A review of discharge planning for people with chronic obstructive pulmonary disease at high risk for readmission
The National Institute of Health Research Northwest London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) is an alliance of academic and healthcare organisations working to develop and promote a more efficient and sustainable uptake of innovative and cost-effective interventions into care for patients.1 Patients who require long-term care for conditions such as chronic obstructive pulmonary disease (COPD) may have differing service needs and are often involved with many healthcare organisations and health professionals.2 A CLAHRC work stream has focused on the development and roll out of a COPD discharge care bundle in North West London in order to reduce hospital readmissions and improve the patient's quality of life.
To understand the potential benefits that care bundles could confer, we undertook a review of the interventions that reduce readmission to hospital with the aim of informing the CLAHRC COPD bundle initial development. A care bundle being a group of evidence-based interventions that address a particular health issue to prevent further episodes of illness.3 There is emerging evidence that care bundles may reduce hospital mortality.3,4
A comprehensive search for interventions associated with a reduction in COPD readmissions and improved functioning was performed using the following databases, with no limits applied: Medline, Pubmed, PsycINFO, EMBASE, Cochrane Library, CINAHL, Database of Abstracts of Reviews of Effectiveness, and TRIP. Additional searching of conference proceedings and web browsing was undertaken to identify further publications. In total, 714 references were identified after duplicates were removed. We identified themes of integrated and intermediate care, psychological support, nutritional care and pulmonary rehabilitation, as interventions that reduced readmission and improved functioning. Pulmonary rehabilitation especially had substantial evidence for reducing readmission and improving functioning.
When focusing upon readmission, potential deficits were identified in communication, medical errors, and recognition that some COPD readmissions may not be disease driven but may be due to a psychosocial component and/or social isolation.5,6 In a Canadian study, adverse events associated with COPD exacerbations were significant in both hospitalised and discharge care programmes.7 Care gaps were identified in patient education-related medicines, oxygen therapy and poor documentation of the patient progress over time.7 Furthermore adverse drug events were highest for corticosteroids, anticoagulants, antibiotics, analgesics and cardiovascular medications.8 The lack of monitoring of these medications by health professionals after hospital discharge was the most common cause of preventable adverse drug events.8
In conclusion, there is evidence that in the management of COPD a discharge care bundle for COPD patients could prove beneficial. There are gaps in knowledge requiring further research and considering all readmissions as a failure of care must be undertaken with caution. However, putting into practice that which is already known should have a positive effect upon outcomes.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2011 Royal College of Physicians
References
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