Supported discharge shortens hospital stay in patients hospitalized because of an exacerbation of COPD

Patients and ethics

Over a 12-month period (April 1999–April 2000), physicians not involved in the study who were working in the emergency room (ER) of the hospital, admitted 205 patients with a diagnosis of exacerbated COPD to the respiratory ward. Patients not responding to the initial therapy started in the ER either died or were admitted to the Intensive Care Unit (ICU) of the institution, none were included in the study. By definition, therefore, all the patients included in this study had responded favourably to the therapy started in the ER. Table 1⇓ presents their main clinical and physiological characteristics. Once in the ward, patients were assigned to the supported discharge or the control group accordingly, mainly, to their site of residency (the city of Palma de Mallorca or somewhere else, respectively). This was because nursing support at home could be provided only for those patients living in Palma de Mallorca. Therefore, patients were included in the supported discharge group (n=105) if they chose voluntarily to participate in the programme after being fully informed of its aims, nature and potential risks and lived in the city of Palma de Mallorca. The remaining patients (n=100) did not fulfil these criteria (mainly because they lived outside the city, although three patients living in the city refused to receive home care) and served as controls. This project was approved by the Ethics Committee of the institution.

Inpatient treatment

All patients received standardized treatment that included: 1) aerosolized bronchodilators (ipratropium bromide 130 µg and fenoterol 250 µg four times daily); 2) systemic glucocorticoids (inpatient regimen: metilprednisolone 40 mg three times daily for one day, 40 mg twice daily one day and 40 mg once daily up to hospital discharge. Home regimen: descending doses of oral prednisone for twelve days starting from 30 mg); 3) antibiotics (amoxycillin 875 mg and clavulanic acid 175 mg three times daily for seven days or clarythromycine 500 mg twice daily for seven days); and, 4) controlled oxygen.

In all patients, both in the supported discharge programme and the control group, the decision to discharge the patient from hospital was taken according to the clinical judgement of the physicians in charge (experienced Spanish board certified pulmonary specialists). Such a judgement can not be quantified precisely; rather, it is a composite picture of the physiology of the patient (cardiac and breathing frequency, body temperature, arterial blood gases) as well as their willingness to accept discharge. All patients were discharged on this basis as soon as possible.

The supported discharge programme

Patients in the supported discharge programme were allowed to use nebulizers (Micron®, Medel Elettromedicali, Italy) and/or continuous O₂ therapy at home if deemed necessary by the attending physicians. The day after hospital discharge, a specialized, hospital-based, clinical nurse visited them at home. Thereafter, home-visits were scheduled according to patient's needs. The programme nurse had daily meetings with the pulmonologists in the hospital to coordinate home-care needs. If necessary, during regular working hours the nurse could be reached by the patient (or the nurse could reach the doctor in the hospital) through a mobile phone. Likewise, if required, the nurse could send the patient back to hospital for immediate medical assessment by the pulmonary team (including new hospitalization if necessary).

At each visit at home, the nurse assessed the patient's general condition, shortness of breath intensity, and presence of cough or sputum production. Also, body temperature, heart rate, blood pressure, respiratory rate and arterial oxygen saturation (S_a,O2) (Nanox 2, Medlab GmbH, Germany) were measured. At the end of the home support period, before being definitively discharged from the supported discharge programme, a lung specialist in the pulmonary clinic visited the patient.

Data analysis

To assess the viability and effectiveness of the supported discharge programme, several outcomes were defined a priori. These included: 1) LOS in hospital; 2) number of patients requiring hospitalization while still under the supervision of the supported discharge nurse at home (home-readmission's (HRA)); 3) number of patients requiring hospitalization during the first 2 weeks following final discharge from the supported discharge programme (early readmission's (ERA)); 4) number of patients requiring hospitalization after 2 weeks from final discharge of the supported discharge programme (late-readmission's (LRA)); and 5) mean number of hospital beds utilized daily by respiratory patients. Other variables included in the analysis were the number of nurse visits at home per patient and the number of mobile phone calls.

Results are expressed as mean±sd and range. The unpaired t-test and the Chi-squared test were used to compare quantitative and qualitative variables, respectively, in the supported discharge and control groups. A p-value <0.05 was considered statistically significant.

