The national COPD clinical audit report COPD: who cares matters, published today, shows that some aspects of care have improved since the last audit in 2008, but is still not good enough in many areas.
COPD (chronic obstructive pulmonary disease) is the collective term for emphysema and chronic bronchitis, and is mainly caused by smoking. People with COPD have breathing difficulties, which can affect the quality of their everyday life. Flare-ups of COPD, also termed exacerbations, are a major cause of hospital admission, disability, and mortality. Treatment can help to manage COPD but there is no cure. COPD: who cares matters describes the care of 13,414 patients admitted to hospital as a result of their COPD flaring up. The audit sample is believed to be the biggest collected worldwide to date, comprising patients from 183 acute units/142 NHS trusts in England and 16 units/six health boards in Wales (a 100% NHS trust/health board recruitment rate) between 1 February and 31 April 2014.
The National COPD Audit Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme (NCA)*. The National COPD Audit Programme is led by the Royal College of Physicians, working closely with stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society UK (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).
It is encouraging that mortality in hospital has reduced from 7.8% in 2008 to 4.3% in 2014 (though the reason for this is far from clear) and that the median length of stay has reduced from five to four days over the same time. There has been a large rise in the number of patients able to leave hospital early due to early/supported discharge schemes – from 18% in 2008 to 40% in 2014. Management of the sickest patients has generally improved.
However, the audit found that standards of care differ greatly across England and Wales, findings also observed in the survey of organisation and resourcing of COPD care published in November 2014. Both audits found that patients had variable access to specialist respiratory care. In the clinical audit, although patients were seen and treated promptly on admission, there were often significant delays in getting a specialist opinion from a member of the respiratory team to patients needing to stay in hospital. Many patients were managed on non-respiratory wards. Importantly, 45% of patients were discharged within 3 days, many of whom had no contact with respiratory specialists, and one in five patients were not seen by a respiratory expert at all during their stay. The same audit showed that patients received much better evidence-based care when seen by respiratory specialists.
Weekend care was also an issue, with far fewer patients being discharged. The percentage of patients seen by the respiratory team within 24 hours of admission was also notably less for those patients admitted on Fridays (47%), Saturdays (39%) and Sundays (58%) compared to other days (62‐66%).
There was also room for improvement in five key clinical areas:
- Correct prescribing of oxygen, known to reduce the risk of death, was absent in the care of 32% of patients.
- Smoking cessation support (the only intervention that alters the long-term prognosis and reduces recurrent admission risk in COPD): only 58% of patients who smoked had evidence of smoking cessation advice being given and there was wide variation across sites.
- An MRC dyspnoea (breathlessness) score, a key predictor of outcome and disability, was only recorded in 61% of cases, although this was an improvement on the 46% reported in 2008.
- Recording of spirometry, the key diagnostic test for COPD, was available in only 46% of cases, worse than the 54% recording found in the 2008 audit.
- 44% of patients had no assessment made for pulmonary rehabilitation at the point of discharge.
All of these necessary processes were more likely to have been delivered when patients were seen by a member of the respiratory specialist team.
The report makes detailed recommendations for commissioners and for hospitals including:
- Patients admitted with COPD exacerbation should receive a respiratory specialist opinion within 24 hours, 7 days a week.
- Hospitals should appraise carefully their staff rosters at weekends and on Mondays, the former having the lowest rate of discharges and the latter the highest rate of admission and longest times to clinical review.
- Patients with COPD exacerbation who need onward hospital care after their stay on the medical admissions unit should be managed in a respiratory ward.
- Hospitals should reappraise their complement of respiratory beds to ensure it reflects their size and respiratory/COPD admission burden.
- There needs to be better coordination of care at the point of discharge, and better linkage into community COPD services, so that COPD patients benefit from onward expert respiratory care after they have left hospital
For further recommendations see the executive summary below.
Dr Robert Stone, COPD audit clinical lead for secondary care said:
We seem to be managing the ‘front end’ of the admission better, but there is a problem getting respiratory specialists (who provide better evidence-based care than the non-specialists) to patients in a timely fashion, particularly at weekends. Many patients don’t get to see a respiratory specialist and there remains a major issue getting the patients onto a respiratory ward. For this reason we are recommending, amongst other things, that patients should receive a specialist opinion within 24 hours; those that need to stay in hospital beyond 24 hours should be cared for on a respiratory ward.
Professor Mike Roberts, lead for the national COPD audit programme said:
The audit highlights how much medical care has changed since 2008. There is better acute care for patients but shorter inpatient stays mean the opportunity to benefit from seeing a specialist is often missed, particularly at weekends. Systems need to improve to ensure all patients receive the best care, 7 days a week and regardless of their length of stay.
Dr Bernard Higgins, chair of the BTS said:
The British Thoracic Society welcomes the latest report from the national COPD audit programme which shows significant improvement in several aspects of COPD care. We congratulate all those whose hard work has helped achieve this. There is, however, room for us to do better still and we believe that the key to this is to provide expert respiratory care during every hospital stay for COPD patients, and to develop systems to extend this provision of expert care into the community.
For more information about the COPD national clinical audit or to arrange an interview with a spokesperson, please contact Linda Cuthbertson, head of PR, on 0203 075 1254 / 0774 877 7919, or email Linda.Cuthbertson@rcplondon.ac.uk
- Chronic obstructive pulmonary disease (COPD) is a common and usually progressive disease and is a leading cause of mortality and morbidity globally: the World Health Organisation estimates that COPD is responsible for 5% of annual deaths globally. It causes progressive breathlessness with cough and wheeze, punctuated by exacerbations (flare-ups) that may lead to hospital admission. While 835,000 people in England have been diagnosed with the disease, a further two-million people with COPD may be unidentified (Department of Health, 2010). COPD is the fifth-biggest killer in the UK and the only major cause of death on the increase. Respiratory disease is the third-leading cause of death in England, with approximately 23,000 people dying from COPD each year[1]. More than six-million people in England suffer with COPD or asthma. Respiratory disease is one of the principal reasons for emergency admission to hospital
- The National COPD Audit Programme brings together primary care, secondary care, pulmonary rehabilitation and patient experience. This national audit programme comprises comprehensive multidisciplinary, collaborative working and aims to drive improvements in the quality of care and services provided for COPD patients in England and Wales. It is led by the RCP, working closely with a range of key stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).
*About HQIP, the National Clinical Audit Programme and how it is funded
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.