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Evid Based Nurs 4:89 doi:10.1136/ebn.4.3.89
  • Treatment

Home supported discharge was as effective and safe as standard hospital admission in patients with chronic obstructive pulmonary disease


 
 QUESTION: Is immediate or next day home supported discharge as effective and safe as standard hospital admission in patients presenting to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD)?

Design

Randomised {allocation concealed}*, unblinded, controlled trial with 8 weeks of follow up.

Setting

A hospital in Edinburgh, UK.

Patients

184 patients (mean age 69 y, 53% women) who presented to hospital on a weekday with an exacerbation of COPD. Exclusion criteria were an impaired level of consciousness, acute confusion, acute changes on radiography, an arterial pH <7.35, or a serious medical or social reason for admission. Follow up was 93%.

Intervention

122 patients were allocated to home support and were discharged immediately or the next day with an appropriate treatment package (antibiotics, corticosteroids, nebulised bronchodilators, and, if necessary, home oxygen). These patients had a home visit by a respiratory nurse the day after discharge and every 2–3 days thereafter until recovery, at which time they were discharged from follow up. Nurses reviewed patient progress weekly with the consultant. Specialist advice was available daily and changes in prescription could be obtained in consultation with the patient's general practitioner (GP). 62 patients were allocated to hospital admission with standard care in the respiratory medicine unit.

Main outcome measures

Time to discharge, readmission rate, respiratory function tests, additional care by GPs or other carers, quality of life, and estimated healthcare costs.

Main results

The median time to discharge was 7 days for the home supported group and 5 days for the admitted group (p<0.01). At 8 weeks, no differences existed between the home supported and admitted groups for the rate of readmission (25% v 34%), respiratory function, attendance by GPs and carers, or quality of life. The estimated mean total health service cost was £877 per patient for the home supported group and £1753 per patient for the admitted group.

Conclusion

Home supported discharge was as effective and safe as standard hospital admission for patients referred to hospital with an exacerbation of chronic obstructive pulmonary disease.

Commentary

  1. Della Roberts, RN, MScN
  1. Coordinator, Palliative Care Delta Health Services Delta Hospital Delta, British Columbia, Canada

      With the increasing pressure to reduce hospital use, there is a need to identify patients who can be cared for at home rather than in hospital and to determine the necessary services required for effective home based care. These 2 studies by Cotton et al and Skwarska et al make an important contribution in both areas. Earlier studies evaluating the effects of home based care by outreach nurses for people with COPD have shown some improvement in mortality and quality of life, but no data exist on reductions in hospital usage.1 These 2 studies extend the literature by showing that a select group of patients with exacerbations of COPD in hospital can be discharged early with home based care. Results showed that hospital stay was reduced while maintaining comparable levels of safety and treatment success as those patients who were cared for in hospital. This evidence is strengthened by the randomised controlled trial designs.

      Both studies identified patients with mild to moderate exacerbations of COPD and limited comorbidity as appropriate for early discharge service. In both studies, most patients admitted to hospital were not considered eligible for home care on medical grounds. Therefore, screening for the appropriateness of patients is critical to the safety and effectiveness of early discharge home based care. Consideration should be given to incorporating these study findings into the established guidelines for the management of COPD.24

      Skwarska et al provided a more indepth outcome analysis, evaluating the effects on quality of life as measured by the Chronic Respiratory Questionnaire. No difference was found between groups for quality of life. Although this is an important measure for the patient, neither this study nor the one by Cotton et al evaluated the effects on caregiver burden. Skwarska et al showed that general practitioners and patients with COPD found early discharge service acceptable, although satisfaction levels of the home based group were not compared with the usual care group. Future studies should examine if home based care shifts the burden of care from the healthcare system to the caregivers.

      The cost to caregivers was not considered in the economic analysis by Skwarska et al. Although the study showed significant cost savings with supported discharge, only traditional health service costs and not those attributed to the caregivers or community health resources (other than general practitioner care) were measured.

      The home based service in both studies involved home visits by nurses with specialised respiratory knowledge and expertise in providing home visiting, and consultation with respiratory specialists. Such home based care interventions will be of particular interest to those who are developing community based programmes. The findings showed that respiratory nursing expertise is required in early discharge home based care to assess patients and to access consultation. In both studies, 1 respiratory nurse delivered the home based service; however, community practice models commonly involve a group of general home care nurses. Therefore, the ability to widely implement such a strategy may be limited. Further research comparing the effectiveness of specialist nursing care to the more common practice model involving a group of general home care nurses would be beneficial to determine the best care delivery models for this patient population.

      Another important aspect of the intervention was the availability of specialist respiratory medical care for consultation with the home based nurse. Typically, specialist medical consultation for home based care is limited and more accessible to hospital based services. This specialist medical consultation support may have been an important aspect of the intervention that supported the effectiveness of home based care. Those who are interested in generalising these findings to home based early discharge services in their communities need to acknowledge that both specialist nursing care and specialist medical consultation are important components of early discharge care.

      References

      Footnotes

      • Sources of funding: Scottish Office and the Royal Infirmary of Edinburgh and Associated Hospitals Trust Endowments.

      • For correspondence: Professor W MacNee, Respiratory Medicine Unit, Colt Research Laboratories, Wilkie Building, Medical School, Teviot Place, Edinburgh EH8 9AG, UK. Fax +44 (0)131 536 2274.

      • * Information provided by author.

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