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A nurse-led community scheme for managing patients with COPD

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Margaret Barnett, BSc Nursing Studies, RGN, SCM, Respiratory Course Dip, COPD Dip.

Chronic Obstructive Pulmonary Disease Nurse Specialist, Chest Clinic, Derriford Hospital, Plymouth

Exacerbations of chronic obstructive pulmonary disease (COPD) are the most common cause of admission to hospital, amounting to over 1000 cases a year to Derriford Hospital, Plymouth. This has a major impact on hospital resources, increasing pressure on acute hospital medical beds, especially in winter. In 2000, the COPD home-care service was established in Plymouth after a six-month pilot scheme.

Exacerbations of chronic obstructive pulmonary disease (COPD) are the most common cause of admission to hospital, amounting to over 1000 cases a year to Derriford Hospital, Plymouth. This has a major impact on hospital resources, increasing pressure on acute hospital medical beds, especially in winter. In 2000, the COPD home-care service was established in Plymouth after a six-month pilot scheme.Other UK schemes have focused on either setting up early discharge programmes or acute respiratory assessment services for inpatients, with a view to short-term follow-up in the community (Gravil et al, 1999; Davis et al, 2000).The focus of the Plymouth scheme is community based and its aims are to stabilise or treat exacerbations, managing patients where possible in the community. This entails identifying patients with ‘multiple hospital admissions’, otherwise known as ‘revolving-door admissions. As a local benchmark, multiple hospital admissions were determined as more than three admissions a year, arising from exacerbation of a patient’s COPD.In the UK, COPD is one of the most common and important chronic respiratory diseases (Box 1). It causes around 30 000 deaths a year in the UK, which is just over one in 20 of all deaths (Halpin, 2001). This results in considerable morbidity, impaired quality of life, time off work, and more hospital admissions and GP consultations than asthma (Bellamy and Booker, 2000).In less than 20 years, COPD is expected to become one of the five leading medical burdens on society worldwide (Lopez and Murray, 1998). In the UK, this will have enormous economic consequences for an overstretched health service. The condition is estimated to cost the NHS 500 million a year (Bellamy and Booker, 2000).COPD is often underdiagnosed in primary care so many patients go untreated (Bellamy and Booker, 2000) until they present to their GP with symptoms of increased breathlessness, owing to considerable loss of lung function. In addition, many professionals often view this medical condition as unexciting, designating patients as ‘heart-sink’ cases with a self-inflicted disease for which little can be done medically.

Setting up the home-care service
At Derriford Hospital, COPD accounts for 10% of acute admissions to the medical assessment unit, the average length of stay being 9.9 days. Patients are at added risk of contracting hospital-acquired secondary infections, which extend their stay and incur further costs. At Derriford, an attempt to address the problem was developed initially using a ‘winter pressures’ initiative, to relieve pressure on acute medical beds in the hospital.In September 2000, following a successful six-month pilot, the COPD community-led service, funded by the Plymouth Primary Care NHS Trust, was established. Under the scheme, patients receive regular home visits from nurse specialists, to optimise individual drug therapy and improve patients’ symptoms and quality of life. The service provides support and education to patients and carers on drug therapy, smoking cessation and health promotion issues. At the outset the scheme employed two nurse specialists, but its success resulted in extra funding being obtained about 18 months into its operation for a further two nurses and a part-time physiotherapist.

