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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is probably more national and international audit data collected by clinicians on the hospital management of patients admitted with exacerbations of Chronic Obstructive Pulmonary Disease &#40;COPD&#41; than for any other lung disease&#46; Large data sets from Spain<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the UK<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> supported by that from over 400 hospitals across 13 European countries in the European Respiratory Society &#40;ERS&#41; audit<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> are amazingly consistent in their findings of wide variation in process of care and outcomes for patients both across&#44; and within countries&#46; Despite the widespread dissemination of management guidelines&#44; based substantially upon research evidence of effectiveness&#44; the majority of patients admitted to European hospitals do not receive the standard of care recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Whilst guidelines are not protocols it is difficult to justify why across Europe over 40&#37; of patients treated for exacerbation of COPD had no spirometry result available to the admitting team to confirm the diagnosis whilst antibiotics were given to 90&#37; of patients who did not meet the guideline criteria for antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Whether we examine length of stay&#44; readmission rates&#44; or use of oxygen the variation remains 2&#8211;3 fold between units and the challenge to Respiratory Medicine is how do we move from data collection to better care for patients&#63;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Audit is a quality improvement process&#46; The data inform us of where the problems lie when measured against ideal care-the guidelines&#44; but this is just the beginning&#46; The critical steps are to plan improvements and then put those into place&#46; The linkage of organisation and resources to clinical process and outcome data provides insights that can inform the improvement plan&#46; Audit outcomes for patients managed with Non-Invasive Ventilation &#40;NIV&#41; are much poorer than in randomised controlled trials&#46; In some European hospital units audit confirms that NIV is simply not available&#44; in others there is limited availability&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In contrast 38&#37; patients receiving NIV did not meet the guideline criteria for NIV&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> More detailed data from the UK audits suggest that NIV is started too late for some and is often given to severely acidotic patients who should receive intubation and ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In other cases to end stage patients who may be better managed along a palliative care pathway&#46; Exploring the data helps understand the problems but improving care quality remains the challenge&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is however a good evidence base for the effectiveness of quality improvement interventions available from Cochrane<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which should inform our next steps&#46; Simply reporting data to clinical teams produces effects ranging from none at all to substantial improvement&#46; To optimise benefits&#44; clinicians who are not performing well should be targeted as having most to gain with data sharing led by colleagues&#46; Opinion leaders and those who we look to as experts have a responsibility to promote audit results as those most likely to influence change&#46; Clear targets for improvement are required&#44; best set at a national level to provide a shared vision for change but supported by local targets determined by individual hospital audit findings&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other approaches which have shown greater promise in changing clinician behaviours&#46; Educational outreach visits where experts spend time at an institution reinforcing good practice have a positive impact in some areas of clinical practice&#44; notably prescribing&#46; The concept of peer visiting between teams from different hospitals is now common practice in some European countries notably the Netherlands and UK&#46; There is evidence of the effectiveness of mutual peer review of COPD services&#44; although improvement may take years to achieve&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The reality for most clinicians is that improving care for COPD patients can appear too huge a task to address&#46; Implementation of a complex series of improvement interventions requires whole organisation change&#46; The answer may lie with a simple quality improvement tool designed by clinicians for clinicians&#58; the clinical care bundle&#46; Developed originally in the USA to combat variance in mortality from across intensive care units&#44; the bundle consists of a small number of high impact evidence based interventions known to make a difference to patient outcomes&#46; The bundle forms the core of a management protocol for the patient with that condition and implementation of each element is recorded on a proforma&#46; When enacted together the resulting clinical benefit is much greater than the sum effect of the individual interventions if used at different times&#44; or if partially implemented&#46; The deployment of a ventilated patient care bundle across the USA brought about a massive reduction in ICU mortality and variation in outcomes across centres&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This success led to the creation of others related to specific conditions or patient groups&#46; More recently COPD discharge bundles have been researched demonstrating beneficial outcomes not just to patients but to the job satisfaction of staff too&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> A quality improvement sub set from the European COPD Audit participants has since met in London and Barcelona to consider the development of European Admission and Discharge bundles for COPD&#46; Such a bundle might include&#58; all patients to have an arterial blood gas within 1 hour of presentation&#44; those with acidosis having a decision about ventilatory support made within 2<span class="elsevierStyleHsp" style=""></span>h&#44; patients managed using controlled oxygen if hypoxic&#44; and a chest radiograph taken and reported within 2<span class="elsevierStyleHsp" style=""></span>h of admission&#46; All are simple measures which are recommended by the guidelines but demonstrated not to be applied in a significant proportion of patients in the European Audit&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The benefits of the bundle is it provides aims for good care that are clear to everyone&#44; that are possible to achieve&#44; condenses a guideline of hundreds of pages to a few key processes&#44; and which when documented provides a simple ongoing audit tool&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The evidence base for this approach to COPD quality of care improvement requires strengthening through further research evaluation&#46; We spend a vast resource each year on research into COPD management to build an effective evidence base from which to derive guidelines&#44; but what value does that have if that care is not implemented in real life clinical practice&#63; The challenge for the respiratory community is to turn the data into better care for patients&#46; It is possible but it requires a resource and a co-ordinated effort&#46; We have yet to see evidence of either implemented across Europe&#46;</p></span>"
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Editorial
Chronic Obstructive Pulmonary Disease Audit – Turning Data Into Better Care for Patients
Auditoría de la enfermedad pulmonar obstructiva crónica: convertir los datos en una mejor asistencia de los pacientes
