COPD remains one of the most prevalent chronic illnesses among adults
For patients with chronic obstructive pulmonary disease (COPD), acute exacerbations usually mean admission to the hospital. “That’s a given,” says Pamela Brown, CRTT, CPFT, assistant director of respiratory care at the Cambridge Health Alliance/ Somerville Hospital in Somerville, Mass. According to Brown, repeated exacerbations are one of the hallmarks of COPD. With worsening dyspnea, cough, and frequently fever, patients are sent to the emergency department or to the clinic by their primary care practitioners. “If the patient’s condition meets the criteria for severity, he or she will be admitted,” Brown says.
Patients with COPD typically experience 3 or 4 such episodes each year, spending an average of 3 days in theÿhospital each time. Several studies have examined how home-based interventions might reduce the frequency of these recurrent exacerbations and thereby reduce the number of costly hospital admissions.1 But once an exacerbation is under way, the patient is routinely admitted to the hospital.
For Brown, having patients with COPD in the hospital offers an opportunity to provide some much-needed teaching and psychological support. Depending on the patient’s condition, hospitalization also gives Brown a chance to perform pulmonary function testing. While COPD patients are in-house, she reviews their inhaler technique, addresses nutrition, and tries to arrange for appropriate patients to be enrolled in pulmonary rehabilitation. With hospital stays being kept as short as possible, she does not have much time. But since patients with COPD receive little in the way of routine respiratory care once they are discharged, she does the best she can. “There really is no alternative,” Brown says.
Or is there? Recently, a group of pulmonary physicians and respiratory nurses in Scotland demonstrated that even exacerbations of COPD severe enough to warrant admission to the hospital can be treated safely and effectively at home.2 According to Robin D. Stevenson, FRCP, consultant physician in respiratory medicine at Glasgow Royal Infirmary, the approach requires hospital-based assessment by a pulmonologist and expert nursing support in the field. In a demonstration project that has now become part of his hospital’s regular service, Stevenson and colleagues found that 80 percent of patients referred from the community with exacerbations of COPD could be managed at home. To his surprise, a large majority of those patients actually preferred home treatment, including many patients who lived alone, in public housing, with limited economic means.
Why consider managing acutely ill patients in such surroundings? One reason, according to Stevenson, has been a shortage of hospital beds. “In the United Kingdom, the number of acute medical beds–and particularly acute respiratory beds–has been savagely reduced over the past 10 years,” he says. Before that time, each city had one or more chest hospitals originally established for the treatment of tuberculosis. With the closing of the chest hospitals, however, chest medicine was integrated into the large general hospitals. “So in the past 10 years we have had an increasing battle to find acute medical beds,” Stevenson says. Meanwhile, as he points out, COPD remains one of the most prevalent chronic illnesses among adults; exacerbations of COPD account for a significant proportion of all hospital admissions.
“Yet in looking at these patients with exacerbations of COPD, I felt that many of them didn’t really need to be in the hospital,” Stevenson says. Many of the cases he saw were straightforward, without serious complications. Nor did they require complicated management in the hospital. “They were getting nursing care, nebulized bronchodilators, steroids, antibiotics, and sometimes oxygen. We can give all that at home,” Stevenson realized. He also reasoned that most patients with exacerbations of COPD are fairly stable. “They don’t deteriorate all that quickly. We get a bit of warning when they are not doing well,” Stevenson says.
“So I took the view that we could assess them in the hospital on day one with a chest x-ray–because the chest x-ray is the single best discriminator of how they’ll do–take a full history, do a physical examination, simple spirometry, and blood gases. If we get all that, we’ll have a pretty good picture of
how those patients will do,” Stevenson says. Unless an exacerbation was extremely severe, or complications were present, he predicted that home treatment would be suitable and set about testing this hypothesis in a formal study. Patients who were sent home would be supplied with all drugs, a nebulizer, and oxygen if needed. Nurses would visit each day to monitor progress, ensure that patients were receiving all their
medications, and provide education and reassurance.
