Self-management care plans for patients with severe chronic obstructive pulmonary disease: a quality improvement project
Intended for healthcare professionals
Evidence and practice    

Self-management care plans for patients with severe chronic obstructive pulmonary disease: a quality improvement project

Sarah Ann Durber Advanced nurse practitioner, Peel House Medical Practice, Accrington Pals Primary Health Care Centre, Accrington, Lancashire, England

Why you should read this article:
  • To be aware that acute exacerbations of chronic obstructive pulmonary disease (COPD) are a significant public health challenge worldwide

  • To read about a quality improvement project in general practice that aimed to support self-management for people experiencing acute exacerbations of severe COPD

  • To recognise the important role of practice nurses in leading the delivery of self-management education to patients with chronic conditions

Self-management of chronic conditions is not a new concept, but it is often underused in primary care. This article describes the development, implementation and outcomes of a quality improvement project in an English general practice that aimed to ensure 100% of patients with severe chronic obstructive pulmonary disease (COPD) had a personalised self-management care plan in place within a six-month period between January 2020 and July 2020. The intention was to standardise COPD care among healthcare professionals and empower patients to recognise symptom changes faster to reduce acute exacerbations of COPD, hopefully leading to a reduction in hospital admissions. An evidence-based self-management template was designed and embedded into routine care for all patients with COPD. Project delivery involved the use of telephone and remote consultations. The project achieved its aim, with general practice nurses having a crucial role in its success.

Primary Health Care. doi: 10.7748/phc.2023.e1822

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@sarahannwillia3

Correspondence

sarah.durber@nhs.net

Conflict of interest

None declared

Durber SA (2023) Self-management care plans for patients with severe chronic obstructive pulmonary disease: a quality improvement project. Primary Health Care. doi: 10.7748/phc.2023.e1822

Published online: 20 December 2023

Chronic conditions, such as chronic obstructive pulmonary disease (COPD), are one of the main causes of death and disability globally. COPD is the third leading cause of death in the world, with 3.23 million deaths in 2019 (World Health Organization 2023). International and national policy focuses on the need to support patients to self-manage COPD (National Institute for Health and Care Excellence (NICE) 2019, World Health Organization 2020, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023).

A GOLD (2023) report proposed a new definition of COPD as ‘a heterogeneous lung condition characterised by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction’.

An acute exacerbation of COPD is defined as an acute episode in the natural course of the disease that is indicated by a change in the patient’s baseline cough, dyspnoea and sputum, beyond the normal day-to-day variation, that also requires additional medicines (GOLD 2023). These exacerbations pose a significant public health challenge and place a substantial burden on healthcare systems worldwide. Hogea et al (2020) indicated that exacerbations are important causes of suboptimal health status, morbidity and mortality. In addition, frequent exacerbations are linked to inexorable decline in lung function (Hogea et al 2020) and therefore a reduction in physical activity (Dury 2016), impaired quality of life and even increased risk of death (Pumar et al 2014).

There are an estimated 130,000 emergency admissions to hospital due to COPD, with a total overall cost of £48.5 billion, making it one of the most expensive diseases treated by the NHS (Managing Adult Nutrition 2020). In 2021, the author of this article, who is an advanced nurse practitioner in a general practice, developed a quality improvement project as part of their master’s degree to introduce personalised self-management care plans for patients with severe COPD. The aim was to standardise COPD care among healthcare professionals and empower patients to recognise symptom changes faster to reduce exacerbations, hopefully leading to a reduction in emergency hospital admissions. This article describes the development, implementation and outcomes of the quality improvement project.

Significance of chronic obstructive pulmonary disease

COPD is the second leading cause of unplanned hospital admissions in the UK, with north west England being the most affected region (NICE 2019, British Thoracic Society 2020). The Nuffield Trust (2023) identified that many of these admissions are avoidable through supported self-management and early recognition and treatment of COPD exacerbations. North west England has high levels of mortality, deprivation and low income (Office for Health Improvement and Disparities 2021). There is a clear association between COPD hospital admission rates and social deprivation (Lee et al 2019), which emphasises the need for improved self-management services, especially in these deprived areas, where the author’s practice is located.

National guidelines and self-management

For self-management to be effective, patients should know how to monitor their symptoms when they are stable and how to take appropriate action when their symptoms deteriorate (NICE 2019). Many patients are often proficient in recognising worsening symptoms associated with their condition (Goodwin et al 2010). Approximately one third of patients who have a hospital admission related to COPD in the UK are readmitted within 90 days. There is evidence to suggest that self-management plans are an important intervention to empower patients to manage their disease more independently, thus potentially reducing the burden on secondary care (Kong and Wilkinson 2020).

