Acute Back Pain Audit

Public Health Wales / COPD
Chronic Obstructive Pulmonary Disease (COPD)
Quality improvement toolkit
Author:Primary Care Quality and Information Service
Date: July 2008 / Version:1
Status:Final
Intended audience: Public (Internet) / NHS Wales (Intranet) /PHW (Intranet)
The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publication
Purpose and summary of document:
This document is for use by general practitioners treating patients with a diagnosis of COPD. The purpose of this toolkit is to support practices to review and reflect on the service they provide and the information they record following patients COPD consultation.
This audit may be of particular interest to clinicians who have seen the recent WeMeReCBulletin (No ) and the accompanying distance-learning education module (No 25). This audit is designed to reinforce the summary of evidence and the main points within the Bulletin and case study.
This toolkit provides patient review criteria and guidance on how to complete a straightforward small-sample audit. Also included is a review section that follows each timed audit phase. This is designed to prompt reflection and comment on the results of the audit process. Completion of this audit would constitute a suitable piece of Continuing Professional Development that could be included within the appraisal process.
Publication / distribution:

Publication in PHW document database (Primary Care Quality and Information)
Link from PHW e-bulletin

Page Number

Contents

Introduction and background3

Aim of the quality monitoring toolkit3

Methodology3

Exclusion / Inclusion Criteria4

Audit Criteria4

Reference6

Links 6

Appendix A -Data collection sheet7

Appendix B -Practice Review Sheet8

Appendix C -Assessment of severity scale9

Appendix D -Sampling Matrix10

Appendix E -Read Codes11

1Introduction and Background

Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is not fully reversible and is usuallyslowly progressive.1

COPD generally affects those over the age of 35yrs who have a risk factor (invariably a history of smoking) presenting with symptoms of persistent cough, sputum production, or dyspnoea and / or a history of exposure to risk factors for COPD1,3,4,5

COPD is a common disabling condition with a high mortality. The most effective way to reduce deterioration is smoking cessation. Oxygen therapy has been shown to prolong life in the later stages of the disease and has also been shown to have a beneficial impact on exercise capacity and mental state. Many patients respond symptomatically to inhaled beta agonists and anti-cholinergics. Some patients respond to inhaled steroids. Pulmonary rehabilitation has been shown to produce an improvement in quality of life.
The majority of patients with COPD are managed by general practitioners and members of the primary healthcare team with onward referral to secondary care when required.2

2Aim

This small-sample audit offers criteria on which to base a review of the care offered to patients with COPD in a general practice setting. The audit is designed to reinforce the summary of evidence and the main points within the WeMeReC COPD Bulletin and case study. The audit aims to support practices to assess whether the care provided to patients diagnosed with COPD reflects best practice.

3Methodology

3.1Use retrospective data over a12 month period

3.2Set a start and end date for the audit

3.3Compile a list of patients from the practice computer system of all patients with a diagnosis of COPD on practice register

3.4Select a patient sample (suggest using sampling matrix - Appendix D), to a maximum of 50 patients with a diagnosis of COPD

3.5Collect relevant data and record using the data collection sheet provided

(See Appendix A)

3.6Collate and analyse results of the data collection process

3.7Reflect on the results of the audit and decide any changes to practice that you consider appropriate (Using the practice review form enclosed – Appendix B)

3.8Decide on a date to re-audit to confirm changes (if recommended)

The PCQIS recognises that some of the criteria in this audit may involve data that is not currently kept routinely by the practice. Therefore it is recommended that for this audit the practice consider recording this information prospectively, so that these criteria could be successfully reviewed in any future audits of this type.

Inclusion Criteria

Any patient with a recorded diagnosis of COPD at least 6 months previously

Exclusion Criteria

Patients with a recent diagnosis of COPD (Any patients who have had recent eye, chest orabdominal surgery, or who have recently had amyocardial infarction or cerebrovascular accident should not be exposed to Spirometry for six weeks following such an episode 3,4

Audit Criteria

1)All patientswith a record of a diagnosis of COPD have had the following investigations;

a)Chest X-Ray

b)FBC

c)BMI

d)Pulse Oximetery

2)The patient has a record of Spirometery within the audit periodY/N

3)The patient has a record of reversibility testing recordedY/N

4)The patient has a FEV1recorded during the audit periodY/ N

(See appendix C)

5)The patient has a FEV1/FVC recorded during the audit periodY/ N

6)The patients COPD has been classified and recorded as one of the following

a)Mild

b)Moderate

c)Severe

7)MRC Severity score recorded in the last 15 months (See Bulletin for dyspnoea scale)

8)The patient has a smoking status recordedY / N

9)If yes has smoking cessation advice been offeredY/N

10) The patient has a record of short acting bronchodilator (SABA) Prescribed Y/N

11) The patient has a record of Long acting bronchodilator (LABA) prescribed Y/N

12)The patient has a record that inhaler technique has been checked Y/N

13)The patient has a record of 2 or more exacerbation within the audit period Y/N

