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Background to the project Chronic obstructive pulmonary disease (COPD) is a common condition1 with acute exacerbations of COPD (AECOPD) or ‘lung attacks’ causing 12% of acute admissions and being responsible for more than one million bed days per annum in the UK. About a third of patients are readmitted within 90 days of discharge.2 Significant variations in outcomes and provision of care have been noted, implying a role for a systematic quality improvement approach.2 3 We therefore wished to develop and pilot the implementation of a COPD discharge care bundle—a list of five to six evidence-based practices that should be delivered to all patients.4 A care bundle does not specify the entirety of care that should be delivered, but is rather a group of items that administered together should be delivered to all individuals. Developing the care bundle Item selection was based on national and international guidelines, a systematic literature review and input from a multidisciplinary project team described in more detail in the online supplementary material. The project team undertook a process mapping exercise to map the patient pathway from admission to discharge and follow-up. A survey, undertaken to identify elements that were important to patients, identified feelings of isolation and a lack of support postdischarge and prioritised regaining physical function. To ensure coherence within the wider health community, the bundle was discussed at meetings of the Inner Northwest London Care Community integrated service improvement programme for COPD.

rtant to patients, identified feelings of isolation and a lack of support postdischarge and prioritised regaining physical function. To ensure coherence within the wider health community, the bundle was discussed at meetings of the Inner Northwest London Care Community integrated service improvement programme for COPD. Bundle items selected were (figure 1; see online supplementary material for more details):Notify the respiratory clinical nurse specialist of all admissions If the patient is a smoker, offer smoking cessation assistance Refer for assessment for pulmonary rehabilitation Give written information about COPD including British Lung Foundation (BLF) self-management booklet, oxygen alert card and information about patient support groups (BLF Breathe Easy Group) Demonstrate satisfactory use of inhalers Follow-up appointment to be made with a specialist prior to discharge. Figure 1 The chronic obstructive pulmonary disease (COPD) discharge care bundle. CNS, clinical nurse specialist.

Give written information about COPD including British Lung Foundation (BLF) self-management booklet, oxygen alert card and information about patient support groups (BLF Breathe Easy Group) Demonstrate satisfactory use of inhalers Follow-up appointment to be made with a specialist prior to discharge. Figure 1 The chronic obstructive pulmonary disease (COPD) discharge care bundle. CNS, clinical nurse specialist. The care bundle pack included all the relevant referral forms/fax numbers. Referrals could be made by ward nurses, physiotherapists, clinical nurse specialists or doctors. Patients completed a ‘safe discharge checklist’ (online appendix 1), which would be countersigned by the nurse responsible for their discharge, providing an opportunity to address any omissions and to reinforce ward nurses' knowledge of the bundle items. Thus, for example, if at the end of several days in hospital a patient's inhaler technique had not been reviewed (despite their having used their inhalers on multiple occasions), identification of this omission would motivate the discharge nurse to ensure that this was not neglected in future. The safe discharge checklist also included a section to be completed about what to do if the patient felt they were not improving and needed further medical input once they were at home.

tiple occasions), identification of this omission would motivate the discharge nurse to ensure that this was not neglected in future. The safe discharge checklist also included a section to be completed about what to do if the patient felt they were not improving and needed further medical input once they were at home. Patients were also offered a brief phone call 48–72 h postdischarge to check whether they were improving. If not, community input could be expedited. A script was developed with standard questions such as ‘Since discharge are you same/better/worse?’; ‘Is your breathing keeping you awake at night’; ‘Do you have a written self-management plan’”; ‘Do you know what your follow-up plan is?’ (online appendix 2). The clinical nurse specialist making the call then decided whether there was an immediate cause for concern.

uch as ‘Since discharge are you same/better/worse?’; ‘Is your breathing keeping you awake at night’; ‘Do you have a written self-management plan’”; ‘Do you know what your follow-up plan is?’ (online appendix 2). The clinical nurse specialist making the call then decided whether there was an immediate cause for concern. Implementation The care bundle was launched on the respiratory ward at a series of multidisciplinary meetings. A survey of ward staff during the development of the project had revealed low levels of confidence regarding inhaler technique, smoking cessation and pulmonary rehabilitation, so it was clear that staff education would be important. An initial barrier to this was that it was difficult for the staff to attend teaching sessions in a group without impeding clinical work. We developed an educational model where members of the team would spend time on the ward at a stand providing teaching about topics such as smoking cessation and inhaler technique in a ‘drop in’ way. Thus, during the course of a shift all the nurses on the ward had the opportunity to be educated with minimal disruption. This led to improved confidence in these areas, which was confirmed by a staff survey. Pharmacists involved in the project took the opportunity to teach on a daily basis and developed laminated pictorial charts to attach to the drug trolley to reinforce the correct inhaler techniques required.

