Correspondence |
Assisted hospital discharge in patients with chronic respiratory disorders
Sir,There has been growing interest in the use of ‘assisted discharge’ schemes for patients admitted with non-severe exacerbations of chronic obstructive pulmonary disease (COPD).1 This involves selected individuals being discharged from hospital earlier than expected, with nursing support provided at home. We describe the workings of an assisted hospital discharge scheme which has been successfully operating at Aberdeen Royal Infirmary (952 acute admission beds) situated in the North East of Scotland. Patients other than those with an exacerbation of COPD were incorporated over a 3-year period.
Following emergency admission to hospital, potentially suitable patients were assessed by a respiratory physician. Initial assessment occurred from between a few hours after arrival in an acute admission ward, to several days of in-patient care. The clinical criteria by which patients were considered unsuitable included: confusion, pH <7.35, pO2<8 kPa, pCO2>6.5 kPa, tachycardia >110 bpm, respiratory rate >28 bpm, cardiac chest pain, no telephone, living >20 miles from hospital, adverse home circumstances or the patient, family or General Practitioner unwilling. Treatment was optimized and overall suitability discussed with the nursing staff. After discharge, nursing advice (in person or by telephone) was available on a 24-h basis for a minimum of 7 to a maximum of 14 days. If required, oxygen cylinders and nebulizers were given for short-term use. A team of nurses performed daily visits where physiological observations were recorded and the patients progress discussed. When necessary, intravenous antibiotics were administered and venepuncture done. If a patient's progress was considered unsatisfactory, re-admission to hospital could be arranged directly to the respiratory ward, without input by the General Practitioner. All patients entered into the scheme were given an appointment for review at an out-patient clinic, 1 month following assisted discharge.
Over a 3-year period (January 2002 to December 2004), 364 separate patients with either COPD, bronchiectasis, asthma or interstitial lung disease were recruited into our assisted discharge scheme. The age range was 40 to 92 years (mean 68 years). Many of the patients were re-admitted on subsequent occasions over the same period, resulting in 626 assisted hospital discharges in total (Table 1). Prior to the introduction of this scheme, the median length of stay in Aberdeen Royal Infirmary for a patient with COPD was 11.2 days; since its introduction, this has been reduced to 4 days, with a total of 4545 bed days being saved. Assuming that the mean cost of 1 night in hospital is £280 [http://www.isdscotland.org], this translates into a theoretical saving of £1 272 583.
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In a systematic review of seven randomized controlled trials (n = 754 patients with an exacerbation of COPD),2 hospital readmission and mortality rates were not significantly different when ‘hospital at home’ schemes were compared to standard in-patient care. As expected with the former, substantial financial savings were made, along with the increased availability of in-patient beds. Mortality from COPD on admission to hospital is closely linked to the degree of acidosis3 and presence of concomitant medical disorders.4,5 As a consequence, patients with a pH<7.35 were not considered suitable for our assisted hospital discharge, although we elected not to exclude patients with other medical disorders such as clinically stable ischaemic heart disease, diabetes mellitus or cardiac failure.
Assisted hospital discharge schemes can be extended to involve patients with chronic respiratory disorders other than COPD, and successfully operate outwith the realms of randomized controlled trials. Greater emphasis should be made of such schemes in national guidelines, in addition to provision of a suggested working template. Practising respiratory physicians and health authorities should be aware of the existence of assisted hospital discharge schemes, and of potential financial savings plus reductions in bed occupancy.
Department of Respiratory Medicine Aberdeen Royal Infirmary Aberdeen UK e-mail: graeme.currie{at}nhs.net
References
1. Cotton MM, Bucknall CE, Dagg KD, Johnson MK, MacGregor G, Stewart C, Stevenson RD. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax 2000; 55:902–6.
2. Ram FS, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. Br Med J 2004; 329:315.
3. Warren PM, Flenley DC, Millar JS, Avery A. Respiratory failure revisited: acute exacerbations of chronic bronchitis between 1961–68 and 1970–76. Lancet 1980; 1:467–70.[CrossRef][ISI][Medline]
4. Connors AF, Jr, Dawson NV, Thomas C, Harrell FE, Jr, Desbiens N, Fulkerson WJ, Kussin P, Bellamy P, Goldman L, Knaus WA. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med 1996; 154:959–67.[Abstract]
5. Seneff MG, Wagner DP, Wagner RP, Zimmerman JE, Knaus WA. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995; 274:1852–7.[Abstract]
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