A Prudent Approach to Managing People with Chronic Obstructive Pulmonary Disease
Timothy Asibey-Berko, Mark Andrews, Leanne Griffin, Rob Bevan, Rhys Howell, Gautham Appanna, and Keir Lewis
Hywel Dda UHB, ABMU Health Board, Cardiff University, Bevan Commission and Swansea University
Chronic obstructive pulmonary disease (COPD), is the third leading cause of mortality worldwide (J. Vestbo 2013) and is the second commonest cause of admission to hospital. Non-invasive positive pressure ventilation (NPPV) is recommended to treat respiratory failure (A. B. Lumb 2014) but its provision across Wales is inconsistent and where it is delivered within hospitals is variable and imprudent. Although normally delivered on High Dependence Units (HDU), NPPV may be better and safely delivered on medical wards.
Prudent Principle 1
Achieve health and wellbeing with the public, patients and professionals and as equal partners through co-production.
We looked at clinical outcomes and sought the opinions of 14 doctors and 26 nurses caring for people with COPD on the HDU. Opinions of patients who have experienced NPPV will be sought in future stages of the project. The majority of staff felt that while NPPV was beneficial and had short term benefit it was neither cost effective when carried out on the HDU nor should it be restricted to use on the HDU.
Prudent Principle 2
Care for those with the greatest health need first, making most effective use of all skills and resources.
Our data shows a year on year rise in admissions to HDU for people requiring NPPV for COPD. We therefore considered how we might deal with this most prudently. 85% of professionals agreed that providing NPPV for COPD patients in HDU was beneficial in the short term but 63% felt it was not cost effective and 68% felt that NPPV could be safely done on the wards.
Prudent Principle 3
Do only what is needed, no more, no less and do no harm.
98% of staff agreed that a documented ceiling of treatment should be set prior to admitting patients to HDU but data shows this was done in only 14% of cases. 5% of patients died on HDU but 95% were successfully treated requiring an average of 6.8 days, with 19% requiring intubation. A further 10% died whilst on other wards but over 85% were discharged after spending a further 10 days in hospital. Markedly Staff had a worse impression of the benefits of NPPV on discharge rates than actual data indicated (Figure 1).
Prudent Principle 4
Reduce inappropriate variation using evidence based practices consistently and transparently.
Despite National and International Guidelines, 98% of the staff interviewed were not aware of an effective scoring system to help determine which patients would benefit most from NPPV. Some were unaware that NPPV is offered on the medical wards in a neighbouring hospital within the same Health Board and overall outcomes have not been compared.
Impacts and future actions
- Compare outcomes for people receiving NPPV in units across Wales to better inform patients and staff as there may be some negativism about the benefits of NPPV.
- Promote discussion of the potential inappropriate use of NPPV resource that could be equally well delivered outside a HDU setting, freeing HDU beds for other patients.
- Identify opportunities to train and educate staff to ensure greater consistency and application of NPPV across Wales.
- Engage patients and carers to identify opportunities to support them in managing their own COPD which best fits their needs.
- Inform National policy and service leads to ensure Prudent NPPV use in Wales.
Part of Cohort Bevan Fellows 2015-16