Hospital at Home for COPD
Dr Tarek Saba
Consultant Chest Physician
Sister Pauline Berry
Respiratory Nurse Specialist
COPD - A Big Problem
Approximately 1.5 million (only 900,000 diagnosed)
110,000 admissions and 1.1 million bed days
(2002/3)
Mean Length of Stay 2001/2:
9.1 (England)
10.6 (Wales)
What is “Hospital at Home”?
In COPD this means for carefully selected
patients delivering as much as possible of the
care we usually provide in hospital in a patient’s
home:
•Nebulisers, steroids, antibiotics, oxygen
•Nursing care
•Physiotherapy
Why “Hospital at Home”?
•Best practice
NICE/BTS
•Government policy - More community management
of chronic disease
•Patient preference
•Pressure on Inpatient beds
•National COPD Audit 2008
•National Clinical Strategy for COPD 2010 (draft)
What is the evidence?
Cochrane review 2003
approach
Safe and effective
NICE Guidelines 2004
Thorax 2004;59(Suppl 1):1-232
BTS Guideline 2007
“HaH should be offered to patients with exacerbations of
COPD unless there is significant impairment of
consciousness, confusion, acidosis, serious co morbidity or
inadequate social support”
Thorax 2007;62:200-210
What is the evidence?
National Clinical Strategy for COPD 2010:
What kind of service?
•Admission avoidance : A/E and GP
referrals
•Early supported discharge
What kind of service?
•Admission avoidance : A/E and GP
referrals
•Early supported discharge (ESD)
“For most hospitals the preferred model of HaH
should be early supported discharge rather than
admission avoidance”
British Thoracic Society Guideline 2007
What should be the hours
of operation?
BTS Guideline 2007
What should be the hours of
operation?
BTS Guideline 2007
7 days a week 9-5
(weekdays only initially till
staff training complete)
Who assumes clinical
responsibility?
BTS Guideline 2007
Weekly staff clinical meetings
No recommendations on Follow-up
Where should patients be
assessed?
Medical Admissions Unit
Chest wards
All medical wards
Out-patients
Accident & Emergency
Urgent Care Centre
Where should patients be
assessed?
Medical Admissions Unit
Chest wards
All medical wards
Out-patients
Accident & Emergency
Urgent Care Centre
What proportion of patients
are suitable?
30 - 40% of exacerbations of
COPD
BTS Guideline 2007
How many visits?
•First visit should be the day after discharge
•Each patient will spend an average of 11 days at
home on the scheme (range 3.5 - 24) and need
between 4 and 11 home visits
BTS Guideline 2007
i.e.: one visit every 1-2 days
Who should be in the
team?
NICE
Consultant Respiratory Physician
Co-ordinator
Nursing
Physiotherapy
Secretarial
What is the expected
workload?
Mean admission rate for COPD = 210 per 100,000 (05/06)
(30 - 40% eligible)
NICE website 2007
Local population is 330,000
~ 700 admissions per year
Local audit estimate
~ 1000 admissions in 2006
(30 - 40%) x (700 -1000)
~ 200 - 400 per year
~ 4-8 discharges per week
Average 11 days
~ 6 - 12 at home on any one
day
1 visit every 1-2 days
~ 3 - 12 visits/day
What is the likely effect on
bed occupancy?
We expect 6 - 12 patients at home on any one day
“There were no significant differences between the
two groups for the number of days in care.”
NICE 2004
“In the 2nd UK COPD audit the median length of
stay in hospitals with access to ESD was 4 days
compared with 7 days where there was no ESD.”
BTS Guideline 2007
Cost
“…the evidence to date does suggest
that a cost benefit is likely.”
BTS Guideline 2007
COPD Early Supported
Discharge Service
Pauline Berry
Service History
• Long time coming 10 years +
• Agreement reached with only
one PCT, as part of a three
pronged approach to care in
the community:
- Admission Avoidance.
- Rapid Response.
- COPD ESD.
Aims of the Service
• To offer an Early Supported Discharge
scheme for patients admitted to hospital
with an exacerbation of COPD at the
earliest opportunity
• To provide a specialist team of nurses,
physiotherapists and occupational
therapists to deliver the service in the
patients own homes
• To develop a programme with strong
primary and secondary care links provide
a seamless service
COPD ESD Team
• Dr Saba (lead physician)
• Emma Gray (lead COPD early supported
discharge respiratory nurse.)
• Sue Townson (Team Leader of North
Lancaschire COPD early supported
discharge)
• A multi disciplinary team of nurses,
occupational therapists and physiotherapists.
Service Type
• Acceptance into the service BVH via Emma
Gray/ Respiratory Nurses
Monday to Friday 9am-4pm initially
• North Lancashire COPD ESD Team available 7
days a week 8am-7pm
• First visit either day of discharge or within 24
hours. Visits then dependent on patients needs
and will occur for a maximum of 14 days in total
• Under the medical care of Dr Saba (or parent
consultant) whilst on this scheme until discharge
back to the GP when stable
Inclusion into COPD ESD
Patients with:• An established COPD
diagnosis
• Both infective & noninfective exacerbations
• Stable respiratory
disease
• Agreement of parent
consultant and COPD
ESD team
• Requiring further
monitoring
Thorax 2007
Pre-home Requirements
• Heart tracing, chest x-ray, blood results are within
acceptable limits
• Bloods taken for oxygen levels if indicated
• Breathing tests if first presentation
• Sputum sent to culture if green/brown
• Systolic BP >100mmhg, heart rate <110,
temp <38°C, respiratory rate <25
• Examination by senior chest physician
Exclusion
• Impaired consciousness
• Acute confusion
• Significantly abnormal blood
gases
• Serious co-morbidity i.e. heart
disease
• Acute changes on x-ray or
heart tracing
• New low oxygen levels <90%
• New diagnosis of type II
respiratory failure
• New or worsening swelling of
the legs
• Intravenous medication
required
Thorax 2007
Social Issues
• Patients/Carers choice
• If patient lives alone has family input
• Lives within North Lancashire PCT boundaries
and if requires a package of care pays council
tax to North Lancshire
• Has access to telephone
• Can transfer safely from bed to chair
• Patients ability to cope with medicines and
nebulised treatment
Thorax 2007
Service Information
ESD provides:
A manageable treatment
plan and daily
assessment
• The ability to increase
social, OT, physio &
nursing support
• A liaison with secondary
care where appropriate to
discuss treatment options
• A team available daily and in times
of concern for review 8-7pm, 7 days
a week
• The patient has direct access to
CDU in situations of deterioration
whilst on the scheme
• Has 14 days treatment on
discharge as would have been
given in hospital
• Nebulisation taught. Care and
temporary loan of equipment
explained
• Weekly MDT meeting with
consultant support
• Respiratory nurse follow up at
six weeks post discharge from
scheme
Home Checks
• Daily BP, Temperature,
Respiratory rate, SpO2
• Sputum colour /volume
• Treatment compliance
• Education re: COPD and
Self Management Plan
• Telephone contact
encouraged with team
COPD Hospital at Home
June 2010 – March 2011
16
14
12
Patients
Hospital days
Home days
T otal days
T rend
10
8
6
4
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The next Members health
seminar is:
Wednesday 8th June 2011
11 am – 12 pm
Lecture Theatre, Education Centre
Dr O’Donnell, Consultant Stroke Physician
“Telestroke in Lancashire & Cumbria”