National guidelines state that all patients with a diagnosis of COPD should have a personalised self-management care plan in place, which should be reviewed at least annually (NICE 2019, GOLD 2023). The advantages of self-management in COPD have been reinforced by a Cochrane review by Lenferink et al (2017), which confirmed positive outcomes in terms of respiratory-related hospital admissions and health-related quality of life. It is particularly important that people with severe COPD engage with self-management due to the burden of their disease. Severe COPD is defined as forced expiratory volume in one second (FEV1) being 30% to 49% of predicted volume (NICE 2023). FEV1 is the measure of how much air a person can exhale in a single breath. A person with severe COPD will likely have a chronic cough and find it challenging to exercise or do daily activities (GOLD 2023).

Key points

  • Acute exacerbations of chronic obstructive pulmonary disease (COPD) can have significant adverse effects on patients and healthcare systems

  • A quality improvement project was developed to introduce personalised self-management care plans for patients with severe COPD

  • The project achieved its aim of 100% of patients with severe COPD having a self-management care plan in place, thereby improving compliance with national standards

  • Significant factors in the success of the project included the enthusiasm of general practice nurses and the use of telephone and remote consultations

Project development

An unpublished audit in the author’s practice revealed that 19% (n=154/810) of all patients with a diagnosis of COPD had a self-management care plan in place, but only 13% (n=29/226) of those with a diagnosis of severe COPD had a self-management care plan in place. The aim of this project was that 100% of patients with severe COPD would have a personalised self-management care plan in place within a six-month period between January 2020 and July 2020.

The Berwick (2013) report on improving the safety of patients in England identified the need to place the quality of patient care above all other aims. At the beginning of this project it was identified that improvement in compliance with national guidelines was vital to enhance patient care and standardise practice across healthcare professionals.

Engaging key stakeholders

Key stakeholders were informed of the audit finding that only 13% of patients with a diagnosis of severe COPD had a self-management care plan in place. The key stakeholders were initially identified as the business manager, the GP partners, the advanced nurse practitioner team and the respiratory lead nurse. They were made aware of how the current situation was hindering the organisation, to establish a sense of urgency in delivering an innovation for change and drive the project forward. By engaging these key stakeholders early in the development of the project, a shared vision was established. There were several early adopters who were keen to help develop the project, as they saw a benefit for the organisation and patients. Although the general practice nursing team were not initially identified as key stakeholders, they wanted to develop and champion the project.

At the outset, GPs were regarded as crucial participants, but some of them perceived the project as an additional strain on their already demanding schedules. It was hypothesised that they would develop a sense of urgency and help to deliver and establish the structure of the self-management care plans, consequently aiming to comply with national guidelines (NICE 2019, GOLD 2023). However, it became apparent that general practice nurses were better suited for this and, after in-depth discussions, it was agreed that the practice nursing team would be the main healthcare professionals responsible for undertaking the project. The GPs who were initially hesitant quickly became adopters of change. General practice nurses are well-placed to lead the delivery of self-management education to patients because they are frequently the first point of patient contact and are often involved in all stages of care (Fletcher and Dahl 2013).

Developing a shared vision

A series of inclusive, problem-solving meetings was set up during the planning stages to generate ideas and solutions to the barriers that were identified. One of the main drivers for change in a project is the ability to make it sustainable by embedding it within the team’s thinking and their actions (Parkin 2009). This sentiment is echoed by Alvesson and Sveningsson (2016), who consider individual contributions vital in the structure and implementation of any service change.

Following the meetings, the general practice nursing team were convinced of the necessity of the project and their attitudes became a driver in changing other key stakeholders’ attitudes and behaviours. The general practice nursing team helped the author to develop a template for a self-management care plan for patients with severe COPD that could be personalised. This template included succinct information about their condition, how to recognise signs of an exacerbation and how to manage these at home, and when to contact the practice for advice. To ensure that it was evidence-based, the NHS England and NHS Improvement (2020) guide to supported self-management was used to develop the self-management care plan.

