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BTS GUIDELINES |
Correspondence to:
Correspondence to:
Dr R Stevenson
Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow G31 2ER, UK; robin.stevenson{at}northglasgow.scot.nhs.uk
Received 5 May 2006
Accepted for publication 23 August 2006
Keywords: chronic obstructive pulmonary disease; hospital-at-home; guidelines
Intermediate care is a treatment model which bridges the interface between hospital and community care. It often involves cooperation between hospital doctors, general practitioners, nurses, physiotherapists and other healthcare professionals. A specific subtype of intermediate care is Hospital-at-Home (HaH), where active treatment is provided by healthcare professionals in the patient’s home for a condition that otherwise would require hospital care, always for a limited period.
In 2003 a Cochrane systematic review concluded that HaH was a safe and effective treatment approach for selected patients with exacerbations of chronic obstructive pulmonary disease (COPD), and suggested that one in four patients presenting to hospital as an emergency would be suitable for home treatment with nursing support,1 although some felt that this was an underestimate of eligibility for HaH (Stevenson, 2005).
In 2004 the National Institute for Clinical Excellence (NICE) COPD guidelines2 included appraisal of HaH in exacerbations of COPD. A distinction was made between HaH (where hospital admission was avoided) and assisted or early discharge schemes (where a short initial admission was followed by home care). We suggest that it is illogical to exclude cases of early or assisted discharge from HaH and, in this guideline, we will consider HaH as a treatment modality which encompasses both admission avoidance and early supported discharge.
The NICE guideline identified four randomised controlled trials (RCTs) and one service evaluation which were applicable to admission avoidance for patients with exacerbations of COPD, and one RCT related to early supported discharge.
The evidence statements can be summarised as follows:
Recommendations from NICE guidelines
The recommendations from the NICE guidelines are shown in table 1
, but leave many unanswered questions:
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This guideline will attempt to answer the above questions so that both existing services may be modified and also that new services may be set up in the light of the present evidence base.
 | METHODS |
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| GLOSSARY OF TERMS |
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BTS, British Thoracic Society
COPD, chronic obstructive pulmonary disease
ESD, early supported discharge
ERS, European Respiratory Society
FEV1, forced expiratory volume in 1 second
FIO2, fractional inspired oxygen concentration
HaH, Hospital-at-Home
HRQoL, health related quality of life
ICP, integrated care pathway
RCT, randomised controlled trial
SpO2, oxygen saturation
SGRQ, St George’s Respiratory Questionnaire
| SUMMARY OF KEY PRIORITIES FOR IMPLEMENTATION |
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| ASSESSMENT |
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Assessment proformas/protocols/integrated care pathways
Several studies have shown that integrated care pathways (ICPs) can improve the delivery of care. This has been demonstrated by RCTs in the areas of inpatient asthma management, pneumonia, stroke rehabilitation, heart failure and orthopaedic surgery.8,9,10,11,12,13 Given the stereotyped nature of assessment and treatment in exacerbations of COPD, it is a potential area in which to use an ICP, but there have been no trials of this. Most ESD services use assessment proformas, although some have more detailed protocols (Angus, 2005). Examples of such documents can be viewed on the BTS website (http://www.brit-thoracic.org.uk/). [Level of evidence IV]
Recommendation
The decision to treat at home
In making this decision, several questions need to be asked:
On the last question, many studies have demonstrated factors which identify group characteristics of patients at an increased risk of relapsing or requiring admission to hospital during an exacerbation of COPD.14–25
Such factors include:
However, the models developed from these risk factors to predict relapse show only moderate sensitivity and specificity14,26 and are of marginal usefulness when faced with individuals. In a descriptive study of intermediate care for COPD,27 the initial severity of the exacerbation was similar among those treated at home and those who later required admission.
The RCTs looking at HaH for exacerbations of COPD have taken a pragmatic approach in deciding which patients can be managed at home. Since they have repeatedly shown no increase in admission/readmission rates, it is likely that their criteria for managing at home are safe.