Since training for respiratory clinical nurse specialists is not widely available in the United Kingdom, Stevenson decided to recruit experienced acute care nurses from the hospital’s inpatient staff and provide training within the department. The group then set up an acute respiratory assessment service to which general practitioners in the community could refer their patients. Two of the physicians on the team visited local health centers to secure the cooperation of general practitioners and ads were placed in the medical community’s newsletter. “It was emphasized that if appropriate, patients experiencing an exacerbation of COPD would be treated at home,” Stevensonÿsays. The plan was to recruit patients at the time of exacerbation and discharge them from follow-up when they had recovered. “In this way costs would be kept to a minimum and support would be focused at the most crucial times,” Stevenson explains.
The assessment service was open from 9 to 5 on weekdays. The general practitioners made referrals by phone, and the assessment service itself arranged incoming transportation for the patients, either by cab or by ambulance, depending on what the general practitioners specified. According to Stevenson, if a referral was made by early afternoon, the patient would be seen the same day. “Previous negotiation with the ambulance service ensured that our patients were given some priority and most arrived by mid-afternoon,” he says.
At the respiratory unit, the nurses took vital signs and obtained a standard history, including information on the patient’s exercise tolerance before the present illness, other medical disorders, current treatment, and home support. All patients underwent chest radiography, hand-held spirometry, and oxygen saturation testing. For patients whose oxygen saturation was less than 92 percent breathing room air, arterial blood gases were obtained as well.
A respiratory physician then saw the patient and decided whether to admit him to the hospital or send him home with nursing support. According to Stevenson, the decision to admit was based on the degree of disability or frailty, the presence of any coexisting medical disorder requiring admission, and the severity of the exacerbation of COPD. The physician also considered the patient’s mental state and the degree of home support. Criteria used to assess the severity of the exacerbation included clinical signs of respiratory distress, and abnormal chest radiograph and arterial blood gases.3
Patients going home were given a detailed explanation of their treatment and were told that they would receive daily visits from the nurses who had assessed them. The nurses monitored progress with physical assessment, spirometry, and oxygen saturation, and offered reassurance and support. They left copies of their notes at the house each day, just in case the family physician was called for an emergency visit. Once the patient was stable and had returned to normal activity, the nurses sent a discharge summary to the family physician.
However, if the patient’s condition deteriorated or failed to improve, the nurses arranged for readmission. According to Stevenson, about 12 percent of the patients treated in his demonstration project required readmission after initially being sent home. About half of these were readmitted because of worsening COPD and half because of the development of complications such as pneumonia or an episode of chest pain.
For this reason, Stevenson believes it is important to recruit nurses who have experience with acutely ill patients. “An outpatient nurse might not be used to acute illness and might be frightened by it,” Stevenson says. As he points out, in this situation, the nurses have an unusual amount of responsibility. “They have to use their clinical judgement–and they have to be good at it,” he says. “They’re out there in the home, and the patient says to them, ‘Nurse, I’m not so good today.’ If every time that happens, they panic and bring the patient right to the hospital, a program like this won’t work. They have to decide objectively what to do. We’ve been lucky. We have expert nurses who have good common sense, who don’t panic, and who are able to reassure the patients,” Stevenson says.
He believes the calm expertise of the nurses goes a long way to explain why so many patients treated in the program now prefer being treated at home. “Initially, we thought that because of their repeated admissions to the hospital, these patients would have become what we call ‘institutionalized,’ ” Stevenson says. At the start of the program, 44 percent of the patients had been
admitted to the hospital during the previous year. “Thus, we thought we might have trouble persuading patients to go home–especially in view of the fact that the area is economically deprived, the housing tends to be damp, and social supports for most patients are weak,” Stevenson says. But although he and his colleagues thought they knew the area and its people intimately, they were off the mark. “It turns out the patients are really very keen to stay at home–much more than we thought,” Stevenson admits.
He also met with initial resistance from the general practitioners in the area, but that did not last. “They thought we would see the patients between 9 in the morning and 5 in the afternoon, and then all these patients would phone them at 10 o’clock at night, or 2 in the morning,” Stevenson says. In fact, that rarely happened, as patients tended to hold off until they could see the nurse the next day.
