COPD Secondary Care Audit

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COPD Secondary Care Audit Good Practice Repository – Oxygen Version 1: June 2018

Introduction The National Asthma and COPD Audit Programme (NACAP) have collated a series of case studies which highlight good practice in both audit data collection and entry, and in provision of quality COPD care. This

document aims to provide teams with learning to implement locally, and with ideas on how local practice could be improved.

As part of the snapshot secondary care organisational audit (conducted between 3 April and 30 June 2017) question 6.9 of the dataset requested hospitals to develop and submit an improvement plan based on the

audit data. Following an extensive review of the submitted plans some selected examples of good practice have been included. These entries can be identified by the asterisk (*) which follows their hospital and trust name.

Do you have any questions? If you have any questions about any of the content, or would like more detail about any of the case studies, please contact the NACAP team on 020 3075 1526 or via email ([email protected]).

For further information on NACAP, please visit www.rcplondon.ac.uk/nacap.

Contents Macclesfield District General Hospital (East Cheshire NHS Trust).............................................................. 2

Lister Hospital (East and North Hertfordshire NHS Trust) ......................................................................... 2

Queen Alexandra Hospital (Portsmouth Hospitals NHS Trust) .................................................................. 3

Ipswich Hospital (The Ipswich Hospital NHS Trust.................................................................................... 3

Royal Derby Hospital (Derby Teaching Hospitals NHS Foundation Trust) ................................................... 3

Norfolk & Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust)* 4

Whittington Hospital (Whittington Health NHS Trust)* ............................................................................ 5

Queen Elizabeth Hospital King’s Lynn (The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust)* .. 5

Appendices ........................................................................................................................................... 6

Norfolk and Norwich observation charts – Submitted by Lister Hospital (East and North Hertfordshire

NHS Trust)......................................................................................................................................... 6

Anonymised drug chart – Submitted by Ipswich Hospital (The Ipswich Hospital NHS Trust) .................... 8

Prescription card – Submitted by Queen Alexandra Hospital (Portsmouth Hospitals NHS Trust) ............. 9

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Good Practice Repository – Oxygen | Version 1: June 2018 National Asthma and COPD Audit Programme [email protected] | 020 3075 1526 | www.rcplondon.ac.uk/nacap of 9

90% of patients admitted to Lister

Hospital with an exacerbation of

COPD were prescribed oxygen, and

100% were prescribed to target

oxygen saturation.

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Macclesfield District General Hospital (East Cheshire NHS Trust)

The oxygen prescription is printed within the patient drug

prescription sheet.

The oxygen guidelines are available in a laminated form

within all clinical areas.

The integrated respiratory team are on ward everyday reviewing patients and providing guidance to staff in relation

to oxygen administration.

The Chronic Respiratory Early Warning Score (CREWS) has been introduced.

Junior doctors and nursing staff are regularly trained in oxygen prescription.

To find out more, contact details for Macclesfield District General Hospital can be obtained from the COPD

audit team.

Lister Hospital (East and North Hertfordshire NHS Trust)

We have a 7 day respiratory service comprising of a respiratory consultant and clinical nurse specialist which enables us to capture

patients admitted within 24 hours to implement an

appropriate management plan.

The respiratory nursing team

is active in education, auditing, and reinforcing the importance of oxygen

prescribing and titration to achieve target level oxygen

saturations.

Oxygen has a dedicated area on the prescription chart to enforce prescription to set target saturation. In addition a nurse’s signature is required on each drug round.

We have a dedicated respiratory nurse leading in oxygen that, through the use of screen savers on every PC in the Trust, re-enforces the message.

Posters are displayed next to the oxygen outlet to remind the nurses about prescribing and target saturation.

We are in the process of implementing individual oxygen target saturation notes to stick above each patient’s bed to remind nursing staff when giving oxygen and performing observations.

The national average of the percentage of patients admitted with an exacerbation of COPD that were

prescribed oxygen was 72%. Of those on average 97% of patients were prescribed oxygen to target

saturation. (Calculated between May 2017 and May 2018)

Since February 2017 100% of

patients at Macclesfield District

General Hospital were prescribed

oxygen to target saturation.




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We promote the use of the BTS oxygen competency e-learning tool on our knowledge centre, and provide a certificate to staff that complete it.

Our oxygen lead nurse has worked solely on our respiratory ward for 3 months implementing the change over to the use of the Norfolk and Norwich observation charts, which are designed specifically around

the target oxygen saturations.

To find out more, contact details for Lister Hospital can be obtained from the COPD audit team.

Queen Alexandra Hospital (Portsmouth Hospitals NHS Trust)

Historically our trust had a below average rate of oxygen prescription.

In the 2015 BTS Emergency Oxygen Audit Queen Alexandra Hospital had oxygen target saturations

prescribed for only 35% of patients who were using oxygen, compared to a national rate of 53%.

Our Specialist COPD Team began work in October 2017

and in our first month we have managed to improve oxygen prescription to 100% for our COPD patients.

The trust uses a prescription card that is pre-printed with a range of target saturations to select from.

The COPD Specialist Team aims to review patients with an acute exacerbation of COPD within 24 hours of their admission. Part of the team’s admission bundle is to ensure that oxygen is prescribed to target

saturations where appropriate. The team promotes the completion of the prescription, liaising with the medical team responsible for the patient’s care.