with minimal disruption. This led to improved confidence in these areas, which was confirmed by a staff survey. Pharmacists involved in the project took the opportunity to teach on a daily basis and developed laminated pictorial charts to attach to the drug trolley to reinforce the correct inhaler techniques required. Care bundle returns were assessed at the weekly project meeting, which enabled the team to refine the administrative and other processes involved, through the use of a ‘plan, do, study, act’ approach. To increase engagement with the project, the ward nurses completing the safe discharge checklist were entered into a draw for a small prize. Pulmonary rehabilitation has a key role in COPD management and there is evidence that it can reduce accident and emergency attendance and readmission if delivered immediately after discharge with AECOPD.5 In order for health professionals to refer patients and to improve patient compliance, it is important that they have a clear understanding of what it entails and are able to communicate the strength of evidence for its effectiveness. To address this, ward staff attended pulmonary rehabilitation sessions within the Hospital and physiotherapists gave informal teaching. An information leaflet for potential participants was developed with input from patients to ensure that it was written in an appropriate language and addressed typical patient concerns.

o address this, ward staff attended pulmonary rehabilitation sessions within the Hospital and physiotherapists gave informal teaching. An information leaflet for potential participants was developed with input from patients to ensure that it was written in an appropriate language and addressed typical patient concerns. Outcomes The care bundle was initiated in 94 patients on the respiratory ward between 1 October 2009 and 30 September 2010—age 74.6 (11.2) years, 64% male, median length of stay 6 days. Compliance was compared with a random sample (n=22) from the year sampled prior to the project as part of the bundle development process. There were significant improvements in compliance with reference to smoking cessation (18.2% vs 100%), pulmonary rehabilitation (13.6% vs 68%), administration of self-management plan (54.6% vs 97.9%) and review of inhaler technique (59.1% vs 91.2%). Follow-up arrangements were documented in 41% pre and 39% post initiation of the care bundle. Of those in whom the bundle was used 25.5% were smokers. All were offered an appointment with smoking cessation services, although 11 (46%) of the smokers declined to be referred. In the year prior to the bundle, there were 31 referrals to pulmonary rehabilitation for Chelsea and Westminster patients compared with 81 in the year postinitiation—an increase of 158%.

e smokers. All were offered an appointment with smoking cessation services, although 11 (46%) of the smokers declined to be referred. In the year prior to the bundle, there were 31 referrals to pulmonary rehabilitation for Chelsea and Westminster patients compared with 81 in the year postinitiation—an increase of 158%. Four (4%) patients declined to receive a follow-up phone call, 34 (36%) could not be contacted despite two calls and in 22 (23%) the call was not made because of staffing issues. A follow-up call was made successfully in 34 (33%) patients and a cause for immediate concern was identified in 3 (10%) of them. Contact details for many patients were wrong in the electronic patient record, so the safe discharge checklist was modified to include reviewing the contact details in an attempt to address this.

llow-up call was made successfully in 34 (33%) patients and a cause for immediate concern was identified in 3 (10%) of them. Contact details for many patients were wrong in the electronic patient record, so the safe discharge checklist was modified to include reviewing the contact details in an attempt to address this. The 30-day readmission rate was 10.8% for patients where the bundle was used compared with 16.4% where it was not (n=365) (95% CI for difference −2.1% to 13.2%). After implementation of the bundle, there was a downward trend in readmissions but segmented regression analysis showed this not to be statistically significant (figure 2). The aim of this initial study was to demonstrate improvements in process (since the interventions themselves have an evidence base); however, the findings are encouraging and as this intervention is rolled out across further sites the data will become available for a more quantitative evaluation of the link between these process measures and outcomes. In addition, data for this analysis included all patients admitted to the Trust with AECOPD (n=1156) over 3 years, whereas the bundle was only piloted on the respiratory ward. Although the implementation of the bundle might have improved COPD awareness generally within the Trust, looking at total readmission rates is likely to have diluted the actual impact of the bundle. Figure 2 The 30-day readmission rates before and after the initiation of the chronic obstructive pulmonary disease discharge care bundle.