The least restrictive set of absolute criteria for admission which were used in three studies3,6,7 were impaired level of consciousness, acute confusion, pH <7.35, acute changes on the chest radiograph, a concomitant medical problem requiring inpatient stay, insufficient social support, no telephone and residence geographically removed from hospital.
Some of the studies were slightly more prescriptive and required an ECG to be performed,4 or excluded subjects with any respiratory failure28 or those with newly diagnosed type 2 respiratory failure.5[Level of evidence III]
Recommendations
HaH should not be offered to patients with:
90%)–a contraindication if oxygen cannot be provided at home. [Grade D]
Venous blood tests
Venous blood tests may help in some cases to clarify the cause or contributory factors of an exacerbation or help in guiding treatment. The frequency with which such tests affect management in exacerbations of COPD has not been the subject of a study and therefore they are not routinely recommended. [Level of evidence IV]
Recommendation
Sputum analysis
The use of sputum microbiology to guide treatment of an exacerbation of COPD has not been the subject of a study. It is known that the airways of a proportion of patients with stable COPD are chronically colonised with bacteria and consequently an organism cultured during an exacerbation may not be causal.29,30 Similarly, the spectrum of antibiotic-responsive organisms commonly causing exacerbations is well known without the need for culture.18 Consequently, the NICE guideline2 recommends routine sputum culture only for patients admitted to hospital and when the sputum is purulent.
Recommendation
ECG
The usefulness of an ECG has not been the specific subject of a study in exacerbations of COPD. In the absence of specific symptoms or signs such as chest pain or arrhythmia, it is unlikely that this test would alter management. [Level of evidence IV]
Recommendation
Arterial blood gases and pulse oximetry
According to the NICE guidelines2:
Since oxygen therapy can cause decompensation of respiratory failure in COPD, arterial blood gas measurements should be performed before and after 1 hour on the flow rate of oxygen on which it is intended to send the patient home. [Level of evidence NICE]
Recommendation
90%. These should be repeated after 1 hour on the intended therapeutic flow rate of oxygen aiming for 90% <SpO2 <94% and an arterial blood pH >7.35. [Grade NICE]
Chest radiography
In patients presenting to hospital with an exacerbation of COPD, performance of chest radiography leads to a change in management in 7–21% of patients.31–33 In the population of patients considered for HaH, this figure is likely to be lower as these patients are less acutely unwell. However, as the principal differential diagnoses are detectable on a chest radiograph (pneumonia, pneumothorax, pulmonary oedema),34 this test remains important. [Level of evidence IV]
Recommendation
Spirometry
Spirometry is important in confirming the diagnosis of COPD and, unless confused or comatose, even the sickest of patients can attempt an FEV1 manoeuvre. [Level of evidence IV]
Recommendation
| DETAILS OF SERVICE |
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Types of service
1. Admission avoidance following A&E attendance
This model is described in RCTs from Edinburgh3 and Liverpool.4 Patients were assessed in the A&E department by standby specialist respiratory staff, including both nurses and doctors. If admission was not considered mandatory, they were allowed home with a treatment package and follow-up on subsequent days by nurses was arranged.
In Edinburgh, eligibility for HaH was 29%. Hospital admission was necessary for 7% of patients randomised to the HaH scheme before they had been discharged from HaH. In Liverpool, eligibility for HaH was 33% and admission was necessary for 9% of the HaH patients within 2 weeks of randomisation to the HaH scheme. The readmission rate at 8 weeks in the Edinburgh study was 25% for HaH patients and 34% for controls, and in the Liverpool study at 3 months was 31% for HaH patients and 32% for controls.
