Problem Acute exacerbations of COPD are a major cause of hospital admission and readmission. National surveys have revealed significant differences in patient outcomes which are likely to be due to variations in care.
Design A care bundle, comprising a short list of evidence-based practices to be implemented prior to discharge for all patients admitted with this condition was developed, based on a review of National Guidelines and other relevant literature, expert opinion and patient consultation. Implementation was then piloted using action research methodologies in an urban acute hospital.
Key measures for improvement Improvements in process measures based around the items in the care bundle were the provision of smoking cessation advice, referral for pulmonary rehabilitation, and review of inhaler technique. A 72 h post-discharge phone call was evaluated. Data from the first year of the bundle were compared with the year prior to its initiation including 30-day readmission rate.
Strategies for change The care bundle was launched with events to ensure staff awareness. Weekly meetings were held with review of bundle compliance so that areas for attention could be addressed promptly. A plan, do, study, act (PDSA) cycle approach was used. Examples included ongoing support to develop ward nurses' knowledge of correct inhaler use, nurses attending pulmonary rehabilitation sessions and the use of a “safe discharge” checklist.
Effects of change Referral to pulmonary rehabilitation increased by 158% and compliance with assessment for smoking cessation was 100%. Nurse confidence in inhaler technique improved. Roughly 10% of post discharge phone calls identified a cause for concern. The 30-day readmission rate was 10.8% for patients where the bundle was used (n=94) compared to 16.4% where it was not (n=365) (95% CI for difference −2.1% to 13.2%). The bundle has been accepted onto the list of CQUIN measures by London SHA and is being rolled out to further sites.
Lessons learnt Actively involving all staff is vital to ensure that the changes introduced are understood and the process followed. Implementation of a care bundle has the potential to produce a dramatic improvement in compliance with optimum health care measures.
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