The 30-day readmission rate was 10.8% for patients where the bundle was used compared with 16.4% where it was not (n=365) (95% CI for difference −2.1% to 13.2%). After implementation of the bundle, there was a downward trend in readmissions but segmented regression analysis showed this not to be statistically significant (figure 2). The aim of this initial study was to demonstrate improvements in process (since the interventions themselves have an evidence base); however, the findings are encouraging and as this intervention is rolled out across further sites the data will become available for a more quantitative evaluation of the link between these process measures and outcomes. In addition, data for this analysis included all patients admitted to the Trust with AECOPD (n=1156) over 3 years, whereas the bundle was only piloted on the respiratory ward. Although the implementation of the bundle might have improved COPD awareness generally within the Trust, looking at total readmission rates is likely to have diluted the actual impact of the bundle. Figure 2 The 30-day readmission rates before and after the initiation of the chronic obstructive pulmonary disease discharge care bundle. Key learning points Educational efforts must be maintained because of staff turnover and need to be delivered in a way that is easy for staff to access, enabling them to gain and maintain confidence. For the care bundle to be implemented effectively, all healthcare professionals involved in COPD care need to be able to engage with it.

nts Educational efforts must be maintained because of staff turnover and need to be delivered in a way that is easy for staff to access, enabling them to gain and maintain confidence. For the care bundle to be implemented effectively, all healthcare professionals involved in COPD care need to be able to engage with it. We would like to thank all the staff who participated in the project and the patient representatives, particularly Mr Allan Stone. Funding: The work was funded by the NIHR through the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Northwest London and the NIHR Respiratory Biomedical Research Unit of Royal Brompton and Harefield NHS Trust and Imperial College. Competing interests: None. Ethics approval: The study was discussed by both the Brent Ethics Committee and the NHS Brent R&D Committee who determined that formal ethical approval was not necessary. Contributors: All authors were part of the project team developing the bundle. NSH wrote the first draft of the manuscript. All authors approved the final manuscript. Provenance and peer review: Not commissioned; externally peer reviewed.

Background Tobacco smoking is a major public health problem, even more so for smokers who start at a young age. Lung development is affected,1 2 meaning that subsequent decline in lung function starts from a lower base increasing the risk of COPD in later life. Moreover, people who start to smoke before the age of 15 have a higher risk of lung cancer than those who start later even after the amount smoked is taken into account.3 There is compelling evidence that young people are susceptible to branding and advertising and are influenced by the depiction of smoking in films.4 5 Legislation is needed to counter the efforts of the tobacco industry, but this requires political will by legislators at both national and local levels. This in turn depends on effective health advocacy. National figures for smoking rates are available, but we propose that it would be useful to make available local estimates of smoking uptake among children. These could be used to help to focus attention and resources on what is essentially a child protection issue. In England, local authorities now have responsibility for public health and greater awareness of local burden should encourage them to give attention to implementation and enforcement of public health measures.

These could be used to help to focus attention and resources on what is essentially a child protection issue. In England, local authorities now have responsibility for public health and greater awareness of local burden should encourage them to give attention to implementation and enforcement of public health measures. Methods The initial analysis was based on data from the ‘Smoking, drinking and drug use among young people in England’ reports. This is an annual survey of secondary school pupils in England in years 7–11 (mostly aged 11–15) carried out for the Health and Social Care Information Centre. Questionnaires were completed by 6519 children in 219 schools during the Autumn term of 2011. By comparing rates of current smokers at each age with the smoking rates for that cohort surveyed in the year before, the number of new child smokers aged 11–15 could be estimated, giving a figure of 207 000 new smokers between 2010 and 2011 in the UK.6 Current smokers included both regular smokers (one or more cigarettes per week) and occasional smokers (less than one cigarette per week). This UK estimate was then split across geographical areas according to their adult smoking prevalences, based on the assumption that there was likely to be a greater proportion of childhood smokers in areas that have more adult smokers, since parental smoking is one of the strongest predictors of smoking among children.7 8 This would provide a more valid estimate than simply dividing the national figure by the local population.

n the assumption that there was likely to be a greater proportion of childhood smokers in areas that have more adult smokers, since parental smoking is one of the strongest predictors of smoking among children.7 8 This would provide a more valid estimate than simply dividing the national figure by the local population. The adult (18 years and above) population for England, Wales, Scotland and Northern Ireland were collected from each country's relevant data authority. The smoking prevalence for each country was similarly retrieved and applied to the adult population to produce a total aggregated UK smoking population size. Local authority level data were used to get reliable estimates of smoking prevalence for England from The Office for National Statistics Integrated Household Survey (2011/12) and from the Statistics for Wales—Welsh Health Survey—smoking (2011). The total UK number of new child smokers was then apportioned according to the proportion of the total adult smoking population at a given locality. Further details of and links to the data sources used are available in an online supplement.