Limitations of the study

Two aspects of the study deserve comment. Firstly, it was not formally randomized. Instead patients were assigned to the supported discharge or control group based on their site of residency. Although this can theoretically bias the results, it is believed that this was not the case because, post hoc, both groups were similar in size, social circumstances and clinical and functional condition (table 1⇑). Second, patients were discharged from hospital (in both groups) according to the “clinical judgement” of the attending physician (an experienced board certified pulmonary specialist in all cases). This approach, which is identical to that followed by some recent publications in the field 6, 7, is due to the fact that there are no internationally accepted, objective criteria that can guide clinicians in the discharge process of these patients. Therefore, patients are normally discharged at a point in their recovery process where the physician thinks that the patient can finish it at home safely. Given that the supported discharge group was offered nurse supervision at home, it is likely that this point may have been reached earlier in this group than in the control group. However, this possibility is interpreted as, one of the main outcomes, rather than a limitation.

Previous studies

Over recent years, there has been a great deal of interest in exploring alternatives for the clinical management of patients with exacerbated COPD, mostly in UK centres 9. These previous studies have shown that many patients can be successfully managed at home after formal assessment in a specialized respiratory unit in the hospital 5–7. The presented study extends these previous observations by, first, exploring a different (intermediate) alternative for the management of these patients (supported discharge) and, second, by providing evidence about the feasibility of these type of alternative programmes outside the UK, where the different healthcare system peculiarities may facilitate (or limit) their implementation.

Interpretation of findings

With the limitations discussed above in mind, the study shows that the supported discharge programme allows a significant reduction in the LOS of patients hospitalized because of an exacerbation of COPD (5.9±2.8 versus 8.0±5.1 days, supported discharge versus control group, respectively, p<0.001). This was not accompanied by a higher readmission rate but resulted in a lower number of hospital beds used at any given point in time (fig. 1⇑). Several aspects of these results deserve comment.

First, the average LOS in the supported discharge programme was not very different from that reported recently (6.1 days) in the control group of a British study 7. This may suggest that nursing support at home may not have been necessary for these patients. Whether or not this interpretation is correct is limited by the lack of objective criteria for hospital discharge discussed above. Further, it is likely that differences between countries in the way that these patients are managed in hospital may also contribute to explain this observation. Finally, despite the lack of formal randomization in the study, both groups received identical medical treatment and, nonetheless, LOS in the control group was significantly higher than in the supported discharge group. Therefore, it is believed that this is a true reflection of the effectiveness of the supported discharge programme. It was also of some interest to observe that, unexpectedly, the LOS of the control group was lower than that of historical controls hospitalized in the department because of an exacerbation of COPD during 1998 (10.3 days). It is thought that this is a reflection of a dynamic process of global improvement in the clinical management in COPD in the institution and, probably, in other institutions also (in the UK studies reported a similar trend 7). Future studies will determine what is the minimum LOS of a patient hospitalized because of an exacerbation of COPD. The availability of a set of consensus criteria to discharge safely these patients (with or without nursing support at home) would be a valuable tool for such future studies.

Second, the efficacy of the supported discharge programme was assessed by analysing the rate of home HRA, ERA (2 weeks) and LRA (>2 weeks). LRA are part of the natural history of the disease 10 and, therefore, not accountable to the efficiency of the supported discharge programme. In fact, LRA were not substantially different in between the supported discharge and control groups (18.7 versus 12%), particularly when the fact that 46% of the patients included in the control group lived outside of the city (and were, therefore, lost for follow-up) is taken into account. HRA, on the other hand, are due to patients showing poor clinical evolution at home. Whether this represents a failure of the supported discharge programme (as represented by the inclusion in the programme of patients too sick to be cared of at home) or, actually, an advantage of the programme (early detection of poor clinical evolution) is debatable. In any case, the percentage of HRA in the present study was very small (1%). Finally, ERA probably indicate a true failure of the supported discharge programme. The percentage of ERA's in the supported discharge programme (2.2%) was not statistically different from that seen in the control group (1.7%) and lower than that reported by the study of Gravil et al. 5.

Finally, the economical savings of the supported discharge programme were not precisely quantified. However, it seems clear that it is not only feasible but also cost-effective because it reduced the mean number of hospital beds used by the respiratory department through the year (fig. 1c⇑).

Clinical implications

The supported discharge programme was designed for patients hospitalized because of an exacerbation of COPD. By definition, therefore, all patients included in the present report were hospitalized with this diagnosis after showing a favourable response to the therapy started in the emergency room. The results of this study are applicable therefore to this type of patient only. However, the implementation of the programme demonstrated that it could also be used to support home care (and early discharge) in other types of respiratory diseases, such as bronchial asthma or community acquired pneumonia, with equally good results (data not shown). This experience, beyond the scope of the present study, should be taken into account when designing and implementing this type of clinical care strategies.