Chronic obstructive pulmonary disease (COPD) is a common condition with acute exacerbations of COPD (AECOPD) or ‘lung attacks’ causing 12% of acute admissions and being responsible for more than one million bed days per annum in the UK. About a third of patients are readmitted within 90 days of discharge. Significant variations in outcomes and provision of care have been noted, implying a role for a systematic quality improvement approach. The research team has therefore wished to develop and pilot the implementation of a COPD discharge care bundle—a list of five to six evidence-based practices that should be delivered to all patients.A care bundle does not specify the entirety of care that should be delivered, but is rather a group of items that administered together should be delivered to all individuals.
Developing the care bundle
Item selection was based on national and international guidelines, a systematic literature review and input from a multidisciplinary project team described in more detail in the online supplementary material. The project team undertook a process mapping exercise to map the patient pathway from admission to discharge and follow-up. A survey, undertaken to identify elements that were important to patients, identified feelings of isolation and a lack of support postdischarge and prioritised regaining physical function. To ensure coherence within the wider health community, the bundle was discussed at meetings of the Inner Northwest London Care Community integrated service improvement programme for COPD.
The care bundle was launched on the respiratory ward at a series of multidisciplinary meetings. A survey of ward staff during the development of the project had revealed low levels of confidence regarding inhaler technique, smoking cessation and pulmonary rehabilitation, so it was clear that staff education would be important. An initial barrier to this was that it was difficult for the staff to attend teaching sessions in a group without impeding clinical work. We developed an educational model where members of the team would spend time on the ward at a stand providing teaching about topics such as smoking cessation and inhaler technique in a ‘drop in’ way. Thus, during the course of a shift all the nurses on the ward had the opportunity to be educated with minimal disruption. This led to improved confidence in these areas, which was confirmed by a staff survey. Pharmacists involved in the project took the opportunity to teach on a daily basis and developed laminated pictorial charts to attach to the drug trolley to reinforce the correct inhaler techniques required.