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National COPD Audit

VIEWS: 3 PAGES: 16

									 The effect of unit organisation and
resources on outcomes of hospital
admission for COPD exacerbations.

RCP / BTS National COPD Audit 2003

         H Hosker, K Anstey,
    D Lowe, M Pearson, M Roberts
         ERS abstract # 3039
         UK National COPD Audit
                  Aims

   To provide a national benchmark for the
    management of COPD exacerbations,
    allowing regional / local comparisons
   To determine which aspects of resources
    and / or organisation of care explain
    variability of outcomes
   To raise the profile of COPD locally and
    nationally
         UK National COPD Audit –
                 Methods
   Conducted during September 2003 to February 2004
    by Royal College of Physicians / British Thoracic
    Society
   Resources pro forma for each unit, detailing
    aspects of organisation of care in addition to
    resource availability
   Retrospective case note audit of 40 consecutive
    patients (identified prospectively) admitted with
    exacerbation of COPD
   247 acute units (96% of eligible trusts) in the UK
    registered to take part
   236 units completed the audit
UK National COPD Audit
Resources: Suggested quality indicators

 Numbers of doctors available to treat
  COPD
 HDU / ITU on site
 Availability of NIV on site
 Access to respiratory nurse care
 Availability of early discharge scheme
 Availability of pulmonary rehabilitation
  program
UK National COPD Audit
Organisation of care: Suggested quality
 indicators

 Consultant-led PTWR twice daily
 Specialty triage
 Early warning system or ITU outreach
 Admissions ward
 Specialist respiratory ward
 Local written management guidelines
Composite Organisation of care score (total 14 points)
       Ward-based system
       2 daily consultant-led PTWRs
       Specialty triage
       Integrated admissions policy
       Early warning system or ITU outreach
       Admissions ward
       Early discharge scheme (EDS)
       Specialist respiratory ward
       HDU on site
       >median ICU beds / 1,000 beds
       Availability of Invasive ventilation and NIV
       Formal pulmonary rehabilitation program
       All patients have access to a respiratory nurse
UK National COPD Audit


Results: Organisation
    and Resources
        UK National COPD Audit –
       Results From Clinical Cases

   8,013 admissions registered (7,529 patients)
   Mean age 71 years, 53% male
   Mean FEV1 = 37% predicted
   Inpatient mortality 7.4% (IQR 3-11%)
   90 day mortality 15.3% (IQR 9-21%)
   Median LOS 6 days (IQR 5-7 days)
   90 day readmission rate 31.4% (IQR 22-40%)
          UK National COPD Audit
             National Results
   Resources

       7% units – no respiratory consultant on site
       26% units –1 or less WTE respiratory consultant
       44% units – early discharge scheme (mainly
        nurse-led)
       64% had a pulmonary rehabilitation scheme
       18% no HDU
       4% no ITU
       11% no NIV
          UK National COPD Audit –
              National Results
   Organisation of care

       88% units had an admissions ward
       57% had 2 daily PTWRs
       65% specialist respiratory ward
       33% use specialty triage
       61% had EWS / outreach
       9% had no access to a respiratory nurse
       >95% bed occupancy
 Impact of Resources / Organisation
        of Care on Outcomes
25% of variance is explained by patient factors:
   Performance status
   Age
   Blood urea
   SaO2
   Arterial pH
   Albumin
   (FEV1)
   (Previous admission)
 Impact of Resources / Organisation
        of Care on Outcomes
Length of stay (> 7 days) was reduced in units with :


More respiratory consultants (>2.3 per 1,000 beds)
      OR 0.81 for LOS > 7 days, 0.75 for LOS > 14 days
Access to an Early Discharge Scheme
      OR 0.69 for LOS > 7 days
      14% of all admissions entered an EDS
Local written COPD management guidelines
      OR 0.84 for LOS > 7 days
Composite organisational score of 14 factors
      OR 0.80 for LOS > 7 days, 0.83 for LOS > 14 days
 Impact of Resources / Organisation
   of Care on Outcomes (cont’d)
Mortality rates:
   Mortality rates were lower in units with a staff
    ratio of >4 respiratory consultants per 1,000
    beds:
   Inpatient mortality: OR 0.67 (CI 0.50 - 0.90)
   90 day mortality: OR 0.75 (CI 0.60 – 0.94)
   Similar trends for junior doctor numbers and
    all respiratory staff but not for general
    physicians
 Impact of Resources / Organisation
        of Care on Outcomes
Readmission rates:
   No organisational or resource factors were
    identified which affected 90 day readmission
    rates at unit level


Size of hospital / hospital ‘star ratings’:
   No significant association between size of
    hospital or ‘star rating’ on any outcome
   0 and 1 star hospitals: trend towards a higher
    mortality
             National COPD Audit
                 Conclusions
   Mortality and readmission rates vary greatly between
    units
   Resources and organisation of care influence patient
    outcomes of admission for acute exacerbations of
    COPD
   Readmission rates do not seem to be influenced by
    hospital resources / organisational factors
   Organisational factors and number of respiratory
    consultants affect length of stay
   Mortality rates are influenced by number of
    respiratory consultants per 1,000 beds
   More respiratory consultants might be a marker of
    better resources and result in better organisation of
    care within a unit

								
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