Rhona Buckingham

Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations

Background Reports of non-invasive ventilation (NIV) use in clinical practice reveal higher mortality rates than in corresponding randomised clinical trials. Aim To explore factors related to chronic obstructive pulmonary disease (COPD) admissions and NIV use that may explain some of the previously reported high mortality rates. Methods National UK audit of clinical care of consecutive COPD admissions from March to May 2008. Retrospective case note audit with prospective case ascertainment. Participating units completed a web-based audit proforma of process and outcomes of clinical care. Results 232 hospital units collected data on 9716 patients, mean age 73, 50% male. 1678 (20%) of those with gases recorded on admission were acidotic and another 6% became acidotic later. 1077 patients received NIV, 55% had a pH<7.26 and 49% (305/618) had or were still receiving high flow oxygen. 30% (136/453) patients with persisting respiratory acidosis did not receive NIV while 11% (15/131) of acidotic admissions had a pure metabolic acidosis and did. Hospital mortality was 25% (270/1077) for patients receiving NIV but 39% (86/219) for those with late onset acidosis and was higher in all acidotic groups receiving NIV than those treated without. Only 4% of patients receiving NIV who died had invasive mechanical ventilation. Conclusions COPD admissions treated with NIV in usual clinical practice were severely ill, many with mixed metabolic acidosis. Some eligible patients failed to receive NIV, others received it inappropriately. NIV appears to be often used as a ceiling of treatment including patient groups in whom efficacy of NIV is uncertain. The audit raises concerns that challenge the respiratory community to lead appropriate clinical improvements across the acute sector.

Co-morbidities and 90-day Outcomes in Hospitalized COPD Exacerbations

COPD exacerbations resulting in hospitalization are accompanied by high mortality and morbidity. The contribution of specific co-morbidities to acute outcomes is not known in detail: existing studies have used either administrative data or small clinical cohorts and have provided conflicting results. Identification of co-existent diseases that affect outcomes provides opportunities to address these conditions proactively and improve overall COPD care. Cases were identified prospectively on admission then underwent retrospective case note audit to collect data including co-morbidities on up to 60 unselected consecutive acute COPD admissions between March and May in each hospital participating in the 2008 UK National COPD audit. Outcomes recorded were death in hospital, length of stay, and death and readmission at 90 days after index admission. 232 hospitals collected data on 9716 patients, mean age 73, 50% male, mean FEV1 42% predicted. Prevalence of co-morbidities were associated with increased age but better FEV1 and ex-smoker status and with worse outcomes for all four measures. Hospital mortality risk was increased with cor pulmonale, left ventricular failure, neurological conditions and non-respiratory malignancies whilst 90 day death was also increased by lung cancer and arrhythmias. Ischaemic and other heart diseases were important factors in readmission. This study demonstrates that co-morbidities adversely affect a range of short-term patient outcomes related to acute admission to hospital with exacerbations of COPD. Recognition of relevant accompanying diseases at admission provides an opportunity for specific interventions that may improve short-term prognosis.

U.K. National COPD Resources and Outcomes Project 2008: patients with chronic obstructive pulmonary disease exacerbations who present with radiological pneumonia have worse outcome compared to those with non-pneumonic chronic obstructive pulmonary disease exacerbations.

Background: Limited comparative data exist on the outcomes of patients presenting with chronic obstructive pulmonary disease (COPD) exacerbations with or without radiological pneumonia. Objective: To examine the outcome differences amongst these patients. Methods: We analysed 2008 UK National COPD audit data to examine the characteristics, management and outcomes, inpatient- and 90-day mortality and length of stay of patients admitted with COPD exacerbations. Results: Of 9,338 admissions, 16% (1,505) had changes consistent with pneumonia indicated on the admission chest X-ray. They tended to be older (mean ages 75 vs. 72 years), male (53 vs. 50%), more likely to come from care homes, with more disability, higher BMI and co-morbidity, lower albumin but higher urea levels, and less likely to be current smokers. COPD exacerbations with pneumonia were associated with worse outcomes: inpatient mortality was 11 and 7% and 90-day mortality was 17 and 13% for pneumonia and non-pneumonia patients, respectively (p < 0.001). After adjusting for factors that are significantly different between the 2 groups, including age, sex, place of residence, level of disability, co-morbidity, albumin and urea levels, estimated risk ratios for inpatient and 90-day mortality for pneumonia compared to non-pneumonia cases in this series were 1.19 (1.01,1.42) and 1.09 (0.96,1.23), respectively. The adjusted risk ratio of a prolonged acute hospital stay of more than 7 days was 1.15 (1.07, 1.23). Conclusions: Patients who present with radiological pneumonia have worse outcomes compared to those admitted without pneumonia in exacerbation of COPD.

Current and planned palliative care service provision for chronic obstructive pulmonary disease patients in 239 UK hospital units: comparison with the gold standards framework

Patients with chronic obstructive pulmonary disease report a symptom burden similar in magnitude to terminal cancer patients yet service provision and access has been reported as poor. In the absence of a specific national chronic obstructive pulmonary disease service framework the gold standards framework might support service developments. We surveyed 239 UK acute hospital units admitting chronic obstructive pulmonary disease patients, comprising 98% of all acute trusts, about their current and planned provision for palliative care services. Only 49% of units had a formal referral pathway for palliative care and only 13% had a policy of initiating end-of-life discussions with appropriate patients. Whilst 66% of units had plans to develop palliative care services, when mapped against the gold standards framework few were directly relevant and only three of the seven key standards were covered to any significant degree. We conclude that service provision remains poor and access is hindered by a lack of proactive initiation of discussion. Planned developments in chronic obstructive pulmonary disease palliative care services also lack a strategic framework that risks holistic design.

