Chronic Obstructive Pulmonary Disease (COPD): best practice guide

This document is for healthcare professionals and patients to show how this condition could be best managed from the unscheduled care perspective.

6. The Vision for Optimal COPD Care

Drawing on the above workstreams the COPD Working Group distilled the ideal COPD patient pathway into the following acronym:

e Exacerbation Management - Local initiatives and protocols

C Community Respiratory Team - This could be approached creatively in those regions that don't have a CRT where paramedic practitioners or other healthcare professionals might be deployed

O Online and Offline Support - e.g. 'Florence' (an SMS-based text messaging service that allows patients to relay information on their clinical observations to a specialist in real time), COPD websites, technology-enabled care

P Pulmonary Rehabilitation - Including the use of leisure facilities, peer groups, choirs etc. that give the individual a good 'lung workout'

D Documentation of an Anticipatory Care Plan ( ACP) in the Key Information Summary ( KIS), which clearly outlines the patient's physical, psychological and social needs, resuscitation status and level of escalation during an acute exacerbation.


Email: Syed Kerbalai

Phone: 0300 244 4000 – Central Enquiry Unit

The Scottish Government
St Andrew's House
Regent Road

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