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Lung Improvement Programme – Transforming Acute Care Liz Norman Senior Respiratory Nurse Specialist

Elizabeth.Norman@nhct.nhs.uk

0191 293 4253

3 Streams

• NIV – reducing door to mask time

• COPD Extended Care Bundle

• Increasing access to specialist care

• Door to mask time

• Specialist care

• LOS

• Readmission rates

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Improving access to specialist care

What we did – RNS

• Independent facilitator

• Use of data to drive change

• Identified what got in the way of doing the job

• Time –often doing the bare minimum

• Fragmented day/week, overstretched and interrupted

• General dogs body for extra work no one else picks up

• Lack of understanding from others about the role and

time pressures

• Managing patient expectations

• Session held to ‘drill down’ barriers

• Identified what we could do to change and RNS key aims

Using job plans for more efficiency

• Sessional job plans for structure and focus • Demand and capacity work with OSM • Identified peaks and troughs in work pattern • Restructured each RNS week -Based on information from

mapping event, RNS priorities and demand and capacity figures

– Reduced O/P clinics – now working to full capacity

– Reduced Supported discharge visits – freed up time for work identified as a higher priority (FoH)

– Organised time for admin and teaching – Prioritised acute care/assessments for inpatients as

key to quality patient care and staff/job satisfaction

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Why focus on acute care?

• The RNS team identified the following: – Patients are the reason we do our job

– Every inpatient should have a specialist assessment

– Assess all patients and see all newly diagnosed patients

– Promote early discharge

– Identify sick patients – prompt NIV – ensure sick patients transferred to a respiratory ward

– Promote self management

– Reduce length of stay

– Reduce re-admissions

Data –% COPD patients stay on a respiratory ward

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Recovery post austerity measures

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Number patients seen by Respiratory Nurse Specialists

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Implementing a Care Bundle

• Aim:

– 6 quality standards for all patients with COPD

– Design of the document

– Engaging staff to implement - Target those with the least resistance! Those who already input with the patient we used the pharmacists!

– Staged roll out

– Data collection – recruit your audit team

– Feedback on performance

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Length of stay by ward and site

Length of stay

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Mean

W2

WGH

Median W2

WGH

Mean

W17

WGH

Median W17

WGH

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W18 NT

Median W18

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Mean

W24 NT

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W24 NT

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WGH P = 0.66 NTGH P = 0.0046

Readmissions

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5.0%

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30.0%

bundle pre bundle bundle pre bundle bundle pre bundle bundle pre bundle

W2 WGH W17 WGH W18 NT W24 NT

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30 day readmissions

90 day readmissions

Re - Admissions with respiratory cause

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NIV

• In Situ:

– Established Physio led service

– Robust protocols

– Consultant support for difficult decision making

• Aims:

– Controlled oxygen as default throughout the hospital

– Minimise delays “door to mask time”

Predicting mortality in AECOPD requiring ventilation

Steer, Gibson, Bourke: ERS 2012, NIV prize

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NIV

• Mapping event – identified delays (door to mask time)

• Walked through the process on the shop floor – This identified simple steps for improvement – i.e

supply of blood gas syringes

• Used data to inform decisions – Local data

– Research evidence on mortality

– Continuous feedback – data collected

NIV – Reducing Door to Mask Time

• Human factors: clinician and physio – Inappropriate extended controlled O2 trials

– Feedback and support

• Organisational – CXR request by triage nurse?

• Median time from assessment to CXR = 19.5 – 65 mins

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NIV

• Root cause analysis for specific problems

• Individuals taught when necessary

• Education package targeted two groups:

– Consultants & Emergency care staff

– Physiotherapists

– Education package focused on improved decision making

– Emphasised support available/treatment protocols

Median door to mask time

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Learning

• Project management

• Time to reflect and develop

• Using evidence and local data to inform decisions

• Linking national and local data

• Identifying risks and gaps

• Knowing what is good

• How to manage change

• The strategy can be applied to other conditions/departments