According to Sister Una Flanigan, RGN, even patients who have needed to be readmitted have not done so on the weekends or at night. “It tends to happen when we’re around for some reason,” Flanigan says. “I think they wait because they know us and they know that if we bring them to our assessment service, they will see a respiratory doctor. They also realize that if they have to be admitted, they won’t have to go through the casualty department–they can go straight to a ward.” According to Flanigan, general practitioners have grown to like having the respiratory assessment service for the same kinds of reasons. “Instead of trying to get through to casualty, and trying to get the patient seen quickly, they have a direct telephone line to us,” Flanigan says.
Flanigan emphasizes that although COPD is a chronic illness, this program deals with an acute phase–the same phase she and the other nurses became familiar with in the hospital. “We knew that we would be assessing patients on our own, without the medical backup that is quickly available in the hospital. So we felt it was doubly important to be familiar with signs that the patient is deteriorating,” Flanigan says. When patients have to be readmitted, it has often been because they have developed some other medical condition, such as angina. “Then it is helpful to have knowledge of the symptoms of other medical conditions as well,” Flanigan says.
She finds that reassurance has special importance for patients with COPD. Anxiety is a big factor. Stevenson agrees. “What seems to happen in the history of these patients is they have an infection, they get over it, but they don’t seem to recover all the way. They see that as evidence of progression of the disease. That’s when they start to crack, and they start to panic a bit,” he says.
However, Flanigan has discovered that in the home, the patients’ own coping skills can be mobilized, and patients can do amazingly well. “Some people are surprised that we send patients home who live alone, but many cope quite well. Other patients, some who are surrounded by family, just don’t cope well–for a variety of reasons,” Flanigan says.
According to Brown, patients experiencing an acute exacerbation of COPD are often so anxious that they require medication such as lorazepam. She believes that the anxiety may help to explain why patients seem to retain so little of the education they receive while in the hospital. Energy conservation, breathing retraining, and nutrition are not topics that can be covered in a single session. Brown also tries to teach use of the peak flow meter, which can be helpful for patients who become symptomatic after discharge.
But there is rarely enough time. According to Gloria Morris, BS, RRT, clinical coordinator at Boston Medical Center in Boston, the educational component is really the key to overall treatment of COPD.4 Patients should be provided with educational materials, and their ability to understand these materials should be assessed while they are in the hospital. “But that is time-consuming. And it is one of the corners people are beginning to cut. As lengths of stay are getting shorter and shorter, and caregivers at the bedside are getting fewer and fewer, we are defeating our own purposes, because we can’t provide this type of education,” Morris says.
For this reason, she finds the concept of home treatment of acute exacerbations to be intriguing. “From the educational standpoint, the home situation sounds ideal. The patient isn’t distracted–for, as you know, it is very hard to concentrate in the hospital. By and large, patients with COPD also tend to be elderly and they don’t learn as fast. Teaching at home can be done a little bit each day and you can assess whether they have absorbed it. That way you can build on what they have already absorbed,” Morris says.
Like Pamela Brown and other practitioners in the United States, Flanigan uses the acute phase to provide some of the education patients seem not to have absorbed during previous episodes of care. There is no regular home respiratory care for people with COPD in the United Kingdom, just as in the United States. Now that Flanigan knows how much these patients need, she would like to be able to provide follow-up visits. But she realizes that the growing demands of the acute service will not allow it. She gives patients her card at the time of discharge, however, and it is not uncommon for them to call. “It is not always when they have a specific question,” Flanigan says. “Sometimes they just need someone to talk to.”
India Smith is a contributing writer for RT
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2. Gravil JH, Al-Rawas OA, Cotton MM, Flanigan U, Irwin A, Stevenson RD. Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet. 1998;351:1827, 1853-1855.
3. Siafakas NM, Vermeire P, Pride NB, et al. ERS–consensus statement: optimal assessment and management of chronic obstructive pulmonary disease (COPD). Eur Respir J. 1995;8:1398-1420.
4. National Lung Health Education Program Executive Committee. Strategies in preserving lung health and preventing COPD and associated diseases. Chest. 1997;113(2 suppl):1235-1635.