This type of scheme requires high staffing levels and is most suited to busy inner city hospitals. [Level of evidence 1b]
2. Admission avoidance following direct GP referral
This model was described in an observational study from Glasgow.27 Local GPs referred patients directly to the respiratory department of the hospital where they were assessed on the same day by a respiratory nurse and a respiratory trainee doctor. Eligibility for HaH was 80% and 15% were admitted from HaH.
One study based on direct GP referral carried out assessment in the patient’s home by a nurse or physiotherapist and did not include plain chest radiography. Eligibility for HaH was very high (only 1.5% of patients were not considered suitable) and 6% were admitted later from HaH.35
These schemes suffer from significant numbers of inappropriate referrals although some early exacerbations may be aborted. [Level of evidence III]
3. Early supported discharge (ESD)
This model was described in studies from Glasgow7 and Hull.5 Patients admitted with exacerbations of COPD were assessed on the morning after admission by the respiratory team, which therefore did not need to be available to see patients throughout the day. The readmission rate at 60 days in the Glasgow study was 29% for HaH patients and 30% for controls, and in the Hull study at 3 months the readmission rate was 33% for HaH patients and 44% for controls.
Eligibility for HaH was slightly higher than in admission avoidance schemes: 38% in Glasgow and 36% in Hull. Early inpatient assessment after a period of hospital care may therefore increase eligibility for HaH. Furthermore, recruitment for early supported discharge after admission allows the HaH team to plan its activity economically. [Level of evidence 1b]
4. Combination of admission avoidance and ESD
This model was described in an RCT from Barcelona.6 Patients were assessed in the emergency room by a specialised respiratory team. Admission was avoided in 68% of the HaH patients and, in those admitted, the length of stay was reduced to 1.7 days compared with 4.2 days in the control group. Eligibility for HaH was 39% and 10% were readmitted from the emergency room. [Level of evidence 1b]
A similar combined approach was used in an observational study from Southend in England where a generic rather than a specialised respiratory team carried out HaH.36 Eligibility for HaH was not shown, but the outcome measures were otherwise similar to those with specialised teams. [Level of evidence III]
Second UK COPD audit (2003)37
In this audit 44% of hospitals had access to ESD and, in these, eligibility for ESD was 31%. The types of service in the hospitals with ESD were:
Recommendations
Hours of operation
1. Admission avoidance schemes
The models designed to recruit patients from A&E had variable hours of operation. In Edinburgh the team worked from 09:00 hours to 17:00 hours, Mondays to Fridays.3 In Liverpool the service operated from 08:00 hours to 18:00 hours 7 days a week,4 and in Barcelona the hours of service were 09:00 hours to 16:00 hours on weekdays only.6 In the 2nd UK COPD audit,37 64% of units ran a 5 day service and 27% had a 7 day scheme.
Unless a 24 hour service or next day review approach is adopted, a proportion of the patients will be missed by the HaH programme. The Edinburgh authors predicted that a full service available at all times would be able to support 150 out of 700 patients per year compared with 115 out of 500 presenting on weekdays only.3 In many hospitals the majority of COPD admissions occur in the early evening, and services based on the normal working day will therefore fail to recruit many patients for whom admission avoidance may be possible. [Level of evidence IV]
2. Early supported discharge schemes
Services designed to deliver early supported discharge can function on a 09:00 to 17:00 hour basis, but there will be a delay in assessment at weekends unless a 7 day service is used. [Level of evidence III]
Recommendations
A summary of HaH approaches in COPD is shown in table 3.