Service goals
The service aims primarily to optimise the management of patients who, in the past, have been admitted repeatedly to hospital and to deal with exacerbations of COPD at an early stage, preventing admission where possible. The patients the service deals with have moderate to severe COPD with less than 60% predicted FEV1 and live in Plymouth. The service operates Monday to Friday from 8am to 4pm and referrals are accepted from GPs, medical and respiratory consultants and staff from the chest clinic. Outside these hours the patients’ GP maintains their care.Response to acute referrals occurs the same day, usually within a couple of hours of a GP visit to the patient. The short-term loan of a nebuliser and equipment can be provided, if required, to stabilise the patient’s condition in cases where inhaler medication is not sufficient. In these cases, the COPD team visits daily or as often as necessary until the patient’s symptoms stabilise. Close liaison with GPs is maintained by telephone to provide feedback on the patient’s condition and progress.Referrals also come from GPs, who request advice and support for patients with difficult symptoms, such as breathlessness. We are able to assess patients to ensure they are prescribed optimal treatment and that they are taking their medication correctly. We also advise them on breathing techniques and how to manage symptoms. The patients are usually anxious, lack confidence and so require a great deal of psychological support. These non-acute respiratory referrals are usually completed within seven to 10 working days.

Patient home assessment
The COPD nurse specialist starts by completing a full respiratory and clinical assessment of the patient (Box 2), which involves taking a full clinical history, along with a smoking history, current treatment and the home support available. Non-respiratory issues are addressed by referral to the appropriate agency, such as social services or the district nursing service.Patients receive regular home visits from the team, from weekly to three monthly, depending on the patient’s condition, stability and psychological needs. The majority (45%) of visits are made monthly: they enable nurses to make regular respiratory assessments and monitor the patient’s condition, ensuring early detection of any deterioration. This can then be discussed with the patient’s GP and appropriate management implemented.Protocols and guidelines covering the management of patients with COPD in the community have been implemented to standardise care management. The guidelines include criteria for nebuliser and steroid trials, assessment for home oxygen, and management of exacerbations in the community.As specialist nurses, we are unable to prescribe but nurse advisory drug guidelines enable us to make recommendations to GPs regarding drug management and treatment of exacerbations. These follow the recommendations of the British Thoracic Society (1997). Guidelines have also been developed to enable specialist nurses to follow criteria in deciding whether to treat a patient with an acute exacerbation at home or to refer to hospital (Table 1). The COPD nurse specialist is able to consult with the patient’s GP and the hospital medical registrar if direct admission is required.

Service evaluation
Evaluation of the service took place over three months during 2002 and aimed to establish the effectiveness and impact of the COPD home service in its first two years of operation. Data were obtained from key stakeholders using semistructured interviews and questionnaires.

GP perspective
Ten GPs were interviewed to obtain their opinions on the service using a semistructured format. The majority (90%) was satisfied with the service response time for acute and routine referrals, with the exception of one GP, who felt patients could be managed effectively without our input.A majority felt the service had an impact on the number of consultations individual patients made at the surgery. Three GPs stated that several of their patients who used to visit the surgery two or three times a week had attended less frequently since the introduction of the home visits.Most GPs felt that the number of daily home visits they made had also fallen, mainly because patients are able to ring the COPD service if they feel unwell (provided it is not a medical emergency) for advice, treatment and follow-up. In these cases, after an assessment at home, GPs are contacted by phone and a management plan is discussed. Before the service was established GPs had little alternative other than to offer an appointment or home visit. The majority of GPs felt our patient education initiative had had an impact on controlling patients’ symptoms and therefore stabilising their overall condition, as well as enhancing their self-confidence. However, it emerged that not all GPs were clear about patient-referral criteria and how to access the service directly.

Medical and nursing perspective
Individual semistructured interviews were also arranged with two respiratory consultants at the hospital and with 12 nurses working in the respiratory medical wards and the chest clinic department.The respiratory consultants noticed a small reduction in their outpatient clinics since implementation of the service. They had also discharged several patients from their care for management by the COPD service. In contrast, staff at the chest clinic felt the service had increased their workload. This affected two clinics in particular: the spirometry and nebuliser clinics. The higher workload arose because patients who no longer required home visits by the COPD service were stable and mobile enough to visit nurses in the chest clinic to have their symptoms monitored and have spirometry measurements. However, if any of these patients becomes unstable or unable to visit the chest clinic, the COPD service can resume visits.The six ward nurses interviewed stated that they found the information and knowledge they received from the COPD nurses regarding patients’ normal health status and abilities invaluable in relation to assessing individual patient needs and planning discharge.

