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How we help COPD patients self-manage

The award-winning Easington COPD community scheme is keeping patients out of hospital using a pathway developed by a PBC group. Hugo Minney and Joseph Chandy explain

The award-winning Easington COPD community scheme is keeping patients out of hospital using a pathway developed by a PBC group. Hugo Minney and Joseph Chandy explain

Easington in County Durham is a COPD hotspot. It is a former mining community with a large proportion of elderly people and smokers. The prevalence of the disease is 2.8% – twice the national average – and COPD is the second most common cause of hospital admission.

When Easington PBC cluster looked at unplanned care, we found that COPD was the second highest cost to the group.

We looked at methods that offered safe alternatives to calling an ambulance or going into hospital that were closer to home. The lack of an acute hospital in Easington means patients and their carers face a journey of about six miles to Hartlepool or Sunderland hospitals.

Looking at what we had

In 2007 our PBC cluster, made up of 17 practices with 100,000 patients, established a multidisciplinary working group which included GP practices, ambulance services, patients and health professionals from acute trusts and social services as well as ICE (Intermediate Care in Easington).

ICE is a multi-agency team that provides intensive rehabilitation at home following an acute admission, A&E visit or crisis at home. ICE is a partnership between County Durham PCT and Durham County Council.

41215382We found that a COPD group was already running as part of the former PCT, which included some work by Hazel Betteney, the PCT pharmacist adviser. She had started a patient-centred self-management plan so patients could self-treat as soon as they felt symptoms coming on and this was brought into the current scheme.

The second thing we did was bring together the ambulance trust, social services, district nursing, urgent care and the intermediate care team. Sunderland Hospital, mainly used by patients in the northern half of the cluster, had access to the ICE team but patients admitted to Hartlepool and North Tees did not.

The ICE team assesses patients who have gone to hospital after an exacerbation, then takes them home and sets up a package of home care. We realised that we could capitalise on ICE's capacity and training.

Staff resources and some facilities were already in place, meaning we have been able to set up the new pathway using these resources. But it has been PBC that has given us the power to bring these elements together and develop them further.

Action plan

We developed two pathways to avoid hospital admissions and improve management for patients with COPD.

The first was a self-management plan, which includes a flow chart so that patients know what to do in the event of an exacerbation, and a medication pack with a single dose of steroids that they can take.

The second was a new exacerbation pathway that offers patients early attendance by a specialist clinician followed by the ICE team for up to five days. We have also worked with the out-of-hours emergency care practitioners (ECPs) so that they can administer medication (under patient group directives) before the ICE team arrives.

The option to attend A&E is always available in both pathways.

We also worked with the ambulance trust and are about to launch a pathway whereby when a patient dials 999, the ambulance comes out as normal, but the paramedic knows how to assess the patient and decide whether they are safe to be managed under ICE.

1 The self-management plan

We found that although many patients experienced exacerbations in the early morning, they would often wait until the GP surgery opened before calling the practice, then end up calling an ambulance. Using the self-management plan avoids the delay – which was often four hours – before management of the exacerbation starts.

The COPD self-management plan was launched in November last year and is primarily aimed at those patients with the potential for multiple admissions in a year.

Patients are given a flow chart outlining what to do during the initial stages of an exacerbation. They are given a handheld record so they can monitor their progress, which can be reviewed by the case manager, and their medication pack. The GP, in conjunction with the case management team, decides in advance how their medication should change in the event of an exacerbation. The patient is also given a case manager's telephone number and numbers for out-of-hours help.

The flow chart asks patients to tick which boxes apply to them that day:

• ‘I am more breathless'
• ‘I am coughing more phlegm/sputum'
• ‘My phlegm/sputum has changed colour to yellow or green'

If no boxes are ticked, the patient should continue use of reliever until feeling better.

One box or more moves the patient on to more questions to decide what to do next.

Two or three boxes ticked means patients should start their medication pack and call the case manager's number.

