Claire Hurlin
Clinical and Service Lead CCM
Carmarthenshire Locality
Hywel Dda Health Board

• An Integrated Care Pathway (ICP) is a document that describes a process within
Health and Social Care
• ICP’s are both a tool and a concept
• They embed guidelines and protocols
• They are locally agreed, evidence-based, patient-centred

• The aims of ICPs are that they have:-
– The right people
– In the right order
– In the right place
– Doing the right thing
– At the right time
– With the right outcomes
– All with attention to the patient experience

• Delivery of consistent high-quality care
• Reduction in unnecessary variation in practice
• Implementation of evidence-based care
• Structured documentation
• To facilitate communication & audit

• In 1990 , she died a premature death from
COPD aged 60 years, alone in a hospital ward in the middle of the night, her family were at home in bed thinking that she was recovering from this recent exacerbation
• Years of untreated anxiety and depression -
COPD had sapped her ability to look forward to anything
• Virtually housebound

• Had been a heavy smoker for many years, but quit 8 years before she died
• BMI of 18
• No offer of any help from outside agencies until after she died
• Revolving door patient in and out of hospital with exacerbations for 4 years prior to death
• She saw her son married, but did not live long enough to see her grandchildren born

• Local GP devised a computer (MSS InPS Vision clinical system) based template for use in her practice
• Built on this work to develop pathway
• A Practice Nurse involved in care of patients with COPD was needed to work with, and evaluate the use of, the template during consultations, over a 3 month period
• Practice Nurse since 1990
• Tumble Surgery in the Amman Gwendraeth Valley
• 4 GPs, one with responsibility for Respiratory Disease
• 7,200 patients
• 188 patients on the COPD register – prevalence of 2.6%

QOF REQUIREMENTS
– Register of patients with a diagnosis of COPD
– Confirmed by spirometry with reversibility
– Smoking Status
– Smoking Cessation advice
– FEV
1
– Inhaler technique
– Flu vaccination
– MRC Dyspnoea score

• Colour coded sections
– Diagnosis
– Exception reporting
Unsuitable Dissent
– Significant History

• Primary Language
• Interpreter needed
• Family History of Note
• Home Situation
– Occupation
– Carer Details
– Housebound
– On Home O2

• Smoking History
Record smoking status EVERY YEAR for non-smokers until 26 years, and ex smokers annually until 3 years non smoking
– Smoking History
• Passive Smoking Smoking Cessation Advice
PACK YEARS = number smoked x number of years smoked, divided by 20
CIGARS – 1 HAVANA = 5 CIGS
1 HAMLET = 3 CIGS
1 SMALL CIGAR = 2 CIGS
TOBACCO FOR ROLL UPS 25gms = 50 cigs

• Pack Years
• Referred to Smoking Counsellor
• OTC NRT
• Refused smoking help
• Smoking review not indicated
• Weight
• Height
• Waist Circumference
• BP

• ADVICE RE EXERCISE – Encourage all COPD patients to exercise within limits of disease. Consider referral to exercise scheme for mild COPD patients. Consider referral to Pulmonary Rehabilitation for moderate – severe COPD
• ADVICE RE DIET – Consider referral to dietician if BMI
<20
• REFER TO DIETITIAN
• EXACERBATIONS
– ACUTE EXACERBATION
• SYMPTOMS
– SPUTUM EXAMINATION
– List of symptoms in green

• INHALER TECHNIQUE
– Inhaler technique good
– Inhaler technique poor
• PULMONARY FUNCTION TESTS
– PEFR
• SPIROMETRY –
– NB: For QOF purposes, COPD diagnosed where
FEV1 <70% FEV1/FVC ratio <70%

• SPIROMETRY
Contra Indicated/Declined
Not Indicated
• REVERSIBILITY TEST RESULTS
– Reversible airway obstruction
– Irreversible airway obstruction
• STEROID TRIAL protocol

• RESPIRATORY SYMPTOMS
– MRC Dyspnoea Scale
• PATIENT PROGRESS
– Excellent
– Fair
– Slight
• SELF MANAGEMENT PLAN GIVEN
• IMMUNISATIONS
• ANXIETY & DEPRESSION
– Same 2 questions asked in QOF

NEW DIAGNOSIS
–Mild = 50 – 80%
–Moderate = 30 – 49%
–Severe = <30%
–Asthma
–Emphysema

• EXAMINATION
– O/E Chest
– Peripheral Cyanosis
– Central Cyanosis
– SOA (swelling of ankles)
– Acute Cor Pulmonale
– Chronic
– O/E Heart

TEST RESULTS
– CXR CXR REQUESTED
– ECG
– ECHO – lots of info for clinicians to follow
– Pulse Oximetry O
2 saturation
– Alpha 1 Anti-Trypsin Test – Think of doing this test if patient has FH, early onset of symptoms, or minimal smoking history

–COPD self management plan given
–annual review done
–follow up review done
–frequency of exacerbations
–nutritional state

REFERRALS
– Dietician
– CDM Team
– Expert Patient Programme
– Pulmonary Rehabilitation
– Chest Physician
– Occupational Therapy
– Oxygen assessment

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On Palliative Care Pathway
– Consider all patients with end-stage illness including dementia, COPD, LVF etc. Include in the register if any of the following apply:
• Death predicted in the next 12 months
• Clinical indicator of need for palliative care
• DS1500 issued
– DS1500 completed
– Medication Changed/Review/Review with
Patient
– Drug Dose altered Drug Stopped

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BENEFITS TO PATIENTS o It will avoid duplicating questions patients are repeatedly asked at reviews o It will avoid conflicting advice o Patients will be offered all necessary services that are available o Offers them a better say in their management o Allows the right steps to be taken at the right time o Provides a robust method of capturing the patients journey of care o Clinical details are contained within one template

BENEFITS TO CLINICIANS
– Clinicians will know where the patient is on their journey of care – includes prompts for guidance
– In Primary Care, all clinical details needed at a consultation are on the one template
– Clinicians will all be “singing from the same hymn sheet”
– Mini protocols/guidelines are included (the red text added in), facilitating accuracy and consistency in our care
– Efficient use of staffing resources

– Since the ICP captures patient information in a consistent way, questions which were previously repeated during reviews do not need to be asked.
– Systematic provision of advice and information
– The BLF self management plan and ICP provide robust, evidenced-based information that can be repeated and reinforced as required.
– Referrals to other services are recorded and monitored

• In 2009, she died, aged 79, a peaceful death having been implemented on to the
COPD ICP when first diagnosed allowing her to self manage, have the support of relevant services and when the time came placed on the end of life pathway allowing her to die in the place of here choice – home with her family surrounding her.

Towards the last 5 years of her life it was noted through the ICP that she was depressed and commenced on the relevant treatment.
Although she was virtually housebound a team of relevant support staff had been implemented allowing her to stay at home, supported by an identified case manager who linked all her care together
As well as seeing her son married she had seen both the grandchildren born

• Pilot showed 86% of patients had fewer exacerbations after they had started on the pathway
• There were 57% fewer exacerbations post pathway
• 43% patients received a change in their management plan as a direct result of starting on the pathway

1. A template which will enable the care pathway to be used on other primary care clinical systems has been developed.
2. Development of a report to include all of the clinical information in the care pathway which can be printed and sent with referral letters. This will avoid duplication of tests and improve continuation of care management between primary and secondary care.
3. Roll-out of the pilot to other practices within the health community.
4. Improvements to the self management plan have been identified and feedback given to BLF.