1. Anne Marie Marley Respiratory Nurse Consultant BHSCT Dr Stephen Tate Respiratory Physician SET

2.  Achieve consensus on respiratory patient flow issues across NI  Identify immediate high impact changes to implement improvement  Identify capacity/resource issues  What additional support is required to effect change  Try and get some data

3.  Wide consultation-email, meetings, Regional workshop  ICP leads, clinicians, MDT, managers  Perceived problems-Unnecessary admission, process for senior decision making, could more patients be managed in community, more ambulatory care, better inpatient flow, improved discharge planning  Task and finish work-COPD Bundles, ambulatory pathways for PE and pleural effusion

4.  Further develop Respiratory MDT to include 7 day working and extended hours  Improve sharing of information across systems- NIECR  Targeted reviews and risk stratification  Develop a ‘champion’ to lead and co-ordinate service development including utilisation of voluntary sector  Direct access to respiratory team/decision maker  More accessibility to IV antibiotics (DN teams)  Training for NH staff on exacerbation man/end of life  Develop regional criteria, consistent guidelines for community teams to reduce variation

5.  Develop ambulatory pathways between ED/AMU/Respiratory teams  Develop physician of the week, small MD team to manage ‘take in’ and liaise with GP’s –impact on rotas and elective work  Reduce size of MAU’s to support redistribution of speciality bed base-consider high dependency patients for safe out of hours take in  Review clinical, MDT and bed capacity to ensure it can meet admission volume (support to ED, twice daily take in rounds, regular pull from MAU, discharge planning)  Consider direct admission arrangements-link to HUB/Community teams/GP’s  Develop respiratory assessment unit for rapid assessment  Consider breathlessness service with cardiology/COE  Improved joint working with Older people’s services-Negotiate handover process for frail elderly  Improved coding of disease presentation to support service planning and commissioning

7.  All sites to implement ambulatory pathways (PE and unilateral pleural effusion)  Implement COPD discharge care bundle (RSF)  Review capacity, prioritising community for rapid assessment and admission avoidance (RSF)  Develop direct take for chronic respiratory disease patients-longer term action  Hasten implementation of the NIECR and extend notation to all clinicians