Roles and responsibilities

At the author’s practice, healthcare professionals’ understanding of COPD and self-management appeared to be varied. Due to different levels of experience, some general practice nurses felt they lacked the appropriate skills, knowledge or education to be able to adequately provide education on self-management, whereas others felt they lacked the time to be able to adequately give the correct information. These issues were identified as a potential barrier for the project, so training was included during the initial stages of the project. Education, communication, support and time are crucial for staff as they become familiar with the change (Lewin 1947, NHS England 2018). To make the transition easier, the new personalised self-management care plan was embedded into the COPD template on the practice’s electronic clinical records system so that it was easily accessible to all healthcare professionals when undertaking an annual review and to reduce variations in clinical practice.

Data collection

Ethical approval was sought from the GP partners to conduct a data search of potential patients who would benefit from this quality improvement project. The approval was given on the grounds that any data collected were anonymised to protect patient privacy and data confidentiality.

Baseline data were collected from the practice’s electronic clinical records system by the administration staff, who were familiar with data collection and auditing. The demographic data collected included age, gender, date of COPD diagnosis, current medicines, self-management care plan issued, and the number of exacerbations and/or admissions to hospital in the past 12 months. Baseline data were consequently compared with further data obtained during the implementation phase. Therefore, the quality improvement project as a whole can be considered a comparator (Simpson et al 2018).

Addressing challenges

The NHS (2019) Long Term Plan indicated that over the next ten years the NHS would offer a ‘digital-first’ option. General practice has been under considerable strain for many years (McKinstry 2017). Alternatives to face-to-face consultations have been explored, including the addition of a telephone-first approach to attempt to ease demand on services (Newbould et al 2017). The project was being conducted in a general practice that already used telephone triage managed by the advanced nurse practitioner team for patients with minor illness. However, on 23 March 2020 it was announced that GP practices must move immediately to total digital triage with remote management wherever possible, in response to the coronavirus disease 2019 (COVID-19) pandemic. This included the suspension of routine services such as COPD annual reviews, which had significant ramifications for the project.

An urgent meeting was undertaken with the key stakeholders to decide how best to continue. There was discussion on whether the project would have to be put on hold while the practice managed the COVID-19 pandemic response. However, there is a body of evidence that nurse-led telephone interventions in primary care are useful in the self-management of COPD and may improve patients’ health and well-being (Walters et al 2013, Billington et al 2015, Sidhu et al 2015, NICE 2019).

Patients with severe COPD were identified as being at high risk of death if they were to contract COVID-19. At that time, the UK Health Security Agency and the Department of Health and Social Care (DHSC) (2021) defined individuals as ‘clinically extremely vulnerable’ if they were at a very high risk of severe illness or death from COVID-19, and these patients were placed on a ‘shielded patient list’. Those with a severe respiratory condition, including severe COPD, were included on this list and asked to remain at home for a 12-week period (UK Health Security Agency and DHSC 2021).

Considering the body of evidence available for nurse-led telephone reviews, the author proposed that since the pilot group for the project included clinically extremely vulnerable patients, it would be particularly beneficial for this group to ensure that their COPD was as stable as possible and for them to have a self-management care plan in place. This was later reflected in the NICE (2020) COVID-19 rapid guideline for community-based care of patients with COPD; this guideline has since been withdrawn because current practice is to manage COVID-19 risk in line with the risk of other respiratory infections.

Project implementation

Implementation of the project began in January 2020. The initial pilot phase was planned for a six-month period from January 2020 to July 2020.

The varied nature of the general practice nurse’s role means that patients with COPD are often seen opportunistically, on an ad hoc basis. Patients with COPD often booked an appointment with the nurse for another reason and were overdue for their annual review. This meant that in some cases a holistic and comprehensive annual review was not being undertaken. In the author’s opinion, this may have been the reason why the practice’s compliance with national guidance was so low. It could also have been because the limited number of appointments available meant that full annual COPD reviews were not always being undertaken. Lisspers et al (2014) identified that dedicated clinics in primary care could benefit the management of COPD.

The implementation of the project enabled the general practice nursing team to address these issues with dedicated COPD clinics and provide a comprehensive COPD annual review (NICE 2019, GOLD 2023). These dedicated clinics appeared to work well for the purposes of the project, especially in the context of the changes due to COVID-19. However, following discussions with stakeholders, it was identified that disease-specific clinics do not work for the daily workload in general practice, so their adoption will not be taken forward. This is due to wasted appointments, staff fatigue and booking errors.

Addressing challenges

Kotter (1996) identified that delays during implementation of service improvement can negatively affect the momentum established. A rapid solution can often be to use a Plan-Do-Study-Act (PDSA) cycle (NHS England and NHS Improvement 2022). A PDSA cycle gives stakeholders the opportunity to see if a suggested change will succeed and is a powerful tool for learning in a safe and less disruptive way for both staff and patients (NHS England and NHS Improvement 2022).

