Teams in South Tipperary General Hospital and St Vincent’s University Hospital received specialised quality improvement training from March to June 2018. They were shown how to use QI tools to implement changes in their COPD care pathway. This included improvement interventions such as direct or expedited access to respiratory specialist care, clinical admission and discharge bundles and standardised clinical assessment.
Despite the short timeframe, the teams fully engaged with the process, embraced their projects and saw positive changes within their team structures. They learned new quality improvement (QI) skills to apply to any setting or practice area, and changed local culture towards QI and patient experience.
Patients with COPD exacerbation experienced improvements in care including:
The initiative was funded by the Clinical Strategy and Programmes Division in the HSE, and led by the Royal College of Physicians of Ireland with input from the National Clinical Programme for COPD.
Over the short timeframe, both sites succeeded in reducing Emergency Department (ED) wait-times, increased the percentage of inpatients receiving respiratory specialist review, increased admission avoidance where appropriate and identified areas for future improvements.
The response from teams at both sites has been overwhelmingly positive. Team members have described a greater feeling of teamwork and sense of empowerment to achieve real change to impact their patients and has given perspective to the occasional frustrations at the perceived inability to effect change.
South Tipperary General Hospital saw a 98% time reduction from patient registration to first respiratory specialist review, and a 100% rate of consultant review within 6 hours of registration. Additionally, the Clonmel team achieved an improvement from 1 inpatient in 7 having a respiratory consultant review to 100% of COPD admissions seeing a respiratory consultant review within 24 hours of admission.
Over the course of the project, the admission rate for COPD presentations dropped from 100% to 22% with the intervention of early respiratory specialist care.
Given that the average length of stay in the hospital was four days in 2017, the team has estimated the bed-day savings due to their intervention is at least 1700 per annum.
This was already a very well established team with an existing high standard of quality within the service. The project took place against a backdrop of concurrent process redesign within the on-call system to direct patients admitted through the ED to the relevant specialist team as soon as possible. The team undertook an in-depth review of the processes around COPD admissions and identified a number of areas for improvement.
A daily check-in has been established between the ANP in Acute Medical Unit (AMU) and the COPD Outreach Team. As a sustainable solution, the Respiratory CNS will engage in this process when there is no COPD Outreach Team cover. On the first day of implementation, the team were notified of a new patient presenting with AECOPD. The patient was reviewed within 5 hours and discharged within 28 hours with a complete review of inhaler prescriptions, technique and a follow-up plan.
The collaborative plan is very patient-centric, reduces the frequency of admission and aims to facilitate people to stay in their own home in a well- supported and holistic way.
Bernie MurphyCEO of patient group COPD Support Ireland
During a series of onsite face-to-face learning sessions, teams were supported by expert RCPI faculty members to examine current practices, identify areas for improvement and apply Quality Improvement (QI) tools to implement changes to impact clinical outcomes and improve patient experience.
Between learning sessions, the teams implemented specific change ideas at local level through a methodology known as Plan > Do > Study > Act, which allows for small tests of change with immediate learning and honing of ideas to ultimately deliver sustainable, locally-owned improvement.
A key focus of the project was patient-centeredness. There was collaboration with the patient representative group, COPD Support Ireland, from the earliest opportunity, with the CEO as a member of the Working Group. Teams were encouraged to keep the patient experience at the heart of their thinking throughout the pilot.
I am pleased to see the positive results of this COPD collaborative pilot. I'm grateful to the participating sites for their hard work and enthusiasm together with CSPD for the funding to conduct this pilot. The COPD collaborative is an attempt to improve COPD care and the initial results are very exciting. With the funding now available from the CSPD, we can look forward to significant achievements in more of our hospitals with consequent improvement in the care given to our patients and reduction in the bed days related to COPD admissions.
Professor Tim McDonnellConsultant Respiratory Medicine and Clinical Lead National Clinical Programme COPD
COPD was chosen as the focus for this improvement project as it has considerable impact on quality and quantity of life for the patient, involving long term medical care, frequent hospital admissions for many and often resulting in premature death.
It was the fourth leading cause of death in Ireland in 2016.
Following this highly successful pilot, HSE Clinical Strategy and Programmes agreed to sponsor a new national quality improvement collaborative focusing on COPD.
The collaborative is being coordinated by RCPI and is fully endorsed by the National Clinical Programme for COPD.
Over the summer we invited multidisciplinary project teams to sign up to the 15-month improvement collaborative, which is completely free of charge.
19 multidisciplinary respiratory teams from all over Ireland attended the first Learning Session in City West Hotel Dublin on 11 September 2018.
With RCPI supporting us, we are part of an actual collaborative and the gravitas behind that holds sway with management. We can finally achieve real things.
Participant in St Vincent's University Hospital