A lot of our focus over the past three years as a CCG has been directed at COPD. It is of course part of our Quality, Innovation, Production and Prevention agenda and we have looked at the design of the whole care pathway.
We already had a team of COPD community nurse specialists who work to keep patients on the optimum medication and out of hospital.
Although funded by, and based in, the community, the team has an office in the hospital and are an important bridge between primary and secondary care, working within the multidisciplinary team and helping to facilitate speedy discharge home of patients who have needed hospital treatment.
They are also responsible for pulmonary rehabilitation and nurse-led community follow-up clinics. GPs refer patients to them if they need more support in managing their condition or preventing exacerbations.
Despite these services, unscheduled hospital care for COPD costs us more than £1m per year.
When we looked in detail at the admission figures it was clear there were
a lot of people with COPD turning up at A&E with breathing difficulties, usually via 999 calls, who would then be admitted for a short stay.
Another issue we were aware of was the high number of patients with undiagnosed COPD. Nationally, only around a third of patients with COPD are thought to be recorded on GP systems.
No diagnosis means no proper management and support and, again, increased likelihood of ending up in hospital through the emergency route.
In mid-Essex, we have 4,000 patients with a recorded diagnosis of COPD, but based on the characteristics of our population, we believe the real figure to be more like 8,000 – which is around 2.6% of our adult population.
Analysis of the data for one month’s 999 response call-outs showed that 50% of patients needing the ambulance service for acute exacerbation were unknown to the COPD team.
It is shocking how many people suffer with a disease without seeking help for their condition.
Redesigning the 999 pathway
We were fortunate to have spent some time visiting a nurse consultant in Suffolk who was looking into the possibility of involving paramedics in redirecting these patients from the default of ‘trip to A&E’.
East of England Ambulance Service data suggested 50% of current COPD emergency admissions by ambulance could be diverted to community teams.
Through our own regular respiratory meetings, the respiratory consultant, the lead GP on long-term conditions, the COPD nurse, and the ambulance service lead discussed what the criteria for referral to the community COPD team should be and came up with a diagnostic pathway for the ambulance crews to work with.
They assess the patient at home as usual and, if they meet the criteria, they ring the COPD nurse specialist team through a dedicated mobile number. The flow chart below shows how paramedics decide whether patients can cope until the nurse arrives to see the patient within a maximum of four hours.
The start-up spend on the project was £194,000. It was also agreed that if we went above the capacity we had planned for under the new pathway, those additional patients would be taken to A&E as before, rather than overwhelming the community service.
Once the criteria were in place, the COPD nurse specialists took on the training of the ambulance staff, which occurred during their routine skilling sessions.
They also trained a couple of lead paramedics to continue with the job of cascading the pathway down to other staff. To increase capacity in the community to deal with the predicted rise in caseload, we employed two additional full-time, band-six nurses, increasing the grade of one of our existing nurses and providing extra administration capacity.
By October 2011, the referral criteria were in place and the paramedics were trained but the additional capacity in the COPD team was not yet finalised.
This led to a soft start of six months whereby if the ambulance team had a patient who met the criteria, they could call the dedicated mobile number just as they would when the project went live, and the nurses would advise them whether they had any capacity available to manage the patient.
It shows the willingness of those involved that they were keen to get the ball rolling before the full resources had been put in place.
At the moment, this is a 9am to 5pm weekday service, although by the end of November 2012 we hope to have extended that to weekends.
Unexpectedly, our data analysis showed there was as much need for the 9am to 5pm daytime service as overnight.
The pathway has been running formally since April 2012, so we do not yet have the first year’s data. But our business plan predicted that in the first year we would be able to reduce COPD referrals to acute care by 40% with a 20% increase in new diagnoses.
We estimate that from that point on we could see a 10% additional year-on-year reduction in admissions and 10% year-on-year increase in diagnoses.
In year one, this equates to a reduction of COPD admissions from 469 to 282 while, in the financial year 2012/13, we anticipate 135 fewer admissions, creating a saving in the region of £300,000.
Over the three years we expect to reduce admissions by 277, equating to a saving of £650,000.
We have also predicted we will find around 800 new cases of COPD in the first full year of the new referral pathway and a further 400 cases in years two and three, so 1,600 new cases from the 2009/10 baseline.
Promoting the service
A few months in, referrals from the ambulance to COPD team have not been what we expected.
We are currently working really hard to promote and embed the pathway through the paramedics and other routes, and are having weekly meetings with the leads from the CCG, community COPD service and ambulance service to improve the numbers.
The additional strategies we now have in place include:
⦁ Arrangements for ambulance control to contact the COPD community team when a 999 call is taken and ambulance dispatched. If the patient is known to the team they will contact the paramedics at the patient’s home and take over patient care. Frequent flyers have been flagged up with them to make this even easier.
⦁ A system where any patient who gets as far as A&E will be picked up by the COPD nurse specialist in hospital to shorten the length of stay and facilitate discharge.
⦁ Discussions with the lead nurse in A&E with a view to embedding this pathway at the triage stage to prevent admissions from COPD patients arriving by ambulance where possible.
⦁ More work to promote the pathway to the paramedics to make sure all staff are aware of the option, including a message attached to paramedics’ payslips last month.
It was a slightly faltering start, but our work suggests that this is mostly due to awareness of the pathway. We hope these strategies will quickly get us back on track with regard to redirection of referrals and reduced admissions.
It should be pointed out that even though our ambulance referrals to the community COPD team have not been as many as we expected at this early stage, just having the additional staff in the community team managing the caseload has had an impact.
The latest figures – for up to the end of July – show that admissions for COPD through A&E have fallen by 19%.
Everyone is on board with this pathway and we believe the initial stumbling blocks will be overcome as people get used to the new pathway. We need it to become the norm and that is what we are heading towards. Our next step is to widen this service to cover out-of-hours.
In future, we may also consider a triage system from ambulance control, using the same referral criteria, so rather than
a 999 call leading to an ambulance call-out, a referral could be made straight to the community COPD team, bypassing the ambulance altogether.
Depending on this pathway’s success,
we are considering widening this to
other long-term conditions, such as heart failure.
Dr Bryan Spencer is clinical vice chair and Su Stephens is business development manager, long-term conditions, at Mid Essex CCG
60 second summary
⦁ Initiative A COPD pathway where patients with COPD exacerbation who call 999 are routed by paramedics to community COPD nurses. Anticipated pathway will also engage with patients who do not know they have COPD – estimated to be as many as 4,000 in Essex
⦁ Staffing To cope with extra caseload, two full-time, band-six nurses were recruited, the grade of an existing nurse was increased and additional admin support was provided
⦁ Costs Set-up costs were £194,000 in first year
⦁ Outcomes A 19% reduction in A&E admissions in the first three months. Business plan is to reduce admissions by 277 equating to a saving of £650,000 over three years
⦁ Contact firstname.lastname@example.org