2011/12) and from the Statistics for Wales—Welsh Health Survey—smoking (2011). The total UK number of new child smokers was then apportioned according to the proportion of the total adult smoking population at a given locality. Further details of and links to the data sources used are available in an online supplement. Results The estimated proportion of children aged 11–15 who started to smoke in 2011 are presented by location as a heat map in figure 1. Tables with daily, weekly, monthly and annual figures for each UK country (see online supplementary table S1) and for Local Authorities and Districts in England and Wales (see online supplementary table S2) are available online (http://dx.doi.org/10.1136/thoraxjnl-2013-204379). Of 3.7 million children aged 11–15 across the UK, an estimated 463 start to smoke daily in England, 55 in Scotland, 30 in Wales and 19 in Northern Ireland. In each Welsh region, a mean (SD) 10 (4.5) children start smoking each week, from a mean population of 8200. Of 74 000 children in Birmingham, 9 start to smoke daily; in London it is 67 from a population of 458 000. Figure 1 Estimate of proportion of children aged 11–15 who started smoking in England and Wales in 2011.

Results The estimated proportion of children aged 11–15 who started to smoke in 2011 are presented by location as a heat map in figure 1. Tables with daily, weekly, monthly and annual figures for each UK country (see online supplementary table S1) and for Local Authorities and Districts in England and Wales (see online supplementary table S2) are available online (http://dx.doi.org/10.1136/thoraxjnl-2013-204379). Of 3.7 million children aged 11–15 across the UK, an estimated 463 start to smoke daily in England, 55 in Scotland, 30 in Wales and 19 in Northern Ireland. In each Welsh region, a mean (SD) 10 (4.5) children start smoking each week, from a mean population of 8200. Of 74 000 children in Birmingham, 9 start to smoke daily; in London it is 67 from a population of 458 000. Figure 1 Estimate of proportion of children aged 11–15 who started smoking in England and Wales in 2011. Discussion Although the historical trend for smoking in both adults and children is downwards,6 the figure is still high and pressure needs to be maintained to ensure that the necessary public health measures are sustained and new initiatives are introduced to reduce it further. Measures that are recognised to be effective and need to be sustained include making tobacco less affordable by increasing taxation and reducing the illicit trade as well as continuing to run sustained, well-funded anti-smoking media campaigns. New measures include putting all cigarettes out of sight in all shops (due to be implemented in England in Spring 2015), the introduction of legislation for standardised packaging to reduce children's exposure to branding and the extension of smoke-free legislation to private vehicles. The banning of additives such as menthol which make cigarettes more palatable for children is also an important objective.

ted in England in Spring 2015), the introduction of legislation for standardised packaging to reduce children's exposure to branding and the extension of smoke-free legislation to private vehicles. The banning of additives such as menthol which make cigarettes more palatable for children is also an important objective. The data presented here are based on extrapolation from survey data and thus necessarily approximate. However, the availability of local estimates will enable pressure to be brought directly to bear on those with responsibility for developing and enforcing regulations in particular locations which may be more salient than a national figure.

e are based on extrapolation from survey data and thus necessarily approximate. However, the availability of local estimates will enable pressure to be brought directly to bear on those with responsibility for developing and enforcing regulations in particular locations which may be more salient than a national figure. Local authorities, which following the Health And Social Care Act (2012) now have responsibility for public health, should be encouraged to develop tobacco control policies and programmes designed to reduce local smoking prevalence and live up to their obligations under both the WHO Framework Convention on Tobacco Control Article 5.3 to protect their public health policies from the commercial and vested interests of the tobacco industry (http://www.who.int/fctc/guidelines/adopted/article_5_3/en/) and also the Tobacco Control Plan for England (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213757/dh_124960.pdf). Action on Smoking and Health (ASH) has developed the Challenge, Leadership and Results (CLeaR) standard for tobacco control, which was launched in July 2012 and as of August 2013, 89 out of around 150 upper tier authorities have signed up to it. The CLeaR standard is effectively a score card which local authorities can use to check whether their tobacco control policies live up to best practice (http://www.ash.org.uk/information/clear-excellence-in-local-tobacco-control).