Pulmonary rehabilitation in the United Kingdom.

We audited the UK provision of pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) and the quality of the programmes provided against national standards. All eligible UK Acute Trusts were invited to participate in a national audit of COPD in 2008. Eleven quality indicators for PR were derived from the National Institute for Health and Clinical Excellence (NICE) and the British Thoracic Society guidelines. Participants provided details of staff involved in their programme to self-assess whether they met each quality indicator in full, partially or not at all. Data were collected using a bespoke Web tool. Data were received from 239 acute units, a trust participation rate of 98%. Of the 239 units, 138 (58%) had provision of PR for all eligible patients and 76 (32%) for some but not all patients. Of these 214 PR, 13 (6%) programmes met all 11 quality indicators in full, median 8 with an interquartile range (IQR) of 7-9 for all PR programmes. One third of the programmes fully met the standards that continuation PR phases be provided, staff be trained in resuscitation and services be fully audited. Despite widespread provision of PR in the UK, the quality of programmes is variable and often less than satisfactory. Lack of funding is cited as a primary barrier to all eligible COPD patients not receiving PR. Those responsible for PR must act to improve the quality of services and audit their effectiveness before service expansion to meet future demand that can be justified.

Clinician perceived good practice in end-of-life care for patients with COPD

Patients with chronic obstructive pulmonary disease (COPD) have significant end-of-life needs, but are much less likely than patients with cancer to access or receive appropriate palliative care. Little is known about the existing availability or quality of available services within the United Kingdom. We surveyed 100 NHS acute hospitals enquiring into the provision of care for patients with COPD and requesting examples of current good practice that might be used to set standards. Forty-two percent of hospitals had formal palliative care arrangements for patients with COPD, whereas 59% had plans to develop or further develop services. Analysis of qualitative data suggested four strands that highlighted good practice; teams, care pathways, service components and linkages. These data may help to inform the debate leading to the development of standards in end-of-life care for patients with COPD.

The UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project – a feasibility study of large‐scale clinical service peer review

RATIONALE, AIMS AND OBJECTIVES Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale. METHODS All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals. RESULTS A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4-week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions. CONCLUSIONS It is possible to deliver successful large-scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation.

Managing patients with COPD exacerbation: does age matter?

INTRODUCTION there is little information about the relationship between age and management of COPD exacerbation (AECOPD), although older persons are known to be at a greater risk of hospital admission. METHODS we have investigated responses from the clinical and patient questionnaire elements of the 2008 UK COPD audit, splitting the data into age decile. RESULTS age ranged from 27 to 102. Patient-reported data suggested older patients had inferior knowledge of COPD, undertook less self-care and were less likely to recognise symptoms of exacerbation prior to hospitalisation. Clinician-reported data showed that although older patients had severe disease and symptoms, greater co-morbidity at presentation and higher mortality, fewer were seen in hospital or followed up subsequently by respiratory specialists. Older patients were more likely to have a DNR order signed within 24 h of admission, irrespective of co-morbidities or performance status. The observations were particularly applicable to those aged 80 or above. CONCLUSIONS clinicians should consider increasing age as a specific risk factor in the management of COPD. Acute units and community teams should review carefully their protocols and pathways for how they assess, manage, discharge and follow-up older patients with COPD exacerbation.

A randomized trial of peer review: the UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project: three-year evaluation.

RATIONALE Peer review has been widely used within the National Health Service to facilitate health quality improvement but evaluation has been limited particularly over the longer-term. Change within the National Health Service (NHS) can take a prolonged period--1-2 years--to occur. We report here a 3-year evaluation of the largest randomized trial of peer review ever conducted in the UK. AIM To evaluate whether targeted mutual peer review of respiratory units brings about improvements in services for chronic obstructive pulmonary disease (COPD) over 3 years. METHODS The peer review intervention was a reciprocal supportive exercise that included clinicians, hospital management, commissioners and patients, which focused on the quality of the provision of four specific evidence-based aspects of COPD care. RESULTS Follow-up at 36 months demonstrated limited significant quantitative differences in the quality of services offered in the two groups but a strong trend in favour of intervention sites. Qualitative data suggested many benefits of peer review in most but not all intervention units and some control teams. The data identify factors that promote and obstruct change. CONCLUSION The findings demonstrate significant change in service provision over 3 years in both control and intervention sites with great variability in both groups. The combined quantitative and qualitative findings indicate that targeted mutual peer review is associated with improved quality of care, improvements in service delivery and with changes within departments that promote and are precursors to quality improvement. The generic findings of this study have potential implications for the application of peer review throughout the NHS.

Introducing the national COPD resources and outcomes project

BackgroundWe report baseline data on the organisation of COPD care in UK NHS hospitals participating in the National COPD Resources and Outcomes Project (NCROP).MethodsWe undertook an initial survey of participating hospitals in 2007, looking at organisation and performance indicators in relation to general aspects of care, provision of non-invasive ventilation (NIV), pulmonary rehabilitation, early discharge schemes, and oxygen. We compare, where possible, against the national 2003 audit.Results100 hospitals participated. These were typically larger sized Units. Many aspects of COPD care had improved since 2003. Areas for further improvement include organisation of acute care, staff training, end-of-life care, organisation of oxygen services and continuation of pulmonary rehabilitation.ConclusionKey Points: positive change occurs over time and repeated audit seems to deliver some improvement in services. It is necessary to assess interventions such as the Peer Review used in the NCROP to achieve more comprehensive and rapid change.