hospital at home for copd dr tarek saba consultant chest physician sister pauline berry respiratory...
TRANSCRIPT
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 Safe and effective approach
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?
7 days a week 9-5 (weekdays only initially till staff training complete)
BTS Guideline 2007
Who assumes clinical responsibility?
Weekly staff clinical meetings
No recommendations on Follow-up
BTS Guideline 2007
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 daysBTS Guideline 2007
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)
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
NICE website 2007
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.”
“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
NICE 2004
Cost
BTS Guideline 2007
“…the evidence to date does suggest that a cost benefit is likely.”
COPD Early Supported Discharge Service
Pauline Berry
• 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.
Service History
• 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
Aims of the Service
• 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.
COPD ESD Team
• 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
Service Type
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
Inclusion into COPD ESD
• 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
Pre-home Requirements
• 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
Exclusion
• 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
Social Issues
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
Service Information
• 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
• Daily BP, Temperature, Respiratory rate, SpO2
• Sputum colour /volume
• Treatment compliance
• Education re: COPD and Self Management Plan
• Telephone contact encouraged with team
Home Checks
0
2
4
6
8
10
12
14
16
Patients
Hospital days
Home days
Total days
Trend
COPD Hospital at Home June 2010 – March 2011
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”