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• National COPD Collaborative in Progress in Ireland (Response to Morton et al (2019) paper)
  Orla Woods, Lucia Prihodova, Rachel MacDonell, John Brennan, Richard W Costello and Tim J McDonnell
  Published on: 2 September 2019

• Published on: 2 September 2019

  National COPD Collaborative in Progress in Ireland (Response to Morton et al (2019) paper)

  • Orla Woods, Post-Doctoral Researcher with the National COPD Collaborative Royal College of Physicians of Ireland
  • Other Contributors:
    • Lucia Prihodova, Research Manager; Post-Doctoral Researcher
    • Rachel MacDonell, Programme Manager National COPD Collaborative
    • John Brennan, Quality Improvement Faculty; General Practitioner
    • Richard W Costello, Respiratory Consultant
    • Tim J McDonnell, Respiratory Consultant

  We read with interest the recent study by Morton et al. A “National COPD Collaborative” quality improvement (QI) initiative (The Collaborative) which is currently on-going in Ireland is also evaluating the efficacy of bundles, amongst other interventions, in improving COPD care. Running from September 2018 to December 2019, the Collaborative comprises 18 consultant-led teams in 19 hospitals across the country working to improve care for patients presenting with an acute exacerbation of COPD (AECOPD). The Collaborative is being run by the Royal College of Physicians of Ireland (RCPI) in conjunction with the Clinical Strategy and Programmes Division of the Irish Health Service Executive (HSE) and the National Clinical Programme for COPD within the HSE.
  COPD is a major health burden in Ireland, as in the UK; based on the 2011 census (total population 4,588,252 [1]), it is estimated that at least 440,000 people in Ireland have COPD (of whom over 180,000 have moderate or severe disease) [2]. In 2015, Ireland had the highest rate of COPD hospital admissions out of all OECD countries [3]. The cost burden of COPD on the HSE is substantial; in 2014, the total cost of COPD hospitalisations was €70,813,040.00 [4]. According to the OECD, the average length of hospital stay (LOS) for COPD in Ireland in 2017 was eight days[5].
  Prior to the initiation of the National COPD Collaborative, treatment of AECOPD within the acute Irish healthcare setting was highly varied; many a...

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  We read with interest the recent study by Morton et al. A “National COPD Collaborative” quality improvement (QI) initiative (The Collaborative) which is currently on-going in Ireland is also evaluating the efficacy of bundles, amongst other interventions, in improving COPD care. Running from September 2018 to December 2019, the Collaborative comprises 18 consultant-led teams in 19 hospitals across the country working to improve care for patients presenting with an acute exacerbation of COPD (AECOPD). The Collaborative is being run by the Royal College of Physicians of Ireland (RCPI) in conjunction with the Clinical Strategy and Programmes Division of the Irish Health Service Executive (HSE) and the National Clinical Programme for COPD within the HSE.
  COPD is a major health burden in Ireland, as in the UK; based on the 2011 census (total population 4,588,252 [1]), it is estimated that at least 440,000 people in Ireland have COPD (of whom over 180,000 have moderate or severe disease) [2]. In 2015, Ireland had the highest rate of COPD hospital admissions out of all OECD countries [3]. The cost burden of COPD on the HSE is substantial; in 2014, the total cost of COPD hospitalisations was €70,813,040.00 [4]. According to the OECD, the average length of hospital stay (LOS) for COPD in Ireland in 2017 was eight days[5].
  Prior to the initiation of the National COPD Collaborative, treatment of AECOPD within the acute Irish healthcare setting was highly varied; many aspects of the COPD hospital care pathway, including the diagnosis of COPD at presentation, LOS, treatment approaches and availability of respiratory consultant-led team(s) dedicated to in-patient care of AECOPD (as opposed to out-patient care), were not standardised between hospital sites. As Morton et al imply, improving care for patients with AECOPD relies on appropriately expert clinicians reliably following evidence based practice. Therefore, the National COPD Collaborative is attempting to improve and standardise the treatment of COPD/AECOPD patients across participating hospitals, at the following stages:
  1) Presentation (e.g. time from registration to first medical review; time from registration to decision to admit)
  2) Admission (e.g. time from registration to first respiratory specialist review; LOS; DECAF assessment [6], documented COPD diagnosis – spirometry; chest x-ray; steroids and route [PO/IV], antibiotics and route [PO/IV])
  3) Discharge (e.g. inhaler technique; script review with patient; written self-management plan; follow-up)

  In order to effect improvements in the care of AECOPD across participating hospital sites, the Institute for Healthcare Improvement “Breakthrough Series Collaborative” is being used to build QI capability amongst teams. Individual teams employ the “Model for Improvement” [7] , which utilises Plan, Do, Study, Act (PDSA) cycles, to bring about change. One of the primary aims of the National COPD Collaborative is to facilitate participating acute respiratory teams in the development their QI skills which will, therefore, allow them to apply QI methods to bring about treatment improvements at a local level.
  Evaluation of the Collaborative focuses on assessment of monthly patient data which is submitted by each hospital for 22 measures related to the care of AECOPD at presentation, admission and discharge (the “bundles”); these will be analysed over time using run charts for QI purposes.
  The hospital phase of the National COPD Collaborative will be completed by September 2019. Morton et al note that “Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation”. We speculate that should any improvement in patient care be demonstrated at the end of the National COPD Collaborative, this change may be due, at least in part, to the enthusiastic engagement of sites with QI methodology which allows them to adapt QI processes to the needs of their own hospital, while standardising care for patients with AECOPD nationally.

  References
  1. CSO. Census through History. 2019 30 July 2019]; Available from: https://www.cso.ie/en/census/censusthroughhistory/.
  2. Jennings, S., Preventing chronic disease: defining the problem. 2014, Health Service Executive
  3. NPSO, National Healthcare Qualtiy Reporting System Annual Report 2018, N.P.S. Office, Editor. 2018, Department of Health.
  4. COPDSI, Manifesto for COPD, C.S. Ireland, Editor. 2015.
  5. OECD. Hospital average length of stay by diagnostic categories: Chronic Obstructive Pulmonary Disease and bronchiectasis. 2017 30 July 2019]; Available from: https://stats.oecd.org/index.aspx?queryid=30165#.
  6. Steer, J., J. Gibson, and S.C. Bourke, The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax, 2012. 67(11): p. 970-6.
  7. Langley, G., et al., The Improvement Guide: A practical Approach to Enhancing Organizational Performance. 2nd ed. 2009, San Francisco: Jossey-Bass Publishers.

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  Conflict of Interest:
  None declared.

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