C. Michael Roberts
Barts and The London School of Medicine and Dentistry, Queen Mary University, Londres, United Kingdom
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is probably more national and international audit data collected by clinicians on the hospital management of patients admitted with exacerbations of Chronic Obstructive Pulmonary Disease &#40;COPD&#41; than for any other lung disease&#46; Large data sets from Spain<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the UK<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> supported by that from over 400 hospitals across 13 European countries in the European Respiratory Society &#40;ERS&#41; audit<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> are amazingly consistent in their findings of wide variation in process of care and outcomes for patients both across&#44; and within countries&#46; Despite the widespread dissemination of management guidelines&#44; based substantially upon research evidence of effectiveness&#44; the majority of patients admitted to European hospitals do not receive the standard of care recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Whilst guidelines are not protocols it is difficult to justify why across Europe over 40&#37; of patients treated for exacerbation of COPD had no spirometry result available to the admitting team to confirm the diagnosis whilst antibiotics were given to 90&#37; of patients who did not meet the guideline criteria for antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Whether we examine length of stay&#44; readmission rates&#44; or use of oxygen the variation remains 2&#8211;3 fold between units and the challenge to Respiratory Medicine is how do we move from data collection to better care for patients&#63;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Audit is a quality improvement process&#46; The data inform us of where the problems lie when measured against ideal care-the guidelines&#44; but this is just the beginning&#46; The critical steps are to plan improvements and then put those into place&#46; The linkage of organisation and resources to clinical process and outcome data provides insights that can inform the improvement plan&#46; Audit outcomes for patients managed with Non-Invasive Ventilation &#40;NIV&#41; are much poorer than in randomised controlled trials&#46; In some European hospital units audit confirms that NIV is simply not available&#44; in others there is limited availability&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In contrast 38&#37; patients receiving NIV did not meet the guideline criteria for NIV&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> More detailed data from the UK audits suggest that NIV is started too late for some and is often given to severely acidotic patients who should receive intubation and ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In other cases to end stage patients who may be better managed along a palliative care pathway&#46; Exploring the data helps understand the problems but improving care quality remains the challenge&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is however a good evidence base for the effectiveness of quality improvement interventions available from Cochrane<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which should inform our next steps&#46; Simply reporting data to clinical teams produces effects ranging from none at all to substantial improvement&#46; To optimise benefits&#44; clinicians who are not performing well should be targeted as having most to gain with data sharing led by colleagues&#46; Opinion leaders and those who we look to as experts have a responsibility to promote audit results as those most likely to influence change&#46; Clear targets for improvement are required&#44; best set at a national level to provide a shared vision for change but supported by local targets determined by individual hospital audit findings&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other approaches which have shown greater promise in changing clinician behaviours&#46; Educational outreach visits where experts spend time at an institution reinforcing good practice have a positive impact in some areas of clinical practice&#44; notably prescribing&#46; The concept of peer visiting between teams from different hospitals is now common practice in some European countries notably the Netherlands and UK&#46; There is evidence of the effectiveness of mutual peer review of COPD services&#44; although improvement may take years to achieve&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The reality for most clinicians is that improving care for COPD patients can appear too huge a task to address&#46; Implementation of a complex series of improvement interventions requires whole organisation change&#46; The answer may lie with a simple quality improvement tool designed by clinicians for clinicians&#58; the clinical care bundle&#46; Developed originally in the USA to combat variance in mortality from across intensive care units&#44; the bundle consists of a small number of high impact evidence based interventions known to make a difference to patient outcomes&#46; The bundle forms the core of a management protocol for the patient with that condition and implementation of each element is recorded on a proforma&#46; When enacted together the resulting clinical benefit is much greater than the sum effect of the individual interventions if used at different times&#44; or if partially implemented&#46; The deployment of a ventilated patient care bundle across the USA brought about a massive reduction in ICU mortality and variation in outcomes across centres&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This success led to the creation of others related to specific conditions or patient groups&#46; More recently COPD discharge bundles have been researched demonstrating beneficial outcomes not just to patients but to the job satisfaction of staff too&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> A quality improvement sub set from the European COPD Audit participants has since met in London and Barcelona to consider the development of European Admission and Discharge bundles for COPD&#46; Such a bundle might include&#58; all patients to have an arterial blood gas within 1 hour of presentation&#44; those with acidosis having a decision about ventilatory support made within 2<span class="elsevierStyleHsp" style=""></span>h&#44; patients managed using controlled oxygen if hypoxic&#44; and a chest radiograph taken and reported within 2<span class="elsevierStyleHsp" style=""></span>h of admission&#46; All are simple measures which are recommended by the guidelines but demonstrated not to be applied in a significant proportion of patients in the European Audit&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The benefits of the bundle is it provides aims for good care that are clear to everyone&#44; that are possible to achieve&#44; condenses a guideline of hundreds of pages to a few key processes&#44; and which when documented provides a simple ongoing audit tool&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The evidence base for this approach to COPD quality of care improvement requires strengthening through further research evaluation&#46; We spend a vast resource each year on research into COPD management to build an effective evidence base from which to derive guidelines&#44; but what value does that have if that care is not implemented in real life clinical practice&#63; The challenge for the respiratory community is to turn the data into better care for patients&#46; It is possible but it requires a resource and a co-ordinated effort&#46; We have yet to see evidence of either implemented across Europe&#46;</p></span>"
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ISSN: 15792129
Original language: English
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