To assess the effect that changing face-to-face appointments to telephone reviews would have on the delivery and any potential knock-on effects, a PDSA cycle was used as a structured evaluation before wider implementation. Although this change had the potential to affect the project, data analysis showed that the use of telephone reviews in the delivery of the quality improvement project had a positive effect. Results showed a continued increase in the number of self-management care plans issued between April 2020 and July 2020, which is the period when telephone reviews were conducted. However, these results could be construed as biased since this group of patients were in the clinically extremely vulnerable category and therefore they were at home for the entire implementation period. Further data would need to be collected now this group of patients have returned to normal daily life.

Outcomes of the project

By the end of the pilot phase, the project aim had been met, with 100% of patients with a diagnosis of severe COPD having a self-management care plan in place. Therefore, compliance with national standards improved (NICE 2019, GOLD 2023), since only 19% (n=154/810) of patients with COPD had a self-management care plan in place before project implementation. Although the project only focused on patients with severe COPD, data analysis shows that the change in routine COPD care became embedded for most staff, with the number of self-management care plans issued to all patients with a diagnosis of COPD rising to 62% (n=505) during the same pilot period as the project. This was an overall improvement of 43 percentage points in comparison with baseline data collection.

Figure 1 shows the number of self-management plans issued to patients with severe chronic obstructive pulmonary disease during the pilot project.

Figure 1.

Number of self-management plans issued to patients with severe chronic obstructive pulmonary disease during the pilot project

phc.2023.e1822_0001.jpg

Consideration of public health measures

Public health measures, such as social distancing and universal mask-wearing, were originally implemented to reduce the transmission of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) (Public Health England 2021). These measures also have been shown to reduce the transmission of other circulating respiratory viral infections. Cheng and Hurst (2021) explained that most COPD exacerbations are caused by respiratory viral infections, especially rhinovirus. Therefore, the widespread adoption of such public health measures could be expected to reduce the transmission of such viruses, not just SARS‑CoV‑2, and thereby lead to a reduction in the incidence of COPD exacerbations (Cheng and Hurst 2021). This was reflected in the data collected at the end of the pilot phase, which showed a significant decrease from 84 COPD exacerbations in 2018 to 38 COPD exacerbations in 2020.

Tan et al (2021) reported that as well as the reduction in transmission of respiratory viral infections, there was also a significant and sustained reduction in hospital admissions for all COPD exacerbations, which coincided with the introduction of the public health measures. This was also reflected in the data collected at the end of the pilot phase, which showed a significant decrease in emergency hospital admissions for COPD exacerbations, with 17 in 2018, 12 in 2019 and none in 2020.

Taking into account the evidence provided by Cheng and Hurst (2021) and Tan et al (2021), it is unknown whether the reduction in the number of COPD exacerbations and the number of emergency admissions to hospital because of COPD exacerbations was due to the introduction of the self-management care plans and earlier recognition of symptoms and treatment, or due to the public health measures and shielding implemented at the same time as the project.

Factors that influenced the success of the project

Overall, the project demonstrated improvements in patient care in relation to reduction of COPD exacerbations, emergency admissions to hospital due to COPD exacerbations and the potential for reduction in associated costs. The championing of the project by the general practice nurses could have been an important factor in the achievement of the project aim. Initial challenges with the project were identified quickly and subsequently addressed using the leadership and communication skills developed in accordance with the Health Education England (2017) multiprofessional framework for advanced practice.

Telephone and remote consultations were another significant factor in the success of the project. However, it is important that appropriate systems, services and support are in place for the future, and that the effect of remote consultations on quality of care and patients’ experience and accessibility is considered using evidence-based research.

Conclusion

The results of this quality improvement project demonstrate that its aim was achieved, with 100% of patients with a diagnosis of severe COPD having a self-management care plan in place by the end of the pilot phase. The 43-percentage-point increase in self-management care plans issued to all patients with a diagnosis of COPD indicated that the project had been embedded in the general practice nurses’ routine COPD management and not just those included in the project. The results also showed a reduction in the overall number of COPD exacerbations and emergency admissions to hospital due to COPD exacerbations. Further research is recommended as it is unclear if these reductions were due to the quality improvement project or the public health measures introduced during the COVID-19 pandemic. Other important findings from this project relate to the selection of appropriate key stakeholders. These individuals underpin the structure of the project and work together to drive the project forward. Without the enthusiasm of the general practice nurses, this project might not have achieved the results that it did.

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