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Recommendations
Team composition
The medical lead in all teams which have published their results has come from a consultant respiratory physician, backed up by junior respiratory trainees. Respiratory nurse specialists have been members of the HaH team in all published randomised trials. Respiratory physiotherapists also participate in several UK schemes.38
Generic HaH models have been described in which home care is provided by non-specialist district nurses.28,36,39 Two of these were small RCTs28,39 and the other an observational study.36 In the latter, the initial assessment was carried out by specialised respiratory staff and the results were broadly similar to the findings in the RCTs where HaH was delivered by specialist respiratory practitioners.3–7
In the 2nd UK COPD audit,37 81% of the schemes were run primarily by respiratory nurses, 11% by general nurses, 2% by physiotherapists and 2% by both physiotherapists and nurses. [Level of evidence III]
Recommendations
Home care team competencies
None of the published studies has dealt with the skills which are necessary for the home care nurses and physiotherapists. The following recommendations are based on the consensus view of the Guideline Development Group. [Level of evidence IV]
Recommendations
Assessment at home after recruitment into HaH scheme
None of the published studies has critically evaluated the various aspects of assessment at home during HaH. However, there is general agreement that the first visit should be on the day after recruitment to HaH and subsequent visits arranged as considered necessary by the respiratory practitioner. In one study, visits were carried out twice daily for the first 3 days.4 In most studies, dyspnoea, cough, sputum colour/volume and vital signs were recorded. Oxygen saturation was measured by oximetry.
The studies on the role of oral steroids in exacerbations have used changes in FEV1 as an outcome measure and have shown that this measurement can detect recovery from an exacerbation.40 Furthermore, a low FEV1 value at admission associated with failure to improve over the first few days of an exacerbation in hospital was highly predictive of a poor clinical outcome.41 In some HaH studies spirometry was carried out using portable electronic spirometers,7,27 but was not always considered essential.36 It is, however, recommended before discharge.2
Telephone contact via the respiratory practitioner’s mobile phone was encouraged6,42 and a copy of the clinical notes left with the patient to assist the general practitioner if called in an emergency.27 In two studies there were weekly team meetings with the hospital respiratory physician.3,6 In an inner city scheme, each nurse visited 5–6 patients daily usually in the mornings with an average of 2–3 assessments carried out in the hospital in the afternoons (Stevenson, 2005). [Level of evidence IV]
Recommendations
Duration of hospital/home care and number of visits
The duration of home care has varied considerably in the published studies, from 3.56 days6 to 24 days,7 with a mean value of 11 days. The number of visits varied from 3.83 to 11.4,7 In one study the intervention was considered to have failed if more than five visits were required.6 These parameters are obviously influenced by the experience and confidence of the practitioners. There is no evidence that the outcomes were affected by the duration of care or by the number of visits.
In the 2nd UK COPD audit37 the median length of stay in hospitals with access to ESD was 4 days compared with 7 days where there was no ESD. The median length of stay in the ESD scheme was 11 days (hospital time + ESD time). [Level of evidence III]
Recommendations
Understanding ESD
Three important points arose from a recent qualitative study which was aimed at evaluating a COPD supported discharge scheme (Clarke et al, unpublished, 2005):
Recommendations
Telemetry
A home telecare system was found to be time consuming for staff as they had to familiarise themselves with the equipment and this was a barrier to its implementation. Procurement and user-friendliness of equipment were problematical.43–45 A review of cost effectiveness in telemedicine found that the literature was limited and the methodology seriously flawed.46 This view was confirmed in a systematic review where only 4% of 600 studies met the criteria for inclusion in a formalised quality review.47[Level of evidence III]
Recommendation
Economics of service provision
The published HaH studies have largely been performed in inner city teaching hospitals. Two of the randomised trials of HaH have included economic evaluations of the intervention. In the Edinburgh study the estimated average cost to the health service of patients in the HaH group was £877 per exacerbation compared with £1753 in the control group.3 Similar findings were reported in the Barcelona study where the average health care cost of HaH patients was 62% less than that of the control patients.6 Difficulty in obtaining funding was the primary reason for inability to set up a HaH scheme for COPD among UK physicians.38 Further more detailed health economic evaluations are required to inform healthcare providers of the cost implications of HaH for COPD exacerbations, but the evidence to date does suggest that a cost benefit is likely. A sample business case is shown in Appendix 3. [Level of evidence III]
Recommendation
| TREATMENT |
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The available evidence base is derived from the study of treatments either performed in an outpatient or hospital setting, not HaH. Certain treatment modalities cannot be delivered in a HaH setting for practical or safety reasons. No reference is therefore made to the utility of some treatments (including intravenous therapies such as theophyllines, magnesium, antibiotics, doxapram or the application of assisted ventilation).
