Developing the model meant nurses taking on more responsibility and required extra training, she says. The nurses are on call 24 hours a day for a patient at home, and up to four patients at a time can use the service.

‘Patients tell us they feel it is a very individualised and personal service,’ Ms Norman says. ‘They like being at home and feel their recovery is quicker, and they sleep better. A lot have also commented that they seem to retain the education better, particular about self-management, in their own homes than if they are in a hospital ward with higher levels of anxiety.’

Interest in shadowing

Clare Stobbart, respiratory specialist nurse, works on the hospital at home service as part of her role. Once it has been agreed that a patient is suitable, she can arrange assessments with physiotherapy and occupational health, if necessary, oxygen, medication and transfer home.

She then meets the patients at home to set up ventilation and provide treatment such as IV antibiotics and nebulisers. Patients are generally under the service for three or four days.

‘We have had a lot of education and training about assessments and clinical skills, which has given us confidence,’ Ms Stobbart says. ‘It is a very holistic service and patients say they feel as if they have a personal nurse.’

The success of the care for COPD patients means that other respiratory teams are interested in visiting their service and shadowing opportunities, Dr Bourke says.

Proved to lead to better outcomes

Rapid access to specialist care is now proved to lead to better outcomes, thanks to the work at Northumbria. Extra staffing and better training is leading to responsive and patient-centred care.

The key elements of the service anticipate the British Thoracic Society NIV quality standards, expected in 2018, Dr Bourke says.

‘Wider adoption of these standards across the NHS will save lives, and while moving to a full specialist emergency care model will present greater challenges to NHS trusts, it should lead to a further improvement in survival,’ says Dr Bourke. ‘We would advocate the opening of a specialist unit with appropriate staffing levels in every hospital in the country.’

Focus on respiratory essentials for nurses

Education for staff at Northumbria Healthcare NHS Foundation Trust on respiratory and COPD care receives more focus than in many hospitals elsewhere.

The specialist nurses and medical consultants together deliver a Respiratory Essentials for Nurses course, which began in 2008.

It is taught over three days of protected time for staff on respiratory wards across the trust.

‘Ward nurses are too often neglected in this regard,’ says consultant in respiratory medicine and clinical lead for COPD and NIV services Stephen Bourke.

‘The feedback from the course was so strong that it was rolled out to all new nurses.’

COPD: chronic, progressive and not fully reversible

An estimated three million people in the UK have chronic obstructive pulmonary disease (COPD). About 900,000 have been diagnosed and an estimated two million are thought to have COPD that remains undiagnosed. Most patients are not diagnosed until they are in their fifties.

COPD is characterised by airflow obstruction that is not fully reversible, according to the National Institute for Health and Care Excellence.

The airflow obstruction does not change markedly over several months and is usually progressive in the long term.

The condition is predominantly caused by smoking, although other factors may contribute.

Exacerbations often occur in which there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations.

Further information

NICE is currently updating its COPD guidance, with the new version expected in November. For the current version click here

British Thoracic Society’s guidance on NIV

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