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 NICE Guidelines 2004 Safe and effective

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?

7 days a week 9-5

BTS Guideline 2007

(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 i.e.: one visit every 1-2 days

BTS Guideline 2007

NICE

Who should be in the team?

Consultant Respiratory Physician Co-ordinator Nursing Physiotherapy Secretarial

What is the expected workload?

Mean admission rate for COPD = 210 per 100,000 (05/06)

NICE website 2007

(30 - 40% eligible) Local population is 330,000 Local audit estimate (30 - 40%) x (700 -1000) ~ 700 admissions per year ~ 1000 admissions in 2006 ~ 200 - 400 per year

~ 4-8 discharges per week

Average 11 days 1 visit every 1-2 days

~ 6 - 12 at home on any one day ~ 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 & non infective 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 10 8 6 4 2 0 Ju n Ju ly Au g Se pt Oc t No v De c Jan Fe b M ar Patients Hospital days Home days T otal days T rend

The next Members health seminar is:

Wednesday 8 th June 2011 11 am – 12 pm Lecture Theatre, Education Centre Dr O’Donnell, Consultant Stroke Physician “Telestroke in Lancashire & Cumbria”