14)If yes how manyCOPD related hospital admissions has been recorded

a) 2-3 admissions

b)4-6 admissions

c)More than 6 admissions

15)The patient has a record of being on regular inhaled steroidsY/N

16)How many courses of Oral Corticosteroids has been prescribed within the audit period

a)None

b)1-3

c)4-5

d)More than 5

17)How many courses of antibiotics has been prescribed for exacerbations within the audit period

a)None

b)1-3

c)4-5

d)More than 5

18)Medication review recorded Y/ N

19)Has the patient been given a written self-management plan Y/N

20)All patients with a BMI of less than 20 has been referred to a dieticianY/N

21)All patients who’s FVC has fallen by 500ml or more over the last 5 years has been referred to a respiratory specialist Y/N

22)The patient has a record of influenza immunisation recorded in the last 15mthsY/N

23)The patient has a record of pneumococcal immunisationY/N

References

1National Institute of Clinical Excellence

2Welsh Assembly Government. GMS Contract Quality and Outcomes

Framework Disease Prevalence 2008/9.

3Anon. Global Strategy for the Diagnosis, Management and Prevention of

COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2007.

4British Thoracic Society (1997) BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax 52(suppl5),S1-S28

5Association for respiratory technology and physiology (1994) Guidelines for the measurement of respiratory function. Respiratory medicine 88,3,165-194

6Welsh Medicines Research Centre (WeMeReC); Chronic Obstructive Pulmonary Disease Bulletin (June 2008)

Links

Below is a list of web sites associated with diagnosing and managing COPD.

British Thoracic Society. BTS COPD Consortium was established in 1997 when the BTS COPD Guideline was published. It aimed to provide related educational materials for healthcare professionals;and to raise the profile of this "cinderella disease" amongst health professionals, patients and policy makers.

Welsh Medicines Research Centre (WeMeReC); Chronic Obstructive Pulmonary Disease Bulletin (June 2008)

Clinical Knowledge SummaryCovers the management of people with persistent symptoms of chronic obstructive airways disease (COPD). Also covered management of exacerbations and end stage COPD.

NICE CG12 Chronic obstructive pulmonary disease guideline.

GOLD Guidelines: Global imitative for chronic obstructive lung disease (GOLD)sets out to improve prevention and treatment of this lung disease.

General Practice Airway’s group

Author
Primary care quality and information service / Date
July 2008 / Status; Final
WeMeReC COPD Audit Version; 0g / 1 / Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS
Public Health Wales / COPD

Appendix A

Data Collection Sheet

Patient / 1a / 1b / 1c / 1d / 2 / 3 / 4 / 5 / 6a / 6b / 6c / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14a / 14b / 14c / 15 / 16a / 16b / 16c / 16d / 17a / 17b / 17c / 17d / 18 / 19 / 20 / 21 / 22 / 23 / Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Total
Author
Primary care quality and information service / Date
July 2008 / Status; Final
WeMeReC COPD Audit Version; 0g / 1 / Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS
Public Health Wales / COPD

Appendix B

Practice Review Sheet

A. What lessons did the practice discover from carrying out this audit?

B. What changes, if any have the practice agreed to implement as a result of this audit?

C. What support would enable the practice to enhance the service it provides to patients?

This audit was compiled by;

Name(s) ______

Signature(s) ______

Practice (name and address)

______

Appendix C

Assessment of severity scale

The following scale is an assessment of the severity of airflow obstruction based on FEV1 as a percentage of predicted value.

NICE / FEV1 / GOLD
- / >80% / Stage1:Mild
Mild / 50-80% / Stage11:Moderate
Moderate / 30-49% / Stage111:Severe
Severe / <30% / Stage1V:Very Severe

(Adapted from NICE and Global Initiative for Chronic Obstructive Lung Disease(GOLD)guidelines)6

Appendix D

Sampling Matrix

Population size
Total number of patients with COPD / Sample size:
95% confidence; +/- 5%)
50 / 44
100 / 79
150 / 108
200 / 132
500 / 217
1000 / 278
2000 / 322
5000 / 357

United Bristol Hospital Trust 2008

Appendix E

Read Codes

The following are suggested read codes for COPD monitoring and diagnosis:

H3…Chronic obstructive pulmonary disease

H31.. Chronic bronchitis

H310.Simple chronic bronchitis

H3100 Chronic catarrhal bronchitis

H310zSimple chronic bronchitis NOS

H32..Emphysema

H32z.Emphysema NOS

H36..Mild chronic obstructive pulmonary disease

H37..Moderate chronic obstructive pulmonary disease

H38..Severe chronic obstructive pulmonary disease

H3y..Other specified chronic obstructive airways disease

H3y0.Chronic obstructive pulmonary disease with acute lower respiratory infection

H3y1.Chronic obstructive pulmonary disease with acute exacerbation, unspecified

H3z.Chronic obstructive airways disease NOS

173H.MRC Breathlessness Scale: Grade 1

173I.MRC Breathlessness Scale: Grade 2

173J.MRC Breathlessness Scale: Grade 3

173K.MRC Breathlessness Scale: Grade 4

173L.MRC Breathlessness Scale: Grade 5

Author
Primary care quality and information service / Date
July 2008 / Status; Final
WeMeReC COPD Audit Version; 0g / 1 / Intended audience: Public (Internet) / NHS (Intranet) PHW (Intranet) / PCQIS