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A simple multifunctional tool for integrated care of COPD

Chronic obstructive pulmonary disease (COPD) affects around 1.2 million people in the UK and has an impact across NHS services[1]. Patients frequently present acutely in the emergency department with an exacerbation of the disease and rely heavily on community services owing to the symptom burden. COPD is often perceived only as a chronic respiratory disease, but its symptom profile can be much broader than just breathlessness, particularly in more severe cases.

‘Integrated care’ has been adopted for many chronic illnesses to improve the quality of healthcare delivery, but there is no framework or consensus on how this service should be delivered for COPD.

We used the National COPD Audit[2] and guidelines from the British Thoracic Society[3] and quality standards from the National Institute for Health and Care Excellence[4] and quality standards to deliver our own model of integrated care, which has improved patient outcomes in our trust.

The model focuses on the same medical team providing care at all stages of the patient’s journey: from the emergency department, to community-based COPD clinics, the hospice and pulmonary rehabilitation. The model facilitates not only continuity of care, but also effective communication between the healthcare professional and the patient.

An important tool to aid this process is a simplified paper-based pro forma which captures all data on the acute admission. This document is shared with community teams electronically in a unified approach. It contains a discharge bundle which is designed to ensure that all aspects of care, such as inhaler technique and smoking cessation, are addressed and that the respiratory team is informed of the patient’s admission at the earliest opportunity. An ongoing educational programme at both individual and departmental levels supports this service. The pro forma also includes the updated strategy for COPD management from the Global Initiative for Chronic Obstructive Lung Disease[5], so the document further serves as an educational aide.

The service assists in the care of more than 300 COPD exacerbations over the winter months in the community, and 1,013 admissions were noted at the acute hospital in the past 12 months. By introducing a more effective communication service using the approach described above, we achieved a significant reduction in length of stay in 2017 compared with 2016, despite increased activity, as well as a reduction in nonelective readmission rates; this translates into high cost savings for the trust and improves quality of care for the patient. Patients were more likely to be seen by a respiratory specialist soon after admission; the specialist could facilitate their discharge and follow up if appropriate, with close surveillance by the community nurse at home if needed.

Patients who may require palliative care assessment, end-of-life discussions and planning, or referral to breathlessness, wellbeing or psychological input were identified early on. Early identification of patients who could utilise these services reduced their symptom burden — the pro forma gave the user a prompt to complete the relevant questionnaires and mobilise relevant services. Continuity of palliative care across sites is also delivered; the patient’s chest physician in the acute hospital and nurse in the community clinic also form part of the palliative service, in which patients are discussed in a multidisciplinary team and reviewed at the end of life.

Using the pro forma and discharge bundle, more patients were also identified from acute admissions and referred in a timely manner for pulmonary rehabilitation. The uptake, as well as completion of the rehabilitation programme, was successful. Improvements in exercise capacity, anxiety and depression, and quality of life were scored; at least 50% of patients demonstrated a significantly successful score from the programme.

The introduction and delivery of a new integrated care pathway for COPD in our area correlated with reduced hospital length of stay for exacerbations, readmission rates and symptom scores. This patient journey approach, which links services across both acute and community sites, has improved quality of care and improved outcomes.

In the future, we aim to optimise the set-up further with more emphasis on self-management platforms using digital health technology. We also aim to establish virtual and rapid-access clinics with more refined pathways for the management of COPD exacerbations in the community.


Kay Roy, consultant physician, respiratory and general internal medicine, West Hertfordshire NHS Trust and Central London Community Healthcare NHS Trust

Audrey Marau, specialist respiratory nurse, Central London Community Healthcare NHS Trust

Lawrence Gora, specialist respiratory nurse, Central London Community Healthcare NHS Trust

Jenny Shrestha, specialist respiratory nurse, Central London Community Healthcare NHS Trust

Glenda Esmond, nurse consultant, Central London Community Healthcare NHS Trust

Citation: Clinical Pharmacist DOI: 10.1211/PJ.2019.20205973

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