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Department of
Respiratory Medicine, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
Correspondence to: Dr R D Stevenson Robin.Stevenson{at}northglasgow.scot.nhs.uk
Received 20 January 2000; Returned to authors 13 March 2000; Revised version received 2 May 2000; Accepted for publication 23 May 2000
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.
METHODSPatients 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 360 patients 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.
RESULTSOn 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 7.83 days 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).
CONCLUSIONSPatients
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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