COPD care improves but ‘still not good enough’ audit finds
Published: 27 Aug 2015
The national COPD clinical audit report COPD: who cares matters, published today, shows that some aspects of care have improved since the last audit in 2008, but is still not good enough in many areas.
COPD (Chronic Obstructive Pulmonary Disease) is the collective term for emphysema and chronic bronchitis, and is mainly caused by smoking. People with COPD have breathing difficulties, which can affect the quality of their everyday life. Flare-ups of COPD, also termed exacerbations, are a major cause of hospital admission, disability, and mortality. Treatment can help to manage COPD but there is no cure. COPD: who cares matters describes the care of 13,414 patients admitted to hospital as a result of their COPD flaring-up. The audit sample is believed to be the biggest collected worldwide to date, comprising patients from 183 acute units/142 NHS Trusts in England and 16 units/6 health boards in Wales (a 100% NHS Trust/health board participation rate) between 1 February and 31 April 2014.
The National COPD Audit Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme (NCA)*. The Audit Programme is led by the Royal College of Physicians, working closely with stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society UK (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).
It is encouraging that mortality in hospital has reduced from 7.8% in 2008 to 4.3% in 2014 (though the reason for this is far from clear) and that the median length of stay has reduced from five to four days over the same time. There has been a large rise in the number of patients able to leave hospital early due to early/supported discharge schemes – from 18% in 2008 to 40% in 2014. Management of the sickest patients has generally improved.
However, the audit found standards of care differ greatly across England and Wales, findings also observed in the survey of organisation and resourcing of COPD care, published in November 2014. Both audits found that patients had variable access to specialist respiratory care. In the clinical audit, although patients were seen and treated promptly on admission, there were often significant delays in getting a specialist opinion from a member of the respiratory team to patients needing to stay in hospital. Many patients were managed on non-respiratory wards. Importantly, 45% of patients were discharged within three days, many of whom had no contact with respiratory specialists, and one in five patients were not seen by a respiratory expert at all during their stay. The same audit showed patients received much better evidence-based care when seen by respiratory specialists.
Weekend care was also an issue, with far fewer patients being discharged. The percentage of patients seen by the respiratory team within 24 hours of admission was also notably less for those patients admitted on Fridays (47%) and Saturdays (39%) and Sundays (58%) compared to other days (62-66%).
There was also room for improvement in five key clinical areas:
- Correct prescribing of oxygen, known to reduce the risk of death, was absent in the care of 32% of patients.
- Smoking cessation support (the only intervention that alters the long-term prognosis and reduces recurrent admission risk in COPD): only 58% of patients who smoked had evidence of smoking cessation advice being given and there was wide variation across sites.
- Recording of MRC dyspnoea (breathlessness) score, a key predictor of outcome and disability, was only recorded in 61% of cases, although this was an improvement on 46% reported in 2008.
- Recording of spirometry, the key diagnostic test for COPD, was available in only 46% of cases, worse than the 54% recording found in the 2008 audit.
- 44% of patients had no assessment made for pulmonary rehabilitation at the point of discharge.
- All of these necessary processes were more likely to have been delivered when patients were seen by a member of the respiratory specialist team.
The report makes detailed recommendations for commissioners and for hospitals including:
- Patients admitted with COPD exacerbation should receive a respiratory specialist opinion within 24 hours, seven days a week.
- Hospitals should appraise carefully their staff rosters at weekends and on Mondays, the former having the lowest rate of discharges and the latter the highest rate of admission and longest times to clinical review.
- Patients with COPD exacerbation who need onward hospital care after their stay on the medical admissions unit should be managed in a respiratory ward.
- Hospitals should reappraise their complement of respiratory beds to ensure it reflects their size and respiratory/COPD admission burden.
- There needs to be better co-ordination of care at the point of discharge, and better linkage into community COPD services, so that COPD patients benefit from onward expert respiratory care after they have left hospital.