To find out more, contact details for Queen Alexandra Hospital can be obtained from the COPD audit team.

Ipswich Hospital (The Ipswich Hospital NHS Trust)

Our paper drug chart is pre-populated with oxygen. The prescriber has only to sign, date the prescription and ring the target saturation appropriate to the

patient. The oxygen section on the chart is located next to a

DVT prophylaxis pre-printed prescription. We

encourage junior doctors to ensure both oxygen and DVT prophylaxis are prescribed appropriately.

To find out more, contact details for Ipswich Hospital can be obtained from the COPD audit team.

Royal Derby Hospital (Derby Teaching Hospitals NHS Foundation Trust)

The trust has achieved consistent high rates of oxygen prescription within the national COPD audit and previous BTS Oxygen audits. In addition our practise in this area has been awarded an innovation award and has been recognised as outstanding by CQC.

The trust has an oxygen team, comprising a respiratory clinician lead and 3 specialist nurses.

Since September 2017 100% of

patients admitted to Lister Hospital

with an exacerbation of COPD were

prescribed oxygen, and all were

prescribed to target oxygen

saturation.

On average 97% of patients admitted to

Ipswich Hospital that required oxygen

for an exacerbation of COPD were

prescribed it. Of those 100% were

prescribed to target oxygen saturation.




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The service is integrated, looking after home oxygen patients and with a clinical nurse specialist (CNS) who acts as in reach oxygen

nurse for the trust.

We have developed a trust wide guideline for the safe

prescription of oxygen therapy based on the prescription of target saturations for all patients admitted to the trust irrespective of their presenting complaint.

All patients admitted are issued with target saturations wristbands.

We have developed an automated electronic alert within our results management system for all acute

hypercapnic respiratory failure patients. The alert highlights these patients and takes the teams through a care bundle.

We have developed an 88-92% template on the electronic EWS monitoring system which has improved titration of oxygen.

Our in reach nurse visits wards with more frequent oxygen use, to prompt safe management, early

weaning of patients on oxygen and supports initiation of home oxygen.

Weekly audits are performed on the ward areas looking at prescription of oxygen and this is fed back to the

wards and the respiratory performance dashboard. Prizes are occasionally awarded to the best performing areas!

Chronic hypercapnic respiratory failure patients are identified from the community by the addition of an

alert on the whiteboard system that is accessed by primary and secondary care.

Regular training during induction is provided in oxygen safety. An e-learning training pack has been

developed to ensure nurses are updated every 3 years.

To find out more, contact details for Royal Derby Hospital can be obtained from the COPD audit team.

Norfolk & Norwich University Hospital (Norfolk and Norwich University Hospitals NHS Foundation Trust)*

The National COPD audit in 2015 had shown that oxygen prescribing was poorly conducted in the trust.

We set up a working group and invited the main stakeholders in the unit, including trust management.

The working group developed an action plan to improve oxygen prescription which included: o reviewing existing guidance,

o ensuring that an official operating policy was in place,

o ensuring that patient medication records and

oxygen charts were fit for the purpose of prescribing oxygen,

o developing a training package to be made

available on the trust learning site, o identifying oxygen champions, and

o developing a communication strategy.

Improvement within the trust was measured by regular spot checks of oxygen prescribing and titration and also participation in the national COPD audit and

previous BTS emergency oxygen audit.

“ We have an active oxygen safety

group, chaired by the trusts head of

patient safety. “

On average 85% of patients

admitted to Norfolk & Norwich

University Hospital that required

oxygen for an exacerbation of COPD

were prescribed it. Of those 100%

were prescribed to target oxygen

saturation.




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Whittington Hospital (Whittington Health NHS Trust)*

We have a long-standing oxygen prescription chart that is included on the single drug chart for every

patient admitted to the hospital.

Our FY1 and FY2 receive oxygen prescribing

teaching including practical procedures induction which has received excellent feedback.

Oxygen prescribing guidance is included on our

COPD proforma and the oxygen guidelines, aligned with BTS guidelines, are available on our intranet.

Queen Elizabeth Hospital King’s Lynn (The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust)*

In order to improve on the low number of patients requiring oxygen being prescribed it they introduced the following: o Regular monitoring via oxygen audits, this

ensured that oxygen was only delivered by those that had been appropriately trained,

o Teaching and informing junior doctors of good practice on departmental induction as well as snapshot educational sessions.

o Educational posters on oxygen administration were disseminated, as well as screen savers implemented on trust PC’s.

On average between February and

December 2017, 99% of patients admitted

to Whittington Hospital that required

oxygen for an exacerbation of COPD were

prescribed it. Of those 100% were prescribed

to target oxygen saturation.

On average between February and December

2017 92% of patients admitted to Queen

Elizabeth Hospital King’s Lynn that required

oxygen for an exacerbation of COPD were

prescribed it. Of those an average of 93%

were prescribed to target oxygen saturation.




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Appendices

Norfolk and Norwich observation charts – Submitted by Lister Hospital (East and North Hertfordshire NHS Trust)




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Anonymised drug chart – Submitted by Ipswich Hospital (The Ipswich Hospital NHS Trust)




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Prescription card – Submitted by Queen Alexandra Hospital (Portsmouth Hospitals NHS Trust)



COPD Secondary Care Audit

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