Abstract
BACKGROUND—We have previously reported the use of a hospital based respiratory nurse service (Acute Respiratory Assessment Service, ARAS) to support home treatment of patients with exacerbations of chronic obstructive pulmonary disease (COPD). A controlled trial was undertaken to compare early discharge with home treatment supported by respiratory nurses with conventional hospital management of patients admitted with exacerbations of COPD. METHODS—Patients with COPD admitted as emergencies were identified the next working day. They were eligible for inclusion in the study if the differential diagnosis included an exacerbation of COPD, but were excluded if other medical conditions or acidotic respiratory failure required inpatient investigation or management. Of 360patients reviewed, 209 were being assessed for other active medical problems and were excluded, 33 potential participants were already involved in research studies and so were ineligible, and 37 did not wish to participate in the study. Eighty one patients were randomised to receive conventional inpatient care (n=40) or to planned early discharge the next working day (n=41). Those discharged early continued treatment at home under the supervision of specialist respiratory nurses. Outcome measures were readmission, additional hospital days, and deaths within 60 days of initial admission. Process measures included number of visits, duration of follow up by the respiratory nurse, and additional treatment provided to support early discharge. RESULTS—On an intention to treat basis, a policy of early discharge reduced inpatient stay from a mean of 6.1 (range 1-13) days with conventional management to 3.2 (1-16) days with an early discharge policy. Twelve patients (30% conventional management, 29.3% early discharge) were readmitted in each group giving a mean difference in readmission of 0.7% (95% CI of the difference -19.2 to 20.6). In the conventional management group readmitted patients spent a mean of 8.75 additional days in hospital compared with 7.83days in the early discharge group, giving a mean difference of 0.92 days (95% CI of the difference -6.5 to 8.3). There were two deaths (5%) in the conventional management group and one (2.4%) in the early discharge group, a mean difference of 2.6% (95% CI of the difference -5.7 to 10.8). CONCLUSIONS—Patients with acute exacerbations of COPD uncomplicated by acidotic respiratory failure or other medical problems can be discharged home earlier than is current practice with support by visiting respiratory nurses. No difference was found in the subsequent need for readmission.
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Selected References
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- Clarke A. Why are we trying to reduce length of stay? Evaluation of the costs and benefits of reducing time in hospital must start from the objectives that govern change. Qual Health Care. 1996 Sep;5(3):172–179. doi: 10.1136/qshc.5.3.172. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Coast J., Richards S. H., Peters T. J., Gunnell D. J., Darlow M. A., Pounsford J. Hospital at home or acute hospital care? A cost minimisation analysis. BMJ. 1998 Jun 13;316(7147):1802–1806. doi: 10.1136/bmj.316.7147.1802. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cockcroft A., Bagnall P., Heslop A., Andersson N., Heaton R., Batstone J., Allen J., Spencer P., Guz A. Controlled trial of respiratory health worker visiting patients with chronic respiratory disability. Br Med J (Clin Res Ed) 1987 Jan 24;294(6566):225–228. doi: 10.1136/bmj.294.6566.225. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Flanigan U. M., Irwin A., Dagg K. An acute respiratory assessment service. Prof Nurse. 1999 Sep;14(12):839–842. [PubMed] [Google Scholar]
- Gravil J. H., Al-Rawas O. A., Cotton M. M., Flanigan U., Irwin A., Stevenson R. D. Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet. 1998 Jun 20;351(9119):1853–1855. doi: 10.1016/s0140-6736(97)11048-0. [DOI] [PubMed] [Google Scholar]
- Haggerty M. C., Stockdale-Woolley R., Nair S. Respi-Care. An innovative home care program for the patient with chronic obstructive pulmonary disease. Chest. 1991 Sep;100(3):607–612. doi: 10.1378/chest.100.3.607. [DOI] [PubMed] [Google Scholar]
- Littlejohns P., Baveystock C. M., Parnell H., Jones P. W. Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation. Thorax. 1991 Aug;46(8):559–564. doi: 10.1136/thx.46.8.559. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Shepperd S., Harwood D., Gray A., Vessey M., Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis. BMJ. 1998 Jun 13;316(7147):1791–1796. doi: 10.1136/bmj.316.7147.1791. [DOI] [PMC free article] [PubMed] [Google Scholar]