Some 63 patients are now on the self-management plan, which empowers them to make their own decisions and choices. Patients like the chart and find it easy to follow. They find it reassuring to be able to work their way down the chart and not necessarily have to do something. Their relatives can also work through it with them.

2 New exacerbation pathway

The new COPD emergency pathway was introduced in June this year so that if patients reach the point of exacerbation, they can be clinically assessed and offered the choice of being managed at home or taken to A&E (see attached flow chart). This is possible whether the patient is already on the self-management plan or not. If they choose to remain at home they are given a five-day package of care by the ICE team, starting with an assessment within two hours by the ICE team.

If the exacerbation happens out of hours, the emergency care practitioners, who are prescribers, can come and administer medication before the ICE team (non-prescribers) arrives.

Initially this care package is mostly nursing and towards the end it is mostly social care. At any time the patient can choose to attend A&E if they prefer, and if they are unable to make or communicate this choice they are automatically taken to A&E.

When the patient is discharged by the ICE team they come back to the practice for pulmonary rehabilitation to prevent future exacerbations.


All this has been achieved within resources already in place, apart from the cost of hiring a car for the urgent care centre so their ECPs can administer medication out

of hours. None of the services involved has had to increase its capacity and the only start-up cost was pump-priming money to pay for the time of those who attended multidisciplinary pathway design meetings, which was very little.

The ICE team numbers about 100 in total and includes nursing staff, therapy staff, social work staff, administrative staff and residential staff plus a team of peripatetic homecare workers allied to the team. Nobody has had to be employed specifically for the scheme but they have all been brought together under one umbrella.

We have a contractual arrangement with North Tees Hartlepool NHS Foundation Trust for a large number of the therapy staff. All members of the team are located in a council premises, which lends itself to effective multidisciplinary working. The consultant from the local acute trust has been supportive of the scheme.

We believe it is a massive achievement to have got agreement on such a pathway between all the different agencies.

We look at each admission to see whether it could have been avoided and we consider referring the patient for pulmonary rehabilitation.

We plan to widen access to oxygen assessment and pulmonary rehabilitation, which is currently restricted to those with severe COPD. At the moment patients can only join at the start of an eight- or 12-week programme – we want them to be able to dip in and out when they've had an exacerbation.


The total cost of admitted care with COPD as primary diagnosis was £348,509 in 2006/7 so there is substantial opportunity to release resources.

The exacerbation pathway should also reduce patient attendance at hospital. This is especially valuable in Easington where every trip to hospital means a substantial journey for patients, carers and visitors. The current total secondary care cost, from which we hope to use resources to provide community services, was £390,367 in 2006/7.

As empowered patients are easier to work with, we expect to show that it makes a difference to the health professionals dealing with them too.

Out of 15 cases studied, eight patients felt that by using these pathways they avoided a 999 call or A&E attendance that they would otherwise have made.

Out of 53 uses of the home management pack, 70% resulted in self-management, 19% used the medication pack and just 11% used the emergency care pathway.

Most of those questioned felt they were managing their condition better than in the previous year.The pathway is not designed to deny patients hospital admission if they want it – it's to offer them more choice.

Hugo Minney is commissioning development manager at Shinwell Medical Group.

Joseph Chandy is PBC chair for Easington

With thanks to: Carol Hardy, clinical champion at County Durham PCT, Sue Hook, manager at ICE, Hazel Betteney, acting senior pharmaceutical adviser, medicines management commissioning, County Durham PCT, Linda Wells, ICE lead nurse, and Esther Mireku, PBC cluster manager, for their contributions to this article

Easington PBC group won the 2008 NAPC partnership award for its work on COPD

60-second summary Joseph Chandy (centre) and Hugo Minney (sitting right) with the Easington and ICE team members Joseph Chandy (centre) and Hugo Minney (sitting right) with the Easington and ICE team members Eastington COPD self management plan Eastington COPD self management plan

Eastington COPD self management plan

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