VOL: 97, ISSUE: 12, PAGE NO: 6
Rob Angus, MBChB, MRCP, is consultant physician, University Hospital Aintree, LiverpoolMore than 730,000 people in the UK have chronic obstructive pulmonary disease (Pauwels, 2000), but this is almost certainly an underestimate, as patients are often not diagnosed until their condition has reached a fairly advanced stage.
More than 730,000 people in the UK have chronic obstructive pulmonary disease (Pauwels, 2000), but this is almost certainly an underestimate, as patients are often not diagnosed until their condition has reached a fairly advanced stage.
In 1994, 27,376 people died of COPD in the UK, making it one of the country's leading causes of death. In the same year there were 5.5 million GP consultations and 203,193 admissions, with an average length of stay of 9.2 days (Pauwels, 2000). COPD, therefore, places an enormous burden on patients, their carers and the health services and results in a large volume of work in both primary and secondary care.
Both the medical and nursing professions as well as many purchasers and providers of health care are beginning to recognise the effect that COPD can have on patients and services.
An acute deterioration in the patient's condition usually results in admission to hospital. Such exacerbations account for 40% of total spending on COPD (Davies et al, 1998), and a great deal of effort has therefore been directed at finding out how to manage patients who are having one.
Models of home care
Several models have been developed to manage COPD patients who are having an exacerbation, including the following:
- Home care teams;
- Acute respiratory assessment services (ARAS);
- Schemes providing an alternative to admission (ACTRITE);
- Rapid discharge schemes.
In the late 1980s and early 1990s, several randomised controlled trials were set up to study the effect of home visits by respiratory care workers on patients (Haggerty et al, 1991). The researchers found that they had little impact on health status, lung function or admission rates and were often a greater drain on resources than inpatient care.
However, one study showed a reduction in mortality rates (Hurd, 2000), and the researchers concluded that the early intervention of a respiratory nurse could benefit patients by preventing a severe deterioration in their condition.
The focus of attention shifted to patients whose symptoms were deteriorating, and ARAS were born.
Pioneered in the UK by a team at Glasgow Royal Infirmary, they offer rapid access to specialist assessment and treatment (Gravil et al, 1998).
The nurse-led service assessed 962 patients over a three-year period. Of these, 145 (15%) needed to be admitted to hospital, 49 (5%) had been inappropriately referred and 115 (12%) subsequently required admission, meaning that 653 (68%) were successfully managed at home.
Since 53% of those cared for at home fulfilled at least one of the European Respiratory Society's criteria for a severe exacerbation (see box), the researchers suggest that at least the same number of patients would have required admission if the service had not existed.
The Glasgow scheme integrated primary and secondary care by offering patients a package of medication and nursing support that included daily visits until the patient's symptoms had settled. There was, however, a suggestion that it created rather than reduced workload.
A number of similar programmes had been set up since then. Edinburgh Royal Infirmary's acute respiratory assessment service aims to manage COPD patients at home after a period of assessment and stabilisation.
A randomised controlled trial based on this scheme is due to be published later this year but preliminary results suggest that, with appropriate specialist nursing support and a package of medication, 25% of patients could be managed safely at home.
A questionnaire completed by patients and GPs involved in the Edinburgh scheme has shown that both support the service while economic evaluation suggests that such schemes can be cost-effective (Davies et al, 2000).
In the belief that admissions could be avoided if suitable patients were identified in the A&E department, North Mersey Community NHS Trust and Aintree Chest Centre, part of Liverpool's Aintree Hospitals NHS Trust, set up a team of specialist nurses, supported by senior respiratory physicians, known as the acute chest triage rapid intervention team (ACTRITE).
Patients who attend A&E with an acute exacerbation of COPD are assessed by the team to determine whether, with suitable medication, nursing and social support, they might safely be cared for at home.
If home care is appropriate ACTRITE provides full support for the patient, including regular home visits from the team's nurses, supported in the evening and at night by the district nursing team.
After a pilot period a randomised controlled trial was performed and the results were presented at the European Respiratory Society's annual congress (Davies et al, 2000).
It showed that, after proper assessment had excluded patients with certain high-risk characteristics, 25% of those who would previously have been cared for in hospital could be cared for at home.
On many occasions this was after an initial assessment of the patient in the A&E department had indicated that admission was required.
The nurse's role
ACTRITE is a nurse-led service. The nurses perform a full clinical examination, organise investigations and analyse the results.
A protocol is in place, and if patients meet the criteria for home care they are reviewed by a member of the respiratory medical team to support the nurse's decision.
Patients are then visited at home every day by a nurse until their condition has stabilised, after which they are discharged into the care of the primary care team.
ACTRITE is funded by the community trust and the project is jointly commissioned with social services. Uniquely, it has access to temporary but immediate social care.
Preliminary evaluations revealed that the service was popular with patients and staff, so it was extended to cover the city of Liverpool.
The nurses involved found it exciting and rewarding to run as they are able to work in an advanced role while maintaining a holistic approach to care: in their assessments they address patients' social care, personal care and nursing requirements.
Working with patients to help them understand their condition and how to take their medication, cope with exacerbations, improve their diet and attempt gentle exercises when recovered are all part of their role.
Requirements for a home service
The British Thoracic Society recently ran a workshop in which the different home service schemes were described. Some key elements for success were highlighted, including the following:
- Dedicated nursing and/or physiotherapy time - a minimum of two staff is recommended, although many teams have three or more whole-time equivalents. Single-handed practice makes it impossible to sustain a daily service with the necessary components of assessment and ongoing care at home;
- The support of medical staff - mainly for medicolegal purposes and clinical support;
- Access to a social carer - although beneficial, some schemes manage without it;
- Staff training - working to written protocols or care pathways alone is not enough and all the teams involved have noted the need for significant lead times before nurses are confident in operating independently at this level. Various organisations offer disease-specific training for respiratory nurses;
- Adequate accommodation - the team requires space in which to carry out patient assessments and store equipment as well as word processing and facsimile facilities so that they can remain in immediate contact with the primary care team. Teams may be based in A&E, the admissions area or outpatients departments, but access to the X-ray department, electrocardiography and blood-gas analysis facilities is vital;
- Locally agreed protocols describing clinical duties and responsibilities - these must explicitly define operations and clinical responsibility and be easy for nurses working in both primary and secondary care to use.
One of the most exciting advances in the delivery of patient care has been the development of specialist nursing teams to address the needs of specific patient groups. And training dedicated secondary care nurses to treat patients with COPD at home has improved the health service's ability to deal with their exacerbations. A recent survey revealed that there are now more than 30 home-care schemes for patients with COPD in the UK (Pauwels, 2000). All are variations on the ARAS and ACTRITE models.
These schemes have the potential to free up medical beds, with logistical and financial benefits, while providing excellent patient care. Their impact on readmission rates is also being investigated.
The Liverpool team is investigating the use of telemedicine to find out whether some nurse visits could be replaced by videophone assessments. Such applications could improve the economic viability of schemes, especially in urban or rural areas.
The introduction of these services is an exciting development for respiratory nursing and the models of care involved may point the way forward for other nurse specialists in the ongoing challenge to improve clinical services for patients in the community.