The NICE guidelines2 have comprehensively reviewed the evidence base for treatments used in exacerbations of COPD. Here we aim to summarise the available guidance and highlight aspects relevant to HaH.
It is expected that all patients will be considered for potential treatment at home with the following modalities: bronchodilators (inhaler or nebulised), oral corticosteroids, oral antibiotics and oxygen. Some patients may have access to physiotherapy in the HaH setting.
When and how to give bronchodilators?
Short-acting bronchodilators (ß agonists or anticholinergics) are effective in increasing FEV1 and reducing breathlessness.2 These can be given in combination and have effects that last between 4 and 6 hours and therefore need to be administered regularly at the time of exacerbation.
Bronchodilators can effectively be administered by nebulisers or hand-held inhalers.2 Nebulised treatments are more convenient to administer as supervision of up to 20 inhalations of a hand-held inhaler would be necessary to produce a similar effect to one nebuliser.48 Nebulised delivery of bronchodilator was the standard treatment for most patients enrolled in controlled trials of HaH.3–5,7,42[Level of evidence NICE]
Recommendations
Who should receive corticosteroids?
Well conducted trials have established a role for corticosteroid therapy in COPD exacerbations.49–51 Rates of treatment failure decrease and duration of hospital stay is reduced by approximately 2 days after corticosteroid administration.
In the randomised trials, a significant number of patients developed glycosuria or required treatment for hyperglycaemia. Employing HaH limits the approaches that can be taken to control hyperglycaemia induced by prednisolone. Particular attention should be paid to diabetics who are prescribed corticosteroids during home care.
The NICE guidelines have proposed the use of prednisolone at 30 mg for 7–14 days in all those hospitalised with an exacerbation and its consideration in outpatients with an exacerbation who can tolerate prednisolone.2 Since HaH patients would be hospitalised if the service did not exist, it is reasonable that they should all be prescribed corticosteroids. [Level of evidence NICE]
Recommendation
Who should be given oxygen?
Oxygenation deteriorates unpredictably during an exacerbation.52 Oxygen administration improves arterial oxygenation and relieves symptoms including breathlessness.53 It is considered that oxygen saturations greater than 90% and less than 94% are optimal and that this is usually achievable with 2 or 4 litres by nasal cannula, or by 24% or 28% by Venturi mask.52 The target oxygenation (90–93%), not mode of delivery, is prescribed in the NICE and joint ATS/ERS COPD guidelines.2,54
Arterial blood gas measurement is necessary to assess the initial response to oxygen therapy and to monitor for worsening hypercapnia with repetition after 1 h.2 Oxygen saturation monitors can be used to monitor the continuing need for oxygen at home. HaH services which were part of randomised trials have provided concentrator or cylinder oxygen to patients.3–5,7,42 It may not be possible to withdraw oxygen from all patients, hypoxic during exacerbation, when they have sufficiently recovered to be discharged from HaH back to primary care.55[Level of evidence III]
Recommendations
Who should receive antibiotics?
It has been shown that those with two or more symptoms of an exacerbation (purulent sputum, increased sputum and increased breathlessness) benefit from antibiotic therapy.56,57 The NICE guidelines recommend the use of antibiotics for those with a history of more purulent sputum, but do not stratify patients towards differing antibiotic therapy.2[Level of evidence NICE]
With severe disease, pathogens such as Staphylococcus and Pseudomonas become more likely and beta lactam resistant organisms are more prevalent in those with multiple antibiotic courses.57,58 Risk factors for treatment failure include increased exacerbation frequency, severe FEV1 impairment, co-morbidity and increasing age.58 It is therefore logical to avoid repeating similar antibiotics in those with recurrent requirements for treatment. [Level of evidence 1b]
Recommendations
What other treatments can be offered?