Patient perspective
Due to the time element of conducting this evaluation and lack of human resources, it was hoped that a sample of 100 patients would give us a comprehensive picture of patients’ perceptions of the service. It needs to be noted that the evaluation was open to bias, in that patients were known to us and may have felt obliged to take part or to provide favourable answers. However, in our previous experience, we found patients to be honest, as it is in their interests to let us know if the service does not live up to expectation. The questionnaires were anonymous and, once completed, were placed in an envelope and collected in a file. I was, therefore, not aware of their source when collating data.The results showed that most patients (91%) were very satisfied with the service and felt it met their needs, while the remainder reported being quite satisfied. Since the introduction of home visits, the vast majority (68%) felt their symptoms had either improved or had stabilised, while 32% reported no change. A high proportion (87%) had developed better understanding of their medication, leading to better compliance; education had also improved their knowledge about their illness and symptoms. This enabled patients to manage symptoms more effectively and made them less prone to having panic attacks.Many said that having telephone access to a nurse to ask even the smallest question gave them peace of mind and boosted their confidence.

Statistical details
The workload audit figures collected over the two years show that the service has led to a drop in hospital admissions, making a major savings for Plymouth Hospitals NHS Trust in terms of bed days (Table 2). Of the 100 patients who completed the questionnaires, 40% had had no admissions since having visits from the service and 25% had had one admission only, showing the beneficial impact of regular maintenance visits.Patients who were referred at the start of the service were very unstable and not necessarily on appropriate treatment for controlling symptoms. Many lacked understanding of their condition, and did not always comply with medication, in particular, inhaled medication. Inhaler technique was generally poor in the majority of those using this form of therapy. A large number were unaware of breathing exercises and chest clearance techniques that can be used to ease symptoms.Additional statistical work needs to be done to establish the outcomes outlined above conclusively. The benefits of the service to patients and health services are summarised in Table 3.Discussion
The evaluation and the data obtained show that the COPD home-care service has had an impact in terms of reducing hospital admissions of patients with exacerbations of COPD. Regular home visits to those who previously had multiple hospital admissions have proved effective in stabilising patients’ symptoms. The service has also helped to reduce patients’ anxiety and panic attacks, which for some had been the cause of previous A&E admissions. Many patients now state how much more confident they feel about managing their symptoms, which is due to their better understanding of their symptoms and knowledge of their medication and its action.Most patients prefer to remain in their own homes, preserving autonomy and personal choice. Family and carers also appreciate our input and feel supported.

Operating the service on a seven-day basis would not only improve the care provided to patients but would also offer greater continuity of care and flexibility. However, this would require further funding. The COPD service also needs to be more widely publicised to raise awareness of its aims among GPs; knowledge of referral criteria also needs to be improved, perhaps by further circulation of support literature.To improve the referral system for nurses at ward level in secondary care, we plan to place appropriate coloured-coded labels on the cover of patients’ medical notes, stating whether the patient is already known to the service. This will keep the COPD service informed of the admission of existing patients and raise new referrals for patients not known to the service.The COPD home-care service demonstrates that it is possible to offer a scheme that not only provides a high-quality service to patients and carers, but that is also safe. Both patients and GPs have found the service to be highly acceptable and felt that it not only enhanced patient confidence but also improved their quality of life.Patients are viewed as individuals not as heart-sink or hopeless cases. The service has offered a lifeline to those who, without the expertise provided through the scheme, would live in fear, spending much time in hospital away from families. Our COPD patients know there is no cure, but the care and understanding we offer gives them considerable comfort and offers some a new lease of life.

The author would like to thank colleagues Dr P. Hughes, Yvonne Planchant, Kirsty Riordan and Fiona Bates and the patients who contributed information for this evaluation.

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