COPD Team in Swansea Bay University Health Board; Service Progression and Evaluation

Purpose

Chronic Obstructive Pulmonary Disease (COPD) is characterised by breathlessness, wheeze, cough and sputum production.  Symptoms frequently worsen, known as exacerbation, which can lead to hospital admission.  COPD admissions are costly for the NHS and patients alike, but are considered avoidable by effective preventative care.

Since data analysis in 2017 there has been further investment in the team owing to positive outcomes. An additional physiotherapist, exercise technician and occupational therapist (OT) have joined. Since July 2021, the Welsh Ambulance Service can refer exacerbating patients, further enhancing admission avoidance services.

The purpose of this service review is to describe, analyse and reflect upon the development of a service that has evolved from an early discharge service (EDS) to include admission avoidance in primary care for patients with an acute exacerbation of COPD and the impact of increasing multidisciplinary team (MDT) input.

A secondary objective is to inspire and encourage other services to invest in MDT support for patients, to optimise patient care, improve quality of life and avoid admission to hospital.

95%
of patients experience a further reduction in disease burden (CAT).
Total service cost avoidances are £868,133
December 2016 to March 2020.

Approach

A retrospective service evaluation of patient reported outcome measures (collected pre and post intervention), readmission, financial and health board data were collated from the team database.

Outcomes

In 2016/17 the COPD Team received 389 referrals.  This increased by 73% to 674 for 2019/20 as a result of increased staffing. 93% of referrals are seen within 1 working day, demonstrating an efficient response.

The COPD Assessment Test (CAT) demonstrated a reduced disease burden in 96% of patients.  The EQ5D5L assessment shows 82% of patients experienced an improvement in quality of life and the visual analogue scale (VAS) score measuring perceived health status improved in 94% of patients.

Subjectively, 92% of patients rated the COPD Team as “good” or “very good”.

After stabilisation, patients are offered a six week home exercise programme (HEP) with the technician. Outcomes improve beyond that achieved after clinical and self-management interventions. After a HEP, 95% of patients experience a further reduction in disease burden (CAT). 78% have improved quality of life (EQ5D5L) and 90% further improve their VAS score. There is 100% patient satisfaction.

Average length of stay (LOS) for COPD exacerbation locally was 8.33 days.  With COPD Team EDS, LOS reduced to 4.2 days, saving 4.13 days per patient, per admission. In a four month period,  91 bed days were saved, enhancing patient flow and experience.

The 3 month readmission rate with COPD Team support is 12.5% compared to the national average of 43% RCP (July 2020). This represents a huge cost avoidance and reduction in secondary care burden.

During exacerbation, admission to hospital is likely (NHS England 2014).  Of exacerbating patients referred by a GP, 67% avoided admission as well as 89% of self-referrals.

Staff feedback demonstrates the value of working within a MDT.  It provides the clinician with different perspectives, wider skill sets and different treatment options, creating positivity, confidence, support and empowerment.

Cost and savings

Additional staffing was acquired from existing monies within the Pulmonary Rehabilitation service as staff were reallocated to better suit service need. The service is running cost neutrally; the cost savings and avoidances generated outweigh staffing and resource costs. Financial estimations do not include savings from reduced emergency service use, GP appointments and wasted medication.

Over a four month period there was an £11,812 cost avoidance, as through reduced LOS, £537 per patient per admission was saved. Combined with reduced readmission costs in this period this increases to £41,050. Primary care cost avoidances were £35,736 (avoided admissions from GP and self-referrals). Total primary and secondary care cost avoidances were £76,786 over a four month period.

The cumulative potential cost avoidances from December 2016 to March 2020 are £210,871 for LOS/bed days savings and £657,262 for reduced readmission and admission avoidance. Total service cost avoidances are £868,133 for December 2016 to March 2020.

Implications

The COPD Team provides a timely and cost effective service that leads to a greater proportion of the COPD population receiving appropriate care. The benefits of the service can be measured in terms of cost savings, reduced LOS, improved patient flow, admission avoidance and improved patient outcomes. Increased staffing leads to greater referral numbers and potential for achieving significant outcomes.  Providing rapid proactive care at the right time, in the right place and by the right MDT is key to effective COPD care.

Data collection and analysis will continue to inform future service development. OT data will be incorporated and examined. Greater staffing has allowed the team to pursue extended scope activities such as independent prescribing, spirometry, phlebotomy and capillary blood gases. Skill set enrichment reduces burden on other healthcare services, as well as the burden of additional appointments for the patient and the team will continue to develop.

Learning will be shared within professional networks, local and national networking and educational events.  The positive impact of providing tailored, extended scope MDT care closer to home will continue to be promoted.  It is hoped other teams can be inspired and supported through experience-sharing in reallocating resources without the need for vast amounts of additional funding.

 

Top three learning points

  1. Quality data collection is vital to support service development
  2. Providing domiciliary COPD care is safe, effective, economical and preferred by patients
  3. MDT utilisation creates holistic, effective care for patients and a supportive and flexible working environment for staff with good job satisfaction.

Funding acknowledgements

This work was unfunded. After initial Welsh Assembly Government money in 2016, further staffing was obtained via sharing of resources across the Pulmonary Rehabilitation service in Swansea Bay University Health Board.

Additional notes

The initial abstract for this piece of work can be accessed at:

https://www.csp.org.uk/innovations/copd-early-discharge-service

https://www.rcplondon.ac.uk/copd-outcomesreport  National Asthma and COPD Audit Programme (NACAP) 2020.   COPD clinical audit 2018/19. Accessed 19/11/2021.

https://www.england.nhs.uk/wp-content/uploads/2014/02/rm-fs-6.pdfNHS England 2014.Overview of potential to reduce lives lost from Chronic Obstructive Pulmonary Disease (COPD). Accessed 19/11/2021