HaH interventions provide the opportunity to offer additional ancillary treatments to the patient. Although components of care such as smoking cessation and pulmonary rehabilitation were not offered as part of the studies forming the evidence base of HaH for COPD, these form part of basic COPD care delivery. Additional support for patients and carers may be provided by home help and occupational therapy services.
Positioning to improve the mechanics of breathing has been shown to improve breathlessness and respiratory muscle strength.59 The use of positive expiratory pressure masks led to greater sputum clearance in a randomised trial.60 Acute administration of nutritional support has been shown to be feasible during exacerbation, but with no clear benefit proven.61 Pulmonary rehabilitation begun in the aftermath of an exacerbation results in improvement in exercise capacity and quality of life evident 6 months after an initial hospital-based programme.62[Level of evidence 1b]
Recommendations
| INTERMEDIATE CARE IN STABLE COPD |
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In 2001 a Cochrane systematic review of home care for COPD concluded that it "is an expensive form of care that has not been shown to improve lung function. There may be some benefits for people with less severe disease, but more research is needed to demonstrate this".63 The most recent systematic review concluded that "there is little evidence to support the widespread implementation of nurse led management interventions for COPD, but the data are too sparse to exclude any clinically relevant benefit or harm arising from such interventions".64 A recent ATS statement concurs: "Many home health interventions are based on empirical recommendations rather than research data".65
Components of the interventions
The components of home care/chronic disease management interventions for stable COPD patients may include:
The relative importance of each component may vary according to the perspective of the patient, carer and health professional. We present the evidence relevant to the following questions, from the RCTs included in the two systematic reviews (together with RCTs published more recently):
Do the schemes improve the quality of life?
Several different types of health related quality of life (HRQoL) questionnaires have been used to measure this important outcome. The commonest measure has been the SGRQ. None of the RCTs of chronic disease management/home care schemes has demonstrated a significant improvement in total SGRQ with the intervention. Some statistically significant differences have been seen in individual components of the SGRQ, but their clinical significance is unclear.
There is currently no evidence to suggest that these interventions improve patients’ HRQoL as measured by total SGRQ score. [Level of evidence 1a]
Recommendation
Do the schemes improve objective measurements of pulmonary function or patient mortality?
There is no evidence that the 6 minute walking test was improved in any of the three schemes where this parameter was measured.65–68 Patients not looked after by a respiratory health worker had a higher chance of dying (relative risk 2.9, confidence limits 0.8 to 10.2) in one study,67 but the other studies have found no such effect and a meta-analysis of the effect on mortality found no significant improvement in the intervention patients.64
There is no available evidence to suggest that such schemes alter pulmonary function or influence mortality rates. [Level of evidence 1a]
Do the schemes alter the frequency of hospital admissions or unscheduled visits to the GP or A&E departments?
Researchers from Spain and Quebec have demonstrated reductions in the frequency of unscheduled visits to hospital A&E departments at 1 year66,69 and 2 years follow-up70 with their chronic disease management schemes. In the Canadian study there was also a significant reduction in unscheduled visits to the family physician at 12 months in the intervention group.66 The Spanish study only included patients receiving long term oxygen therapy,69 whereas the other study involved patients with at least one hospital admission for an acute exacerbation of COPD in the 12 months before entry into the scheme.66,70
These two studies also demonstrated a significant reduction in hospital admissions from all causes in the intervention groups. The Canadian study reported a 40% reduction in admissions for an acute exacerbation, a 57% reduction in admissions for other health problems at 12 months,66 and a 27% reduction in all cause admissions at 2 years.70
Patients in the Spanish study had a significant reduction in hospital stay (7.43 vs 18.2 days).69 Similar findings were reported from the Quebec study (7.2 vs 12.5 days).66 However, several other RCTs have failed to detect or report any benefit in terms of unscheduled visits to the GP,71 visits to A&E departments,72,73 hospital admissions,67,71,72,74,75 or length of hospital stay.73 Overall, the trials defy meta-analysis due to their differing presentation of results.
