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Early discharge of people with chronic obstructive pulmonary disease

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Chronic obstructive pulmonary disease (COPD) is an umbrella term used to describe any respiratory condition that causes long-standing airflow obstruction, which is non or only partially reversible with bronchodilator therapy.


VOL: 100, ISSUE: 06, PAGE NO: 65

Sue Burton, RN, DipHE, is respiratory nurse at Glenfield Hospital, University Hospitals of Leicester NHS Trust


Chronic obstructive pulmonary disease (COPD) is an umbrella term used to describe any respiratory condition that causes long-standing airflow obstruction, which is non or only partially reversible with bronchodilator therapy.



These diseases include emphysema, chronic bronchitis, chronic airflow limitation and some cases of chronic asthma. The World Health Organization global initiative for chronic obstructive lung disease (GOLD) recommendations proposed a new definition of COPD as ‘a disease state characterised by a progressive airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases’ (Pauwels et al, 2001).



COPD has been thought of as a smokers’ disease, but while most people with COPD have a significant smoking history, the GOLD guidelines note that tobacco is not the only cause of the condition. It can be caused by an abnormal reaction to many different particles, for example, air pollution, or occupational dusts and chemicals (Pauwels et al, 2001).



Many patients with COPD are not diagnosed until their disease is advanced. A reason for this is that a significant amount of lung volume can be lost before symptoms appear. Many people who smoke associate a cough in the mornings accompanied by sputum production as a normal side-effect of smoking - this obscures the breathlessness that accompanies COPD.



The diagnosis of COPD is based mainly on symptoms, but an objective measurement, such as spirometry (a lung-function test), should be used to confirm it.



The British Thoracic Society recommends that GPs screen every patient at risk from COPD, especially smokers older than 40 (British Thoracic Society, 1997).



Services for people with COPD
Patients with COPD often experience frequent acute exacerbations of their disease, occurring on average between one and four times a year, and this can mean frequent hospital admissions (Collet et al, 1997). Hospital at-home schemes enabled patients to receive treatment in a familiar environment and prevented a risk of cross-infection from other patients.



It has been estimated that one in four admissions to hospital are for respiratory disease and over half of these are due to COPD. Inpatient bed days due to COPD are suggested to be over five times higher than that for asthma (British Thoracic Society, 1997). These figures are the impetus for the development of nurse-led services for COPD in both primary and secondary care.



Many new types of services have been developed, including home-care teams and acute respiratory assessment services (ARAS) (Skwarska et al, 2000). These services are almost exclusively designed to prevent hospital admission.



One of the driving forces behind the development of such schemes is that admission to hospital can be prevented and length of hospital stay decreased. These schemes therefore provide a cost-effective answer to the problem of utilising hospital beds (Skwarska, 2000; Conway, 1998).



Cotton et al (2000) described patients who were either discharged early from hospital with support or admitted to hospital to receive all their treatment. This study showed that the average hospital stay could be reduced from six to three days for a patient discharged with support. This was achieved with no increase in readmission rates for the early discharge group.



In line with this national picture, University Hospitals of Leicester NHS Trust developed an acute respiratory assessment service (ARAS) (Conway, 1998), but due to long clinic waiting lists and pressures on GPs’ surgeries, the service became a fast-track outpatient service.



In 2001, an evaluation of the service indicated that a reconfiguration was required and plans were instigated to replace ARAS with an early discharge scheme.



Developing an early discharge scheme
Leicester’s Respiratory Early Discharge Scheme (REDS) differs from the ARAS scheme in that patients are admitted to hospital, treated initially for as long as required to stabilise their condition and then discharged with support.



Patients are assessed by medical staff and then assessed by nurses from the REDS team. All referrals to REDS come from hospital staff, not GPs. The scheme also provides assisted and early discharges. Assisted discharge aims to facilitate the transition from hospital to home for people who have been in hospital for some time. Both of these arms of the service focus mainly on patient education.



Two nurse practitioners work in the medical assessment area and assess all respiratory patients who are admitted to hospital. These patients are assessed for their suitability for REDS and referral to other services, for example tuberculosis nurse specialists or the respiratory consultant nurse. Two nurse specialists work in the REDS team and assess patients on the wards, plan discharge and visit the patients at home.



Medical cover is provided by the consultant in charge of the patient’s care. If there are any medical problems following discharge, the patient is readmitted to hospital to be assessed by his or her consultant.



Criteria for admission to the scheme
A set of criteria is used to determine the suitability of a patient for the scheme. This is based on the British Thoracic Society guidelines for deciding whether to treat a patient at home or in hospital for an exacerbation of COPD. These criteria ensure that the patient’s physical, psychological and social requirements are met (British Thoracic Society, 1997) (Box 1).



One of the primary aims of the scheme is to prevent unnecessary admissions in the future by promoting the patient’s independence. This is achieved by education on coping mechanisms and information on practical equipment issues for patients and their families. Many patients have a poor understanding of their diagnosis and treatments, and need advice to help them to cope.



Once a patient is assessed, a discharge date is set and arrangements are made for a nurse to visit the patient at home. The visit occurs within 24 hours of discharge if the patient is discharged during the week, or on Monday morning if discharge is at the weekend. The patients can be visited daily, depending on patient need, for up to one week. Nebuliser compressors and oxygen concentrators are available on short-term loan if they are needed.



The patient’s GP receives a fax explaining how the scheme operates and why a patient may contact them (for problems not involving their respiratory condition).



If respiratory symptoms worsen, the patient can be admitted directly back to hospital. This back-up helps the patient feel more secure about the discharge.



Discharge from the scheme
When the patient is discharged from the scheme, his or her GP will receive a fax detailing the patient’s medication, the prescribed treatment and the most recent spirometry results. The fax also gives details of the patient’s next outpatient appointment.



Patient education
During home visits, information is provided to the patients about their condition, symptoms and the disease process. Breathlessness, nutrition (see p60), coping mechanisms, energy conservation, breathing techniques and differing treatments are also discussed.



Finally the patient’s medication is reviewed with him or her. This includes a review of inhaler technique, and nebuliser and oxygen use. Written information is provided to support these discussions.



Many patients who experience shortness of breath can become anxious and this, in turn, affects their breathing even more. Anxiety management and breathing techniques are discussed to help with this.



Education is aimed at enabling patients to exercise better control of their symptoms if an exacerbation of their disease occurs again. Patients are provided with sputum pots, advice on when to contact their GP, when to send sputum samples and when to start antibiotics if they have a standby course at home.



If patients have concerns about their medication, they are referred to the respiratory pharmacist for help and advice. If necessary, referrals can be made to the respiratory consultant nurse, pulmonary rehabilitation department or respiratory physiology department.



Evaluation of the scheme
Since March 2001, 350 patients have been admitted to the scheme and about 20 per cent have been readmitted within one month. This is broadly consistent with other schemes (Cotton et al, 2000; Skwarska et al, 2000).



This experience has shown that early and assisted discharges enable improved bed utilisation and reduce the risk of nosocomial infections.



Feedback from the scheme shows that patients prefer to be nursed at home. They value having back-up telephone contact numbers and also, most importantly, the benefit of having a health care practitioner who has the time to explain their condition and treatments to them. Armed with this information, patients are more able to cope if the same problems arise again.

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