and as of August 2013, 89 out of around 150 upper tier authorities have signed up to it. The CLeaR standard is effectively a score card which local authorities can use to check whether their tobacco control policies live up to best practice (http://www.ash.org.uk/information/clear-excellence-in-local-tobacco-control). Figures for child smoking uptake in specific areas may be useful when challenging members of parliament who have accepted hospitality, such as trips to Glyndebourne or The Chelsea Flower Show, from the tobacco industry.9

and as of August 2013, 89 out of around 150 upper tier authorities have signed up to it. The CLeaR standard is effectively a score card which local authorities can use to check whether their tobacco control policies live up to best practice (http://www.ash.org.uk/information/clear-excellence-in-local-tobacco-control). Figures for child smoking uptake in specific areas may be useful when challenging members of parliament who have accepted hospitality, such as trips to Glyndebourne or The Chelsea Flower Show, from the tobacco industry.9 There are some limitations of the data presented. Although the Smoking Drinking and Drug Use Survey is relatively large with over 6000 respondents, the analysis is dependent on comparisons by age and sex and the sample sizes within these categories are clearly smaller. The analysis is also dependent on the publicly available data which have been rounded. Although rounding errors will, to some extent, cancel each other out this does add some uncertainty to the national-level estimate. A further limitation, specifically related to the local-level data, is that it is based on the assumption that smoking uptake by children is proportionate to adult smoking rates, since accurate local childhood smoking rates are not available. In addition, the estimates assume a constant ratio between adult and child population across the UK. However, the mean proportion of 11–15-year-olds to over 18s in England is 7.5% with a SD of 0.8%, so the spread is low and this is therefore unlikely to introduce significant bias (see online for data sources). Finally, although the data are presented at a UK level, this is based on an extrapolation of survey data from English children to the UK population.

ear-olds to over 18s in England is 7.5% with a SD of 0.8%, so the spread is low and this is therefore unlikely to introduce significant bias (see online for data sources). Finally, although the data are presented at a UK level, this is based on an extrapolation of survey data from English children to the UK population. In addition to this, while our figures are for under-16s, the age limit on buying tobacco products is 18. It is interesting to note that, although the Smoking Drinking and Drug Use in Young People Survey is collecting data for the 11–15 years age group, the national ambition for reduction in smoking prevalence in young people is for 15-year-olds and is to reduce smoking prevalence from 15% in 2009 to 12% or less by the end of 2015. This is problematic, as the data for 15-year-olds are based on small sample sizes and the CIs wide. Furthermore, there are also no robust data on smoking in 16-year-olds and 17-year-olds. This is a critical transitional period for smoking behaviour and falls below the legal age limit for buying tobacco products, so and it would be useful to have robust annual data on how many contemporary 16–17-year-olds are smoking, and how much. Smoking is among the largest causes of preventable deaths worldwide. The present data should help to raise awareness of childhood smoking and to focus attention on the need to address this important child protection issue.

In addition to this, while our figures are for under-16s, the age limit on buying tobacco products is 18. It is interesting to note that, although the Smoking Drinking and Drug Use in Young People Survey is collecting data for the 11–15 years age group, the national ambition for reduction in smoking prevalence in young people is for 15-year-olds and is to reduce smoking prevalence from 15% in 2009 to 12% or less by the end of 2015. This is problematic, as the data for 15-year-olds are based on small sample sizes and the CIs wide. Furthermore, there are also no robust data on smoking in 16-year-olds and 17-year-olds. This is a critical transitional period for smoking behaviour and falls below the legal age limit for buying tobacco products, so and it would be useful to have robust annual data on how many contemporary 16–17-year-olds are smoking, and how much. Smoking is among the largest causes of preventable deaths worldwide. The present data should help to raise awareness of childhood smoking and to focus attention on the need to address this important child protection issue. Supplementary Material Web supplement Web table 2 Contributors: NSH and DA conceived the paper. NO-S and AC performed the initial analysis to obtain UK estimate. AL-G performed the analysis to produce local estimates. NSH wrote the first draft to which all authors subsequently contributed. Funding: The study was supported by the NIHR biomedical research unit at Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London. Competing interests: None.

Supplementary Material Web supplement Web table 2 Contributors: NSH and DA conceived the paper. NO-S and AC performed the initial analysis to obtain UK estimate. AL-G performed the analysis to produce local estimates. NSH wrote the first draft to which all authors subsequently contributed. Funding: The study was supported by the NIHR biomedical research unit at Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London. Competing interests: None. Provenance and peer review: Not commissioned; externally peer reviewed.