The available evidence is conflicting and it is not clear whether these interventions reduce hospital admissions, unscheduled visits to the family physician/GP or attendance at A&E departments. [Level of evidence 1a]
Recommendations
| AUDIT |
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Suggested audit criteria:
| APPENDIX 1 GUIDELINE DEVELOPMENT GROUP |
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Robin Stevenson—Chair, Consultant Respiratory Physician, Glasgow Royal Infirmary
Robert Angus, Consultant Respiratory Physician, University Hospital Aintree, Liverpool
Maria Blanchard, Consultant Physiotherapist, Central Middlesex and Northwick Park
Julia Bott, Consultant Physiotherapist, North Surrey PCT
Christina Collins-Gilchrist, Clinical Specialist Physiotherapist, Maidstone & Tunbridge Wells
Anthony Davison, Consultant Respiratory Physician, Southend Hospital, Essex
Kate Ford, Clinical Specialist Physiotherapist, Bristol Royal Infirmary
Jonathan Fuld, Specialist Registrar, Cambridge
Martin Johnson, Consultant Respiratory Physician, Western Infirmary, Glasgow
Noel O’Kelly, General Practitioner (GPwSI)—Respiratory Medicine, East Lincolnshire PCT
John O’Reilly, Consultant Respiratory Physician, University Hospital Aintree, Liverpool
Kelly Redden-Rowley, Respiratory Clinical Specialist in Physiotherapy, Sandwell Primary Care Trust
Jane Scullion, Consultant Respiratory Nurse, Glenfield Hospital, Leicester
Rebecca Sherrington, Clinical Nurse Specialist, Respiratory Medicine, Princess Elizabeth Hospital, Guernsey
Stephanie Taylor, Senior Clinical Lecturer, Health Services R&D, Barts and The London, Queen Mary’s School of Medicine and Dentistry
Pamela Vaughn, Clinical Specialist Physiotherapist, Glasgow Royal Infirmary
John Williams, Consultant Respiratory Physician, Halton General Hospital
| APPENDIX 2 HOSPITAL-AT-HOME PATIENT INFORMATION |
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It is accepted that this treatment can be taken safely at home and the outcome is just as good, if not better, than if you had remained in hospital. You can expect to recover in a week or two and return to your normal state of health.
Your treatment will be supervised at home by one of our respiratory nurses or physiotherapists who will visit you on the day after you go home and will continue to visit you until you have almost fully recovered. At the visits your progress will be monitored and your treatment will be adjusted if necessary. In the unlikely event that you do not improve as expected, you will be admitted to hospital for further tests and a change of treatment.
The nurse or physiotherapist will leave details in the house of your illness and the treatment which you are taking in case your GP comes to see you. She will also leave her mobile phone number and you can call her at any time for advice or reassurance.
If you have been lent a nebuliser, it will be taken back if you no longer need it. However, if it remains useful, you will be provided with one for long term use. Similarly, if you need oxygen and if your blood oxygen level remains low, we will arrange for you to have an oxygen concentrator again for long term use.
During your care at home, we will consider what can be done to improve your health so that further flare-ups will be less likely to happen. This might include advice on quitting smoking, exercises, dietary changes and information about COPD which will help you to cope better with your illness. Understanding COPD lets you recognise when things are going wrong and enables you to step up your treatment at an early stage to prevent further deterioration.
| APPENDIX 3 BUSINESS CASE |
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| FOOTNOTES |
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| REFERENCES |
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TOP
METHODS
GLOSSARY OF TERMS