For people with COPD, a discharge care bundle can improve disease control and quality of life, and help them cope better once home, resulting in fewer readmissions to hospital, with associated reduction in costs and improved care outcomes.

Care bundles comprise a set of care practices including checking inhaler technique, referral for smoking cessation support and self-management plans.


Support from the South West AHSN helped us to employ an audit facilitator to enter NACAP audit data, enabling me to track and report on the progress of the new Asthma & COPD Nurse Service. This has helped me make a case to expand our service and employ a second specialist nurse.


Jill Leyshon, Respiratory Specialist Nurse, Royal Cornwall Hospital

What the project involved

The South West Patient Safety Collaborative (PSC), hosted by the South West AHSN, has been working with Royal Cornwall Hospitals NHS Trust (RCHT) since 2019 to support COPD and asthma discharge care bundle implementation in the region, as part of the Adoption & Spread National Patient Safety Improvement Programme.

The COPD discharge care bundles includes follow-up care, checking inhaler technique, referral for smoking cessation support, assessment for pulmonary rehabilitation, emergency drug packs and a self-management plan.

The South West PSC provided:

  • Bespoke quality improvement support
  • ‘Pump-prime’ funding to recruit an audit facilitator to support completion of the National Asthma and COPD Audit Programme (NACAP).
  • Facilitated networking across organisational boundaries within Cornwall and the wider South West region.

A respiratory specialist nurse from RCHT attended South West PSC-led COPD and asthma learning events and webinars.


Since the project began in 2019, RCHT has seen a 46% increase in people with COPD receiving all elements of the bundle for which they are eligible:

  • 54% more people have had appropriate follow-up care arranged on discharge
  • 51% more people had their inhaler technique checked
  • 51% more people have been referred for help to stop smoking
  • 49% of people have been assessed for pulmonary rehabilitation
  • 42% more people have received emergency drug packs
  • 34% more people have received a self-management plan.

Next steps

RCHT continues to engage in ongoing improvement work as a member of the Kernow Respiratory Oversight Group and Southwest Respiratory Network. The South West AHSN is working on other respiratory initiatives.

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